A 68 year-old woman presented at our clinic with symptoms of heartburn, regurgitation and vomiting. The duration of symptoms was six months. The diagnostic work-up consisted of barium esophagography and endoscopy. She did not have any signs during the endoscopy suspecting a gastro-esophageal reflux so we did not perform pH monitoring. Barium study showed two diverticula located in the distal third of the esophagus. The average sizes of the pouches were 4 cm and 2 cm. The diverticula were located 6-7 cm above the cardia measured by endoscopy and a hiatal hernia was also diagnosed.
The esophagus was isolated and completely encircled with a rubber tape for traction. Blunt dissection was carried out in the mediastinum until 8-10 cm above the diaphragmatic crura staying close to the esophageal surface. At the same time the larger diverticular pouch was identified by endoscopy and isolated up to the superior margin of its neck and then resected with a linear endoscopic stapler with the nasogastric tube inside the esophageal lumen. Intraoperative endoscopy was used in order to avoid the narrowing of the lumen by the stapler and to detect an incomplete resection, also to check the stapled suture line for any leak. Endoscopically there was no evidence of leak at the suture line therefore suture of the esophageal musculature was not performed (figure 2). The smaller diverticulum was not resected because of being asymptomatic. A Toupet fundoplication was chosen for the repair of the hiatal hernia. The procedure was finished after 95 minutes. The postoperative course was uneventful.
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