Ann Thorac Surg 2005;80:2080-2081
© 2005 The Society of Thoracic Surgeons
Original article: General thoracic
Invited commentary
John M. Streitz, Jr, MD
Department of Thoracic and Cardiovascular Surgery, Duluth Clinic, 400 East 3rd St, Duluth, MN55805
(Email: jstreitz{at}smdc.org).
The authors [1] present a series of 20 patients with epiphrenic diverticula who were treated using minimally invasive surgical techniques. This seems to be the largest series reported to date and is an important counterweight to the optimistic case reports and small series of similar procedures published in recent years. The authors' main message, stated in the conclusion of their abstract, is that "open surgery should remain the standard..." This recommendation is based on the technical problems that they encountered with this approach. It takes courage and integrity to report negative results as the authors have done, but it is much needed, especially with emerging technologies.
The most striking finding of their study is the esophageal leak rate of 20% and the leak-related death of a patient. Although the authors use the Mayo Clinic series leak rate of 18% for comparison with the open approach, their own leak rate of 20% is more than three times higher than those of the other open series of operations noted in their bibliography (see references 4, 19, 20). Clearly this is a technically difficult approach even in the hands of experts with a substantial number of cases from which to learn. Epiphrenic diverticulum is an unusual condition, and the learning curve for the described approach is steep and long. Most thoracic surgeons will never operate on 20 cases in their lifetimes and are well counseled to utilize the open approach as the standard of care. Minimal access surgery makes sense when the main morbidity of a procedure is the incision and the outcome is comparable to an open operation. In the case of epiphrenic diverticulum it seems clear that maximal technical access is needed to minimize the risk of esophageal leakage and subsequent death from sepsis. Although we may argue about the indications for myotomy and whether to include an antireflux procedure, it can be agreed that a left thoracotomy provides excellent exposure for diverticulectomy, a myotomy of any length, and a fundoplication, and this can be accomplished simply, safely, and in this era of modern epidural analgesia with minimal morbidity from the incision.
 |
References
|
|---|
- Fernando HC, Luketich JD, Samphire J, et al. Minimally invasive operation for esophageal diverticula Ann Thorac Surg 2005;80:2076-2081.[Abstract/Free Full Text]
Top
References