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Epiphrenic Diverticulectomy, Esophageal Myotomy, and Belsey-Mark IV Fundoplication

Tuesday, May 13, 2014

The patient is a 61-year-old caucasian male with a history of progressive dysphagia, and a 25-pound weight loss in the last year.

Through a standard posterolateral thoracotomy in the 6th intercostal space, the authors carefully dissected down to the neck of the epiphrenic diverticulum. After recognizing and preserving the anterior vagus nerve, which was crossing the anterior aspect of the diverticular neck, the authors were able to completely mobilize the diverticulum. The authors dissected down 2 cm on the distal esophagus, from the neck of the diverticulum onto the stomach, performing the esophageal cardiomyotomy. The diverticulum was resected with a TA60 green load stapler. The hypertrophied overlying musculature was used to cover the resection line on the esophagus with interrupted silk.

Next, the anterior gastroesophageal fat pad was carefully removed. The authors reflected the fundus of the stomach upward to perform the two-tier Belsey-Mark IV fundoplication, using double-armed 2-0 silk sutures with three sutures on each tier. The second tier sutures were brought out under the diaphragm and tied on the thoracic side.

A chest x-ray and barium swallow on postoperative day 5 were unremarkable. At four years post-surgery, the patient is asymptomatic and does not require any proton pump inhibitor therapy.

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