一次性食道運動障害を伴う横隔膜上食道憩室再発に対し胸腔鏡補助下・腹腔鏡下手術を施行した1例

Thoracoscopic assisted and laparoscopic surgeries for recurrent epiphrenic esophageal diverticulum complicated by primary esophageal motility disorder

◆要旨：患者は73歳，男性．約9年前に胸腔鏡補助下横隔膜上食道憩室切除術を行い，術後縫合不全をきたしその後憩室再発を認めた．諸検査では右胸腔内へ突出する6cm大の多房性囊状憩室を認め，腹部食道方向への入口部は圧迫狭窄を受け胃内への通過障害が存在した．初回手術時の食道内圧検査では平均下部食道蠕動波高が239mmHgと高値を示し一次性食道運動障害と診断していた．以上の所見から長期間通過障害を伴う横隔膜上食道憩室再発と随伴する一次性食道運動障害を考慮し，胸腔鏡補助下憩室切除術と腹腔鏡下腹部食道筋層切開術ならびに噴門形成術（Heller-Dor）を施行した．術後6か月を経過したが通過障害は改善され食道逆流症状も認めない．

The patient is a 73-year-old man. He underwent thoracoscopic assisted resection of epiphrenic esophageal diverticulum approximately 9 years ago. The suture line leakage occurred postoperatively and later, diverticulum recurred. On examination, multiloculated cystic diverticulum that measured 6cm in diameter was detected, protruding into the right pleural space. Compression stenosis in the ostium toward abdominal esophagus and obstruction into the stomach were also noted. Intraesophageal pressure measured during the first operation showed the average peristaltic wave of the lower esophagus to be 239 mmHg thus primary esophageal motility disorder was diagnosed. Considering the long-term obstruction accompanied by primary esophageal motility disorder and recurrent esophageal epiphrenic diverticulum, thoracoscopic assisted resection of the diverticulum combined with laparoscopic Heller's myotomy and Dor's fundoplication （Heller-Dor operation） was performed. Esophageal obstruction has improved and there has been no symptoms of esophageal reflux, 6 months after surgery.