{"id":607,"date":"2013-03-14T09:39:19","date_gmt":"2013-03-14T09:39:19","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=607"},"modified":"2013-06-09T17:00:36","modified_gmt":"2013-06-09T17:00:36","slug":"12-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=607","title":{"rendered":"12 Divertikly j\u00edcnu"},"content":{"rendered":"

12.1 Definice, historie a klasifikace<\/h3>\n

J\u00edcnov\u00fdm divertiklem rozum\u00edme vakovit\u00e9 vyklenut\u00ed st\u011bny j\u00edcnu do periezofage\u00e1ln\u00edho prostoru. Podle lokalizace rozli\u0161ujeme t\u0159i typy:<\/p>\n

    \n
  1. Parafarynge\u00e1ln\u00ed divertikl na p\u0159echodu faryngu v j\u00edcen (synonyma: kr\u010dn\u00ed, hypofarynge\u00e1ln\u00ed, horn\u00ed, farynge\u00e1ln\u00ed, <\/span>Zenker\u016fv).<\/span><\/li>\n
  2. Hrudn\u00ed divertikl ve st\u0159edn\u00ed \u010d\u00e1sti j\u00edcnu (synonyma: epibronchi\u00e1ln\u00ed, parabronchi\u00e1ln\u00ed, st\u0159edn\u00ed).<\/span><\/li>\n
  3. Epifren\u00e1ln\u00ed divertikl um\u00edst\u011bn\u00fd nad br\u00e1nic\u00ed (synonyma: doln\u00ed, parahi\u00e1tov\u00fd).<\/span><\/li>\n<\/ol>\n

    Historicky prvn\u00ed popis hypofarynge\u00e1ln\u00ed j\u00edcnov\u00e9 v\u00fdchlipky poch\u00e1z\u00ed z roku 1769\u00a0od anglick\u00e9ho chirurga Lundlowa [1]. B\u011b\u017en\u011b je v\u0161ak tato v\u00fdchlipka ozna\u010dov\u00e1na jako\u00a0Zenkerova, podle n\u011bmeck\u00e9ho patologa, kter\u00fd v roce 1874 spolu s von Ziemssenem\u00a0uve\u0159ejnil popis 27 v\u00fdchlipek [2]. Divertikly byly rozd\u011bleny Rokytansk\u00fdm v roce 1840 na pulzn\u00ed a trak\u010dn\u00ed a pak je\u0161t\u011b d\u00e1le diferencov\u00e1ny v roce 1882 Oekomoidem na trak\u010dn\u011b pulzn\u00ed [3]. I kdy\u017e v\u00fdvoj n\u00e1zor\u016f na toto onemocn\u011bn\u00ed pro\u0161el dlouh\u00fdm v\u00fdvojem,\u00a0je tato z\u00e1kladn\u00ed klasifikace st\u00e1le u\u017e\u00edv\u00e1na.<\/p>\n

    Parafarynge\u00e1ln\u00ed a epifren\u00e1ln\u00ed divertikly jsou pro sv\u016fj topografick\u00fd a funk\u010dn\u00ed vztah\u00a0k j\u00edcnov\u00fdm sv\u011bra\u010d\u016fm ozna\u010dov\u00e1ny jako juxtasfinkterick\u00e9. \u010clen\u011bn\u00ed na pulzn\u00ed a trak\u010dn\u00ed\u00a0typ, prav\u00e9, neprav\u00e9, posttraumatick\u00e9 a kongenit\u00e1ln\u00ed v\u00fdchlipky vypl\u00fdv\u00e1 z rozboru\u00a0jejich etiopatogeneze. U n\u011bkter\u00fdch funk\u010dn\u00edch poruch j\u00edcnu se p\u0159i rentgenov\u00e9m vy\u0161et\u0159en\u00ed m\u016f\u017eeme setkat zejm\u00e9na v d\u016fsledku terci\u00e1rn\u00ed peristaltiky s obrazem pseudodivertikl\u016f, kter\u00e9 jsou vytv\u00e1\u0159eny spastick\u00fdm sta\u017een\u00edm j\u00edcnu. Jde o funk\u010dn\u00ed zm\u011bny,\u00a0kter\u00e9 nemaj\u00ed anatomick\u00fd podklad. Zvl\u00e1\u0161tn\u00edm obrazem je rovn\u011b\u017e tzv. intramur\u00e1ln\u00ed\u00a0divertikul\u00f3za j\u00edcnu, jej\u00ed\u017e etiopatogeneze nen\u00ed zn\u00e1ma, vznik\u00e1 dilatac\u00ed hlubok\u00fdch \u017el\u00e1zek ve st\u011bn\u011b j\u00edcnu s propagac\u00ed extraezofage\u00e1ln\u011b. Uva\u017euje se o spojitosti se specifick\u00fdm\u00a0tuberkul\u00f3zn\u00edm z\u00e1n\u011btem \u010di mykotick\u00fdm posti\u017een\u00edm st\u011bny ezofagu. Byla poprv\u00e9 pops\u00e1na Mendlem, McKayem a Tannerem v roce 1960 a dosud bylo publikov\u00e1no jen\u00a0n\u011bkolik p\u0159\u00edpad\u016f, vz\u00e1cn\u011b se vznikem perforace \u010di striktury [4, 5]. Mezi velmi vz\u00e1cn\u00e1\u00a0pozorov\u00e1n\u00ed pat\u0159\u00ed i infradiafragmatick\u00fd (subdiafragmatick\u00fd) divertikl na intraabdomin\u00e1ln\u00ed \u010d\u00e1sti ezofagu. I zde m\u016f\u017ee hr\u00e1t p\u0159i jeho vzniku hypertonie DJS [6].<\/p>\n

    12.2 Etiopatogeneze<\/h3>\n

    V etiologii j\u00edcnov\u00fdch divertikl\u016f se v prom\u011bnliv\u00e9 m\u00ed\u0159e podle jejich lokalizace uplat\u0148uj\u00ed nej\u010dast\u011bji \u010dty\u0159i p\u0159\u00ed\u010diny. Pulzn\u00ed divertikl vznik\u00e1 jako d\u016fsledek zv\u00fd\u0161en\u00e9ho intralumin\u00f3zn\u00edho tlaku v j\u00edcnu. P\u0159ed p\u0159ek\u00e1\u017ekou funk\u010dn\u00ed nebo mechanickou, nej\u010dast\u011bji\u00a0ve sfinkterick\u00e9 oblasti, dojde v m\u00edst\u011b oslaben\u00ed st\u011bny j\u00edcnu ke vzniku v\u00fdchlipky. Trak\u010dn\u00ed divertikl vznik\u00e1 tahem za st\u011bnu j\u00edcnu v d\u016fsledku z\u00e1n\u011btliv\u00e9ho adhezivn\u00edho retrak\u010dn\u00edho procesu v jeho okol\u00ed. Traumatick\u00e1 etiologie se mimo vz\u00e1cn\u00e1 p\u0159\u00edm\u00e1 poran\u011bn\u00ed uplatn\u00ed p\u0159edev\u0161\u00edm jako d\u016fsledek necht\u011bn\u00e9ho peropera\u010dn\u00edho poran\u011bn\u00ed st\u011bny j\u00edcnu nebo jako n\u00e1sledek prov\u00e1d\u011bn\u00e9 operace, nej\u010dast\u011bji myotomie u achal\u00e1zie. P\u0159ipou\u0161t\u00ed se i kongenit\u00e1ln\u00ed p\u016fvod v\u00fdchlipky, zejm\u00e9na u st\u0159edn\u00edho hrudn\u00edho divertiklu (tab. 1).<\/p>\n\n\n\n\n\n\n\n\n
    Tab. 1<\/span>
    \nEtiopatogeneze j\u00edcnov\u00fdch divertikl\u016f<\/span><\/td>\n<\/tr>\n
    Typ divertiklu<\/strong><\/td>\nEtiopatogeneze<\/strong><\/td>\n<\/tr>\n
    pulzn\u00ed<\/strong><\/td>\ntrak\u010dn\u00ed<\/strong><\/td>\ntraumatick\u00e1<\/strong><\/td>\nkongenit\u00e1ln\u00ed<\/strong><\/td>\n<\/tr>\n
    Parafarynge\u00e1ln\u00ed<\/td>\n+++<\/td>\n–<\/td>\n–<\/td>\n–<\/td>\n<\/tr>\n
    Hrudn\u00ed<\/td>\n–<\/td>\n++<\/td>\n–<\/td>\n+<\/td>\n<\/tr>\n
    Epifren\u00e1ln\u00ed<\/td>\n++<\/td>\n—<\/td>\n+<\/td>\n+<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    .<\/span><\/p>\n

    12.2.1 Parafarynge\u00e1ln\u00ed Zenker\u016fv divertikl<\/h4>\n

    Zenker\u016fv divertikl je typick\u00fdm p\u0159edstavitelem pulzn\u00edho divertiklu<\/i>. Vznik\u00e1 v t\u011bsn\u00e9m sousedstv\u00ed mohutn\u00e9ho svalov\u00e9ho masivu hypofaryngu. V t\u011bchto m\u00edstech slo\u017eit\u00e1 anatomick\u00e1 skladba faryngo-ezofage\u00e1lniho p\u0159echodu vytv\u00e1\u0159\u00ed oslaben\u00e1 m\u00edsta zejm\u00e9na v podob\u011b horn\u00edho Killianova a doln\u00edho Laimerova troj\u00faheln\u00edku. Podle Perrota [7] je zde nejm\u00e9n\u011b p\u011bt predilek\u010dn\u00edch m\u00edst s relativn\u011b defektn\u00ed svalovinou predisponuj\u00edc\u00ed ke vzniku v\u00fdchlipky. Tento nesporn\u00fd anatomick\u00fd \u010dinitel v\u0161ak nen\u00ed jedin\u00fdm kauz\u00e1ln\u00edm faktorem vzniku divertikl\u016f. Druh\u00fdm nejv\u00edce zd\u016fraz\u0148ovan\u00fdm \u010dinitelem je naru\u0161en\u00e1 funkce horn\u00edho j\u00edcnov\u00e9ho sv\u011bra\u010de. Vz\u00e1jemn\u00e1 funk\u010dn\u00ed koordinace tohoto \u00faseku j\u00edcnu, kter\u00e1 norm\u00e1ln\u011b zaji\u0161\u0165uje voln\u00fd pr\u016fchod sousta z hypofaryngu do j\u00edcnu, chyb\u00ed. V\u00fdsledkem je tzv. krikofarynge\u00e1ln\u00ed achal\u00e1zie<\/i>, jak ji ozna\u010dil Asherson [8]. Sutherland [9, 7] p\u0159esn\u00fdmi rentgenologick\u00fdmi a manometrick\u00fdmi studiemi zp\u0159esnil jeho p\u0159edstavu tak, \u017ee p\u0159ece jen u t\u011bchto nemocn\u00fdch doch\u00e1z\u00ed ke krikofarynge\u00e1ln\u00ed relaxaci, ale opo\u017ed\u011bn\u011b. Proto p\u0159i druh\u00e9 f\u00e1zi deglutinace u t\u011bchto nemocn\u00fdch ne\u00fam\u011brn\u011b nar\u016fst\u00e1 intralumin\u00f3zn\u00ed tlak, vedouc\u00ed ve slab\u0161\u00edch m\u00edstech st\u011bny ke vzniku pseudodivertiklu. Ten je zprvu mal\u00fd, trvaj\u00ed-li tyto nep\u0159\u00edzniv\u00e9 podm\u00ednky, doch\u00e1z\u00ed k jeho zv\u011bt\u0161ov\u00e1n\u00ed a postupn\u011b k \u00fatlaku j\u00edcnu. Proto maj\u00ed nemocn\u00ed stup\u0148uj\u00edc\u00ed se dysfagii. Sousto pronik\u00e1 p\u0159edev\u0161\u00edm do divertiklu a velmi \u010dasto m\u016f\u017ee doj\u00edt k aspiraci zde stagnuj\u00edc\u00edho obsahu. Rovn\u011b\u017e nov\u011bj\u0161\u00ed pr\u00e1ce vych\u00e1zej\u00edc\u00ed ze zlep\u0161en\u00fdch technick\u00fdch mo\u017enost\u00ed funk\u010dn\u00edho vy\u0161et\u0159en\u00ed v oblasti horn\u00edho j\u00edcnov\u00e9ho sv\u011bra\u010de (HJS) pova\u017euj\u00ed inkompletn\u00ed relaxaci HJS v pr\u016fb\u011bhu polykac\u00edho aktu za hlavn\u00ed p\u0159\u00ed\u010dinu p\u0159i vzniku a v\u00fdvoji Zenkerova divertiklu [10, 11, 12, 13].<\/p>\n

    Traduje se n\u00e1zor, \u017ee hypofarynge\u00e1ln\u00ed v\u00fdchlipka je tvo\u0159ena jen zm\u011bn\u011bnou sliznic\u00ed a submuk\u00f3zou prostupuj\u00edc\u00ed mezi svalov\u00fdmi snopci a \u017ee jde o pseudodivertikl \u010di tzv. nepravou v\u00fdchlipku<\/i>. Podrobn\u00e9 makroskopick\u00e9 a mikroskopick\u00e9 studium na\u0161ich opera\u010dn\u00edch prepar\u00e1t\u016f v\u0161ak tento n\u00e1zor nepotvrzuje. V 80. letech minul\u00e9ho stolet\u00ed jsme retrospektivn\u011b provedli podrobn\u00e9 makroskopick\u00e9 a mikroskopick\u00e9 studium opera\u010dn\u00edch prepar\u00e1t\u016f na\u0161ich operovan\u00fdch a v\u00fdsledky patologick\u00fdch vy\u0161et\u0159en\u00ed tradovan\u00fd n\u00e1zor, \u017ee jde o vychl\u00edpky neprav\u00e9, nepotvrzovaly [14, 15]. Byla provedena retrospektivn\u00ed revize histologick\u00fdch vy\u0161et\u0159en\u00ed 40 resekovan\u00fdch Zenkerov\u00fdch divertikl\u016f z na\u0161eho materi\u00e1lu a uk\u00e1zalo se, \u017ee \u0161lo v\u017edy o divertikl prav\u00fd<\/i>, jeho\u017e st\u011bna byla mimo sliznici a submuk\u00f3zu tvo\u0159ena i svalovinou. V\u011bt\u0161inou byly ve st\u011bn\u011b v\u00fdchlipky z\u0159eteln\u00e9 zn\u00e1mky z\u00e1n\u011btliv\u00e9 infiltrace. Zten\u010den\u00ed svalov\u00e9 vrstvy a jej\u00ed fibrotizace je z\u0159ejm\u011b projevem sekund\u00e1rn\u00edm, v souvislosti se z\u00e1n\u011btem a funk\u010dn\u00ed atrofi\u00ed hladk\u00e9 svaloviny ve vaku divertiklu. V tomto smyslu je proto t\u0159eba pohled na klasifikaci Zenkerova divertiklu poopravit.<\/p>\n

    Zaj\u00edmav\u00e9 jsou n\u00e1zory na vztah mezi funkc\u00ed doln\u00edho a horn\u00edho j\u00edcnov\u00e9ho sv\u011bra\u010de<\/i>. Hunt a Smiley se spolupracovn\u00edky [16] na z\u00e1klad\u011b rentgenologick\u00fdch a rentgenokinematografick\u00fdch vy\u0161et\u0159en\u00ed zjistili hypertonus HJS u refluxn\u00ed ezofagitidy, kr\u010dn\u00ed dysfagie a parafarynge\u00e1ln\u00edch divertikl\u016f ve srovn\u00e1n\u00ed s kontroln\u00ed skupinou. Po \u00faprav\u011b hi\u00e1tov\u00e9 hernie nebo vzniku striktury doln\u00edho j\u00edcnu a vymizen\u00ed pyr\u00f3zy doch\u00e1zelo k poklesu tohoto tlaku nebo i k jeho normalizaci. Usuzovali na vztah mezi hi\u00e1tovou herni\u00ed a vznikem parafarynge\u00e1ln\u00edho divertiklu. Domn\u00edvali se, \u017ee GER je d\u016fle\u017eit\u00fdm, ne-li prim\u00e1rn\u00edm, faktorem vedouc\u00edm ke vzniku krikofarynge\u00e1ln\u00ed dysfunkce a vytvo\u0159en\u00ed parafarynge\u00e1ln\u00edho divertiklu. Podle t\u00e9to p\u0159edstavy p\u0159i insuficienci DJS se kompenzatorn\u011b zvy\u0161uje tlak v oblasti HJS a vytv\u00e1\u0159\u00ed se tak posledn\u00ed z\u00e1brana proniknut\u00ed \u017ealude\u010dn\u00edho obsahu do hypofaryngu. V rozporu s t\u00edm byly v\u00fdsledky Stanciovy a Bennettovy [17], kte\u0159\u00ed nenalezli rozd\u00edl ve v\u00fd\u0161i tlaku HJS u kontroln\u00ed skupiny proti\u00a069 vy\u0161et\u0159en\u00fdm s GER. Rovn\u011b\u017e Silber [18] mezi 1500 nemocn\u00fdmi s HH zjistil jen\u00a03 pacienty s parafarynge\u00e1ln\u00edm divertiklem. U \u0159ady nemocn\u00fdch v\u0161ak zjistil zn\u00e1mky\u00a0krikofarynge\u00e1ln\u00edho spazmu a dysfunkce bez vytvo\u0159en\u00ed divertiklu. Obdobn\u00e9 zku\u0161enosti uv\u00e1d\u011bl i Mullard [18]. Skute\u010dnost, \u017ee porucha koordinace mezi kontrakc\u00ed\u00a0HJS a vyprazd\u0148ov\u00e1n\u00edm hltanu hraje p\u0159i vzniku Zenkerovy v\u00fdchlipky velkou roli, je\u00a0v\u0161eobecn\u011b akceptov\u00e1na. Naproti tomu z\u016fst\u00e1v\u00e1 zat\u00edm nejasn\u00e9, nakolik a p\u0159\u00edpadn\u011b\u00a0jakou roli v tom hraje gastroezofage\u00e1ln\u00ed reflux [13]. \u0158ada autor\u016f se domn\u00edv\u00e1, \u017ee HJS\u00a0hraje d\u016fle\u017eitou roli p\u0159i ochran\u011b proti aspiraci do dechov\u00fdch cest p\u0159i gastroezofage\u00e1ln\u00edm refluxu [19]. Za tohoto p\u0159edpokladu by kr\u010dn\u00ed myotomie prov\u00e1d\u011bn\u00e1 p\u0159i operaci\u00a0parafarynge\u00e1ln\u00ed v\u00fdchlipky mohla b\u00fdt pro n\u011bkter\u00e9 pacienty nebezpe\u010dn\u00e1. Spolehliv\u00e9\u00a0d\u016fkazy pro tuto teorii v\u0161ak dosud chyb\u00ed.<\/p>\n

    P\u0159i hodnocen\u00ed v\u00fdsledk\u016f 51 operovan\u00fdch se Zenkerov\u00fdm divertiklem jsme zjistili\u00a0GER \u0161estkr\u00e1t (11,8 %). U dvou z nich si obt\u00ed\u017ee vy\u017e\u00e1daly zalo\u017een\u00ed antirefluxn\u00ed fundoplikace. Byli to jedin\u00ed dva nemocn\u00ed ze souboru 395 operovan\u00fdch pro RNJ nebo skluznou HH, kte\u0159\u00ed byli vyhodnocov\u00e1ni ve stejn\u00e9m obdob\u00ed, se sou\u010dasn\u00fdm Zenkerov\u00fdm\u00a0divertiklem, co\u017e p\u0159edstavovalo 0,5% v\u00fdskyt hypofarynge\u00e1ln\u00edho divertiklu v sestav\u011b operovan\u00fdch s RNJ [20, 21, 22, 23].<\/p>\n

    Jako zvl\u00e1\u0161tn\u00ed druh divertiklu v t\u00e9to oblasti, odli\u0161n\u00fd od Zenkerovy v\u00fdchlipky, byl pops\u00e1n v roce 1983 divertikl vyklenuj\u00edc\u00ed se v anterolater\u00e1ln\u00edm obvodu j\u00edcnu pod \u00farovn\u00ed krykofarynge\u00e1ln\u00edho svalu, co\u017e odpov\u00edd\u00e1 prvn\u00edmu popisu t\u00e9to patologie Killianem v roce 1908 a Jamiesonem v roce 1934, a proto je tato v\u00fdchlipka ozna\u010dov\u00e1na jako Killian-Jamieson\u016fv divertikl. P\u0159\u00ed\u010dina vzniku nen\u00ed zn\u00e1ma a v souvislosti s touto v\u00fdchlipkou nebyly prok\u00e1z\u00e1ny \u017e\u00e1dn\u00e9 funk\u010dn\u00ed poruchy j\u00edcnu, \u010demu\u017e odpov\u00eddaj\u00ed minim\u00e1ln\u00ed klinick\u00e9 p\u0159\u00edznaky [24].<\/p>\n

    12.2.2 Hrudn\u00ed divertikl<\/h4>\n

    V\u00fdchlipka j\u00edcnu v oblasti bifurkace trachey byla v\u017edy uv\u00e1d\u011bna jako typick\u00fd trak\u010dn\u00ed divertikl. Vznik\u00e1 c\u00edpovit\u00fdm vyta\u017een\u00edm st\u011bny j\u00edcnu nej\u010dast\u011bji specifick\u00fdm z\u00e1n\u011btliv\u00fdm retrak\u010dn\u00edm procesem v mediastin\u00e1ln\u00edch uzlin\u00e1ch. \u00dabytek tuberkul\u00f3zy ve v\u0161ech jej\u00edch form\u00e1ch v posledn\u00edch desetilet\u00edch p\u0159i nezmen\u0161en\u00e9m v\u00fdskytu epibronchi\u00e1ln\u00edch v\u00fdchlipek vedl k n\u00e1zoru, \u017ee jsou \u010dasto kongenit\u00e1ln\u00edho p\u016fvodu [25]. Vznikaj\u00ed jako d\u016fsledek nedokonal\u00e9ho rozd\u011blen\u00ed za\u017e\u00edvac\u00ed a d\u00fdchac\u00ed trubice a perzistuj\u00edc\u00ed v\u00fdchlipka j\u00edcnu je sou\u010d\u00e1st\u00ed fibr\u00f3zn\u00edho pruhu mezi j\u00edcnem a tracheou \u010di bronchem. Jde vlastn\u011b o ur\u010ditou formu nekompletn\u00ed ezofagotrache\u00e1ln\u00ed p\u00ed\u0161t\u011ble.<\/p>\n

    12.2.3 Epifren\u00e1ln\u00ed divertikl<\/h4>\n

    Tato v\u00fdchlipka vznik\u00e1 v doln\u00ed t\u0159etin\u011b j\u00edcnu, obvykle n\u011bkolik centimetr\u016f nad \u00farovn\u00ed hi\u00e1tu. Jde nej\u010dast\u011bji o pulzn\u00ed juxtasfinkterick\u00fd typ divertiklu, u n\u011bho\u017e se za nejv\u00fdznamn\u011bj\u0161\u00ed etiopatogenetick\u00fd faktor pova\u017euje porucha funkce DJS, podobn\u011b jako u divertiklu Zenkerova porucha funkce HJS. V publikac\u00edch z Mayo kliniky [26,\u00a027] mezi epifren\u00e1ln\u00edmi divertikly uv\u00e1d\u011bli v 77 % n\u011bkterou funk\u010dn\u00ed poruchu j\u00edcnu. Ezofagokardi\u00e1ln\u00ed achal\u00e1zie m\u016f\u017ee b\u00fdt vyvol\u00e1vaj\u00edc\u00edm faktorem p\u0159i vzniku epifren\u00e1ln\u00ed v\u00fdchlipky. V posledn\u00edch desetilet\u00edch byla zve\u0159ejn\u011bna \u0159ada prac\u00ed prokazuj\u00edc\u00edch souvislost vzniku epifren\u00e1ln\u00edho divertiklu s funk\u010dn\u00edmi poruchami j\u00edcnu. V pr\u00e1ci z roku\u00a02002 Nehra a kol. vyu\u017eili v prospektivn\u00ed studii 24hodinovou ambulantn\u00ed manometrii u 21 pacient\u016f s diagn\u00f3zou epifren\u00e1ln\u00edho divertiklu a s pou\u017eit\u00edm t\u00e9to metody u v\u0161ech nalezli abnormality v j\u00edcnov\u00e9 motorice. Nej\u010dast\u011bji se jednalo o achal\u00e1zii (43 %), n\u00e1sledoval hypertenzn\u00ed DJS, difuzn\u00ed ezofage\u00e1ln\u00ed spazmus a nespecifick\u00e9 poruchy motility. Tento zp\u016fsob vy\u0161et\u0159en\u00ed m\u016f\u017ee zp\u0159esnit diagn\u00f3zu u t\u011bch pacient\u016f, kde b\u011b\u017en\u00e9 funk\u010dn\u00ed vy\u0161et\u0159en\u00ed j\u00edcnu je norm\u00e1ln\u00ed nebo necharakteristick\u00e9. Auto\u0159i se domn\u00edvaj\u00ed, \u017ee tyto poruchy hraj\u00ed z\u00e1sadn\u00ed roli p\u0159i vzniku epifren\u00e1ln\u00edho divertiklu [28]. Skute\u010dnost, \u017ee v\u011bt\u0161ina epifren\u00e1ln\u00edch divertikl\u016f vznik\u00e1 v souvislosti s funk\u010dn\u00ed poruchou j\u00edcnov\u00e9 motility, potvrzuje i dal\u0161\u00ed \u0159ada v posledn\u00edch letech publikovan\u00fdch prac\u00ed, i kdy\u017e u n\u011bkter\u00fdch divertikl\u016f st\u00e1le funk\u010dn\u00ed porucha nen\u00ed uv\u00e1d\u011bna. Je jen ot\u00e1zkou, nakolik maj\u00ed v\u0161echna pracovi\u0161t\u011b mo\u017enost p\u0159edopera\u010dn\u011b vyu\u017e\u00edt nejmodern\u011bj\u0161\u00ed funk\u010dn\u00ed vy\u0161et\u0159en\u00ed [29, 30, 31, 32, 33, 34, 35, 36, 37, 38].<\/p>\n

    \"Obr.<\/a>

    Obr. 1
    Epifren\u00e1ln\u00ed divertikl vznikl\u00fd po ezofagokardi\u00e1ln\u00ed myotomii pro achal\u00e1zii<\/p><\/div>\n

    Mezi 14 operovan\u00fdmi s epifren\u00e1ln\u00edm divertiklem, kter\u00e9 jsme hodnotili v osmdes\u00e1t\u00fdch letech minul\u00e9ho stolet\u00ed [39, 40], jsme p\u0159edopera\u010dn\u011b prok\u00e1zali poruchu funkce DJS ve smyslu achal\u00e1zie nebo hypertonie DJS u 5 nemocn\u00fdch (35,7 %). Jen t\u0159etinu na\u0161eho souboru jsme m\u011bli mo\u017enost tehdy vy\u0161et\u0159it i manometricky. V\u00fdborn\u00e9ho klinick\u00e9ho a rentgenologick\u00e9ho v\u00fdsledku jsme dos\u00e1hli i pouhou resekc\u00ed \u010di inverz\u00ed divertiklu bez sou\u010dasn\u00e9 myotomie u 9 operovan\u00fdch. Na\u0161e tehdej\u0161\u00ed hodnocen\u00ed bylo, \u017ee tato porucha funkce DJS nen\u00ed jedin\u00fdm etiologick\u00fdm faktorem vzniku epifren\u00e1ln\u00edho divertiklu a je mo\u017eno p\u0159ipustit jin\u00fd, nejsp\u00ed\u0161e kongenit\u00e1ln\u00ed p\u016fvod v\u00fdchlipky, proto\u017ee anamn\u00e9za nemocn\u00fdch ani peropera\u010dn\u00ed n\u00e1lez nesv\u011bd\u010dily pro traumatickou \u010di trak\u010dn\u00ed etiologii. Z dne\u0161n\u00edho pohledu je v\u0161ak sp\u00ed\u0161e pravd\u011bpodobn\u00e9, \u017ee funk\u010dn\u00ed porucha nebyla u n\u011bkter\u00fdch pacient\u016f odhalena, proto\u017ee v t\u00e9 dob\u011b nebylo mo\u017en\u00e9 tak dokonal\u00e9 funk\u010dn\u00ed vy\u0161et\u0159en\u00ed j\u00edcnu. Opera\u010dn\u00ed trauma zeslabuj\u00edc\u00ed st\u011bnu j\u00edcnu p\u0159i myotomii u EKA m\u016f\u017ee b\u00fdt spolu s nekompletn\u00edm prot\u011bt\u00edm doln\u00ed \u010d\u00e1sti DJS p\u0159\u00ed\u010dinou vzniku pulzn\u00ed epifren\u00e1ln\u00ed v\u00fdchlipky v m\u00edst\u011b myotomie. N\u011bkolikr\u00e1t jsme u na\u0161ich operovan\u00fdch s achal\u00e1zi\u00ed tento obraz pozorovali, v\u017edy v\u0161ak bez subjektivn\u00edch obt\u00ed\u017e\u00ed (obr. 1).<\/p>\n

    Podobn\u00fd men\u0161\u00ed divertikl trak\u010dn\u00ed etiologie m\u016f\u017ee b\u00fdt d\u016fsledkem zalo\u017een\u00ed steh\u016f do st\u011bny j\u00edcnu p\u0159i hernioplastice nebo jin\u00e9m opera\u010dn\u00edm v\u00fdkonu v t\u00e9to oblasti. Byl pops\u00e1n i p\u0159\u00edpad epifrenick\u00e9ho divertiklu vznikl\u00e9ho p\u011bt let po zalo\u017een\u00ed adjustabiln\u00ed band\u00e1\u017ee pro obezitu. Pro nebezpe\u010d\u00ed vzniku perforace musela b\u00fdt band\u00e1\u017e odstran\u011bna [41].<\/p>\n

    12.3 V\u00fdskyt<\/h3>\n

    Spolehliv\u00e9 epidemiologick\u00e9 \u00fadaje o v\u00fdskytu j\u00edcnov\u00fdch divertikl\u016f nebyly publikov\u00e1ny. Jde o onemocn\u011bn\u00ed vz\u00e1cn\u00e9 a zve\u0159ejn\u011bn\u00e1 data jsou sp\u00ed\u0161e odhady op\u00edraj\u00edc\u00ed se o klinick\u00e9 zku\u0161enosti. Frekvence j\u00edcnov\u00fdch v\u00fdchlipek v rentgenologick\u00e9m a sek\u010dn\u00edm materi\u00e1lu obvykle nep\u0159esahuje 1%. Mezi v\u0161emi j\u00edcnov\u00fdmi divertikly jsou nej\u010dast\u011bj\u0161\u00ed parafarynge\u00e1ln\u00ed v\u00fdchlipky (70%), n\u00e1sleduj\u00ed hrudn\u00ed a epifren\u00e1ln\u00ed divertikly, jejich\u017e rozli\u0161ov\u00e1n\u00ed se v n\u011bkter\u00fdch publikac\u00edch r\u016fzn\u00ed [9]. V s\u00e9rii divertikl\u016f pozorovan\u00fdch na Mayo klinice v pr\u016fb\u011bhu 40 let byl pom\u011br Zenkerov\u00fdch divertikl\u016f k epifren\u00e1ln\u00edm 5:1 [42]. V na\u0161em opera\u010dn\u00edm materi\u00e1lu z let 1948\u20131982 byly na prvn\u00edm m\u00edst\u011b v\u00fdchlipky Zenkerovy, n\u00e1sledovaly epifren\u00e1ln\u00ed a hrudn\u00ed, kter\u00e9 je nutno operovat jen zcela v\u00fdjime\u010dn\u011b (tab. 2). V obdob\u00ed let 1986\u20131994 jsme na II. chirurgick\u00e9 klinice v Olomouci operovali 12 nemocn\u00fdch s j\u00edcnov\u00fdmi divertikly, 11 bylo Zenkerov\u00fdch, a jen jednou se jednalo o epifren\u00e1ln\u00ed v\u00fdchlipku [43]. Analyzujeme-li publikovan\u00e9 sestavy o j\u00edcnov\u00fdch divertiklech, jen zcela v\u00fdjime\u010dn\u011b je frekvence t\u011bchto operac\u00ed na jednotliv\u00fdch pracovi\u0161t\u00edch v\u00edce ne\u017e n\u011bkolik p\u0159\u00edpad\u016f ro\u010dn\u011b a p\u0159ev\u00e1\u017en\u011b jde o Zenkerovy v\u00fdchlipky.<\/p>\n\n\n\n\n\n\n\n\n
    Tab. 2<\/span>
    \nSoubor operovan\u00fdch z let 1948\u20131982 na I. chirurgick\u00e9 klinice FN\u00a0v Olomouci pro j\u00edcnov\u00e9 divertikly, kter\u00fd byl dlouhodob\u011b sledov\u00e1n [40]<\/span><\/span><\/td>\n<\/tr>\n
    Lokalizace<\/span><\/td>\nNo<\/strong><\/td>\nMu\u017ei<\/strong><\/td>\n\u017deny<\/strong><\/td>\nV\u011bk O<\/strong><\/td>\n\u00damrt\u00ed<\/strong><\/td>\nMortalita %<\/strong><\/td>\n<\/tr>\n
    Parafarynge\u00e1ln\u00ed<\/td>\n51<\/td>\n36<\/td>\n15<\/td>\n62,4<\/td>\n2<\/td>\n3,9 %<\/td>\n<\/tr>\n
    Hrudn\u00ed<\/td>\n7<\/td>\n5<\/td>\n2<\/td>\n57<\/td>\n2<\/td>\n28,6 %<\/td>\n<\/tr>\n
    Epifren\u00e1ln\u00ed<\/td>\n14<\/td>\n6<\/td>\n8<\/td>\n51<\/td>\n0<\/td>\n0<\/td>\n<\/tr>\n
    Celkem<\/td>\n72<\/td>\n47<\/td>\n25<\/td>\n59,9<\/td>\n4<\/td>\n5,6 %<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    .<\/span><\/p>\n

    12.4 Klinick\u00fd obraz, symptomatologie a diagnostika<\/h3>\n
    \"Obr.<\/a>

    Obr. 2
    Symptomatologie nemocn\u00fdch s j\u00edcnov\u00fdmi divertikly v yj\u00e1d\u0159en\u00e1 v pro centech [45]<\/p><\/div>\n

    J\u00edcnov\u00e9 divertikly jsou onemocn\u011bn\u00edm p\u0159ev\u00e1\u017en\u011b vy\u0161\u0161\u00edch v\u011bkov\u00fdch kategori\u00ed. V souboru uveden\u00e9m v tab. 2 bylo 51% nemocn\u00fdch star\u0161\u00edch 60 let a zvl\u00e1\u0161t\u011b vysok\u00fd byl tento po\u010det u parafarynge\u00e1ln\u00edho typu, kter\u00fd je p\u0159ev\u00e1\u017en\u011b geriatrick\u00fdm onemocn\u011bn\u00edm [44]. Pr\u016fm\u011brn\u00fd v\u011bk v\u0161ech operovan\u00fdch byl 60 let. P\u0159eva\u017eovali mu\u017ei po\u010dtem 47, \u017een bylo 25.<\/p>\n

    Symptomatologie Zenkerova divertiklu je zpravidla i p\u0159i jeho mal\u00fdch rozm\u011brech v\u00fdrazn\u00e1, proto\u017ee je d\u00e1na zpo\u010d\u00e1tku hlavn\u011b poruchou funkce HJS. Dysfagick\u00e9 a respira\u010dn\u00ed obt\u00ed\u017ee z regurgitace a aspirace obsahu stagnuj\u00edc\u00edho v divertiklu do plic zt\u011b\u017euj\u00ed \u017eivot nemocn\u00fdm a vedou ke vzniku bronchopneumonie a kachexie. Divertikl st\u0159edn\u00edho j\u00edcnu je naproti tomu zpravidla asymptomatick\u00fd a je n\u00e1hodn\u00fdm n\u00e1lezem p\u0159i rentgenov\u00e9m vy\u0161et\u0159en\u00ed. Teprve dos\u00e1hne-li velk\u00fdch rozm\u011br\u016f, \u010din\u00ed pot\u00ed\u017ee z tlaku prov\u011b\u0161en\u00e9 v\u00fdchlipky na j\u00edcen a okol\u00ed. U epifren\u00e1ln\u00edho divertiklu i nevelk\u00fdch rozm\u011br\u016f, kter\u00e9 jsou spojeny s hypertoni\u00ed DJS \u010di jinou funk\u010dn\u00ed poruchou ezofagu, pramen\u00ed dysfagie p\u0159edev\u0161\u00edm z t\u00e9to poruchy a u nevelk\u00e9ho divertiklu dojde k jej\u00ed \u00faprav\u011b i po pouh\u00e9 ezofagokardi\u00e1ln\u00ed myotomii bez resekce v\u00fdchlipky. Objemn\u011bj\u0161\u00ed divertikly \u010din\u00ed pot\u00ed\u017ee i bez sou\u010dasn\u00e9 dysfunkce DJS sv\u00fdm tlakem na j\u00edcen a okol\u00ed. Frekvence p\u0159\u00edznak\u016f u jednotliv\u00fdch typ\u016f divertiklu v na\u0161\u00ed sestav\u011b je patrn\u00e1 z obr. 2 a odpov\u00edd\u00e1 \u00fadaj\u016fm, kter\u00e9 uv\u00e1d\u011bj\u00ed i jin\u00ed auto\u0159i.<\/span><\/p>\n

    Diagnostika j\u00edcnov\u00fdch divertikl\u016f je zalo\u017eena na kontrastn\u00ed rtg pas\u00e1\u017ei j\u00edcnem, kter\u00e1 nejl\u00e9pe objasn\u00ed rozsah a lokalizaci divertiklu. Mal\u00fd divertikl m\u016f\u017ee b\u00fdt v\u0161ak p\u0159ehl\u00e9dnut a zam\u011bn\u011bn se spazmem j\u00edcnu. U Zenkerova divertiklu, kde je jeho vztah k<\/span>\u00a0poru\u0161e HJS jednozna\u010dn\u00fd, obvykle nen\u00ed nutn\u00e9 manometrick\u00e9 vy\u0161et\u0159en\u00ed j\u00edcnu [12]. U divertiklu st\u0159edn\u00edho j\u00edcnu a zejm\u00e9na v epifren\u00e1ln\u00ed lokalizaci je d\u016fle\u017eit\u00e9 p\u0159esn\u00e9 posouzen\u00ed funkce j\u00edcnu manometri\u00ed. Pokud obvykl\u00e1 stacion\u00e1rn\u00ed manometrie [46] dostate\u010dn\u011b neposoud\u00ed funk\u010dn\u00ed stav ezofagu, pak je vhodn\u00fdm vy\u0161et\u0159en\u00edm 24hodinov\u00e1 manometrie. P\u0159i tomto vy\u0161et\u0159en\u00ed je mo\u017eno posoudit v\u00edce ne\u017e 1000 polknut\u00ed b\u011bhem a mezi j\u00eddlem v pr\u016fb\u011bhu 24 hodin, zat\u00edmco stacion\u00e1rn\u00ed manometrie stanovuje diagn\u00f3zu ne z v\u00edce ne\u017e 10 polknut\u00ed [47, 48, 49]. Endoskopick\u00e9 vy\u0161et\u0159en\u00ed je pro zji\u0161t\u011bn\u00ed divertikl\u016f m\u00e9n\u011b v\u00fdznamn\u00e9 a zvl\u00e1\u0161t\u011b u Zenkerova divertiklu m\u016f\u017ee b\u00fdt \u00fazk\u00fd vstup do v\u00fdchlipky snadno p\u0159ehl\u00e9dnut. V\u00fdznam endoskopie v\u0161ak spo\u010d\u00edv\u00e1 ve zji\u0161t\u011bn\u00ed jin\u00fdch mo\u017en\u00fdch patologi\u00ed, jako jsou n\u00e1dory, ezofagitida apod. Vz\u00e1cn\u011b byla pops\u00e1na koincidence divertiklu s n\u00e1dorem [50, 51].<\/p>\n

    12.5 Chirurgick\u00e1 l\u00e9\u010dba<\/h3>\n

    12.5.1 Indikace<\/h4>\n

    P\u0159i stanoven\u00ed indikace k operaci uva\u017eujeme p\u0159edev\u0161\u00edm o intenzit\u011b obt\u00ed\u017e\u00ed nemocn\u00e9ho, nebezpe\u010d\u00ed mo\u017en\u00fdch komplikac\u00ed a zva\u017eujeme riziko prov\u00e1d\u011bn\u00e9 operace (tab. 3).<\/p>\n\n\n\n\n\n\n\n
    Tab. 3<\/span>
    \nIndikace k chirurgick\u00e9 l\u00e9\u010db\u011b j\u00edcnov\u00fdch divertikl\u016f<\/span><\/span><\/td>\n<\/tr>\n
    Typ divertiklu<\/td>\nObt\u00ed\u017ee \u2013
    \nkomplikace<\/td>\n    		Opera\u010dn\u00ed riziko<\/td>\nOpera\u010dn\u00ed indikace<\/td>\n<\/tr>\n
    Parafarynge\u00e1ln\u00ed<\/td>\n+ + +<\/td>\n+<\/td>\n+ + +<\/td>\n<\/tr>\n
    Hrudn\u00ed<\/td>\no +<\/td>\n+ + +<\/td>\no +<\/td>\n<\/tr>\n
    Epifren\u00e1ln\u00ed<\/td>\n+ +<\/td>\n+ +<\/td>\n+ + +<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    .<\/span><\/p>\n

    Zenker\u016fv divertikl p\u0159edstavuje zpravidla, bez ohledu na moment\u00e1ln\u00ed stupe\u0148 pot\u00ed\u017e\u00ed nemocn\u00e9ho, pro nebezpe\u010d\u00ed rozvoje komplikac\u00ed z aspirace a zhor\u0161uj\u00edc\u00ed se dysfagii v\u017edy indikaci k chirurgick\u00e9mu \u0159e\u0161en\u00ed [52]. Nel\u00e9\u010den\u00fd divertikl se v pr\u016fb\u011bhu let zv\u011bt\u0161uje. Podle velikosti b\u00fdv\u00e1 Zenker\u016fv divertikl klasifikov\u00e1n dle Brombarta [53]: I. stadium \u2013 2-3mm divertikl tvaru trnu r\u016f\u017ee, II. stadium \u2013 10mm kyjovit\u00e1 v\u00fdchlipka, III. stadium \u2013 v\u00edce ne\u017e 10 mm dlouh\u00e1 v\u00fdchlipka sm\u011b\u0159uj\u00edc\u00ed abor\u00e1ln\u011b pod\u00e9l j\u00edcnu, kter\u00fd nekomprimuje, ve IV. stadiu dosahuje divertikl podstatn\u011b v\u011bt\u0161\u00edch rozm\u011br\u016f, le\u017e\u00ed mezi p\u00e1te\u0159\u00ed a j\u00edcnem, kter\u00fd komprimuje. K operaci b\u00fdvaj\u00ed indikov\u00e1ny a\u017e divertikly III. a IV. stadia. D\u016fvodem k operaci jsou sp\u00ed\u0161e v\u00fdjime\u010dn\u011b velk\u00e9 rozm\u011bry v\u00fdchlipky, jak to ukazuje na\u0161e pozorov\u00e1n\u00ed (obr. 3) a obdobn\u00e9 zku\u0161enosti popsali i jin\u00ed chirurgov\u00e9 [54], \u010dast\u011bji p\u0159eva\u017euje v symptomatologii funk\u010dn\u00ed porucha HJS \u00a0\u00a0<\/span>spojen\u00e1 s divertiklem podstatn\u011b men\u0161\u00edch rozm\u011br\u016f (obr. 4). Riziko operace je pom\u011brn\u011b mal\u00e9 i u star\u00fdch nemocn\u00fdch a je d\u00e1no p\u0159ev\u00e1\u017en\u011b jen pr\u016fvodn\u00edmi intern\u00edmi onemocn\u011bn\u00edmi.<\/p>\n\n\n\n\n\n
    \n

    		\n

    \"Obr.

    Obr. 3b
    Peropera\u010dn\u00ed n\u00e1lez<\/p><\/div><\/td>\n<\/tr>\n

    \n

    		<\/td>\n<\/tr>\n
    \n

    		\n

    \"Obr.<\/a>

    Obr. 4b
    Stav po resekci v\u00fdchlipky a krikofarynge\u00e1ln\u00ed myotomii<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    Hrudn\u00ed divertikl<\/strong> je naopak nutno operovat jen v\u00fdjime\u010dn\u011b. Je zpravidla asymptomatick\u00fd a \u010dasto je n\u00e1hodn\u00fdm n\u00e1lezem p\u0159i rentgenov\u00e9m vy\u0161et\u0159en\u00ed a nepr\u00e1vem se na n\u011bj sv\u00e1d\u011bj\u00ed r\u016fzn\u00e9 obt\u00ed\u017ee nemocn\u00e9ho (obr. 5).<\/span><\/p>\n

    Z\u00e1n\u011btliv\u00e9 zm\u011bny v okol\u00ed j\u00edcnu p\u0159i trak\u010dn\u00ed etiologii v\u00fdchlipky jsou \u010dasto potencov\u00e1ny divertikulitidou ze stagnuj\u00edc\u00edho obsahu. To m\u016f\u017ee b\u00fdt zdrojem komplikac\u00ed v podob\u011b perforace, ezofagobronchi\u00e1ln\u00ed p\u00ed\u0161t\u011ble a z\u00e1n\u011btu mediastina. Sami jsme se s t\u011bmito komplikacemi nesetkali. D\u016fvodem k operaci pro n\u00e1s byly v\u017edy obt\u00ed\u017ee z tlaku divertiklu na j\u00edcen a okoln\u00ed org\u00e1ny. Opera\u010dn\u00ed v\u00fdkon m\u016f\u017ee b\u00fdt pro lok\u00e1ln\u00ed z\u00e1n\u011btliv\u00e9 zm\u011bny zna\u010dn\u011b n\u00e1ro\u010dn\u00fd a rizikov\u00fd a je nebezpe\u010d\u00ed poran\u011bn\u00ed bronchu (obr. 6).<\/p>\n\n\n\n\n\n\n
    \n

    		<\/td>\n<\/tr>\n
    \n

    		\n

    \"Obr.<\/a>

    Obr. 6b
    Peropera\u010dn\u00ed n\u00e1lez<\/p><\/div><\/td>\n<\/tr>\n

    \n

    		<\/td>\n<\/tr>\n
    \n

    		\n

    \"Obr.<\/a>

    Obr. 7b
    Stav po resekci v\u00fdchlipky a ezofagokardi\u00e1ln\u00ed myotomii<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    Epifren\u00e1ln\u00ed v\u00fdchlipka \u010din\u00ed i p\u0159i mal\u00fdch rozm\u011brech sv\u00e9mu nositeli pot\u00ed\u017ee, je-li spojena s achal\u00e1zi\u00ed, hypertoni\u00ed DJS \u010di jinou funk\u010dn\u00ed poruchou j\u00edcnu. Myotomie odstran\u00ed dysfagii a p\u0159i mal\u00fdch rozm\u011brech divertiklu se d\u0159\u00edve tradoval n\u00e1zor, \u017ee nen\u00ed nutn\u00e1 ani resekce v\u00fdchlipky, kter\u00e1 m\u016f\u017ee pozd\u011bji regredovat. P\u0159i objemn\u00e9m divertiklu resekce odstran\u00ed tlakov\u00e9 obt\u00ed\u017ee (obr. 7). O nutnosti myotomie rozhoduje funk\u010dn\u00ed stav DJS a j\u00edcnu.<\/p>\n

    12.5.2 Opera\u010dn\u00ed taktika a technika a v\u00fdsledky l\u00e9\u010dby<\/h4>\n

    12.5.2.1 Parafarynge\u00e1ln\u00ed divertikly<\/h5>\n

    Vedle klasick\u00e9 otev\u0159en\u00e9 operace existuje i mo\u017enost endoskopick\u00e9ho v\u00fdkonu.<\/p>\n

    Klasick\u00e1 otev\u0159en\u00e1 operace<\/h6>\n
    \"Obr.<\/a>

    Obr. 8
    Sch\u00e9ma krikofarynge\u00e1ln\u00ed myotomie u parafarynge\u00e1ln\u00edho divertiklu j\u00edcnu<\/p><\/div>\n

    Opera\u010dn\u00ed p\u0159\u00edstup: U Zenkerova divertiklu vol\u00edme p\u0159\u00edstup ke kr\u010dn\u00edmu j\u00edcnu \u0159ezem pod\u00e9l vnit\u0159n\u00edho okraje musculus sternocleidomastoideus od jugula k \u00fahlu \u010delisti. J\u00edcen je na krku l\u00e9pe p\u0159\u00edstupn\u00fd zleva a postup zprava je vhodn\u00fd jen p\u0159i zcela jednozna\u010dn\u00e9 propagaci v\u00fdchlipky vpravo od p\u00e1te\u0159e, co\u017e je v\u00fdjime\u010dn\u00e9. Operovali jsme takto \u00fasp\u011b\u0161n\u011b jednoho nemocn\u00e9ho, u kter\u00e9ho nebyla pom\u011brn\u011b objemn\u00e1 v\u00fdchlipka p\u0159i p\u0159edchoz\u00edch dvou operac\u00edch na jin\u00e9m pracovi\u0161ti p\u0159i p\u0159\u00edstupu zleva nalezena. Nemocn\u00e9ho ulo\u017e\u00edme se z\u00e1klonem hlavy a \u010d\u00e1ste\u010dnou rotac\u00ed na opa\u010dnou stranu. Po prot\u011bt\u00ed k\u016f\u017ee a musculus platysma je nutno protnout musculus omohyoideus. Do hloubky pronik\u00e1me mezi \u0161t\u00edtnou \u017el\u00e1zou, kter\u00e1 je medi\u00e1ln\u011b, a later\u00e1ln\u011b odtahujeme velk\u00e9 c\u00e9vy. J\u00edcen prob\u00edh\u00e1 mezi tracheou a p\u00e1te\u0159\u00ed a po odsunut\u00ed uveden\u00fdch struktur dokon\u010dujeme jeho izolaci v nezbytn\u00e9m rozsahu spolu se zde vyklenuj\u00edc\u00edm se divertiklem nejl\u00e9pe tupou preparac\u00ed. Vyhled\u00e1n\u00ed j\u00edcnu usnadn\u00ed zaveden\u00ed siln\u00e9 sondy anesteziologem. V t\u00e9to oblasti je nebezpe\u010d\u00ed poran\u011bn\u00ed vratn\u00e9ho nervu, kter\u00fd prob\u00edh\u00e1 mezi \u0161t\u00edtnou \u017el\u00e1zou a tracheou.<\/span><\/p>\n

    Opera\u010dn\u00ed technika (obr. 8): P\u0159i preparaci v\u00fdchlipky na faryngoezofage\u00e1ln\u00edm p\u0159echodu si postupn\u00fdm prot\u00edn\u00e1n\u00edm svalov\u00fdch vl\u00e1ken p\u0159ech\u00e1zej\u00edc\u00edch z j\u00edcnu n<\/span>a v\u00fdchlipku izolujeme kr\u010dek divertiklu a\u017e na submuk\u00f3zu. Pak n\u00e1sleduje krikofarynge\u00e1ln\u00ed myotomie, kterou doporu\u010dovali a postupn\u011b za\u010dali prov\u00e1d\u011bt Belsey [55], Ellis [56] a dal\u0161\u00ed j\u00edcnov\u00ed chirurgov\u00e9 b\u011bhem druh\u00e9 poloviny minul\u00e9ho stolet\u00ed [57, 58,\u00a059, 60]. V Olomouci se za\u010dala myotomie soustavn\u011b prov\u00e1d\u011bt od po\u010d\u00e1tku sedmdes\u00e1t\u00fdch let minul\u00e9ho stolet\u00ed.<\/p>\n

    N\u011bkte\u0159\u00ed auto\u0159i ponech\u00e1vali i dosti velk\u00fd divertikl in situ a poukazovali na to, \u017ee po spr\u00e1vn\u00e9 myotomii v\u00fdchlipka vymiz\u00ed [9, 56, 60, 61, 62]. Dnes se tak\u0159ka v\u00fdhradn\u011b myotomie kombinuje s resekc\u00ed v\u00fdchlipky. Myotomii prov\u00e1d\u00edme od b\u00e1ze kr\u010dku abor\u00e1ln\u00edm sm\u011brem na dorzolater\u00e1ln\u00ed stran\u011b j\u00edcnu v d\u00e9lce 30\u201335mm obdobnou technikou jako u ezofagokardi\u00e1ln\u00ed achal\u00e1zie. Pomoc\u00ed disektoru odsunujeme svalovinu od sliznice a postupn\u011b ji n\u016f\u017ekami prot\u00edn\u00e1me. Po dokon\u010den\u00ed myotomie resekujeme v\u00fdchlipku v m\u00edst\u011b kr\u010dku a suturu sliznice prov\u00e1d\u00edme jednotliv\u00fdmi atraumatick\u00fdmi stehy v jedn\u00e9 vrstv\u011b uzlen\u00fdmi dovnit\u0159 nebo i zevn\u011b j\u00edcnu. P\u0159i \u0161it\u00ed sliznice ponech\u00e1me v j\u00edcnu zavedenou silnou sondu, aby nedo\u0161lo ke z\u00fa\u017een\u00ed lumen ezofagu. Svalovinu ji\u017e ne\u0161ijeme a hlubok\u00fd kr\u010dn\u00ed prostor dr\u00e9nujeme Redonov\u00fdm dr\u00e9nem vyveden\u00fdm mimo opera\u010dn\u00ed \u0159ez [62, 23]. Dnes k resekci divertiklu zpravidla u\u017e\u00edv\u00e1me stapler. Re\u00e1ln\u00fd opera\u010dn\u00ed postup je zachycen na obr. 9.<\/p>\n\n\n\n\n\n
    \n

    \"Obr.<\/a>

    Obr. 9a
    Vypreparovan\u00fd Zenker\u016fv divertikl z \u0159ezu p\u0159ed k\u00fdva\u010dem na lev\u00e9 strann\u011b krku<\/p><\/div><\/td>\n

    		<\/td>\n\n

    \"Obr.<\/a>

    Obr. 9b
    Stav po prov e den\u00ed myotomie s prolabuj\u00edc\u00ed sliznic\u00ed j\u00edcnu<\/p><\/div><\/td>\n<\/tr>\n

    \n

    \"Obr.<\/a>

    Obr. 9c
    Okraje myotomie vyzna\u010deny p\u0159eru\u0161ovanou \u010darou<\/p><\/div><\/td>\n

    		<\/td>\n\n

    \"Obr.<\/a>

    Obr. 9d
    Stav po resekci v\u00fdchlipky pomoc\u00ed stapleru<\/p><\/div><\/td>\n<\/tr>\n

    \n

    \"Obr.<\/a>

    Obr. 9c
    Okraje myotomie vyzna\u010deny p\u0159eru\u0161ovanou \u010darou<\/p><\/div><\/td>\n

    		<\/td>\n\n

    \"Obr.<\/a>

    Obr. 9e
    Resekovan\u00fd divertikl<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    Endoskopick\u00e1 operace\"\"<\/h6>\n

    Od po\u010d\u00e1tku 90. let minul\u00e9ho stolet\u00ed se za\u010daly mno\u017eit zpr\u00e1vy o endoskopick\u00e9 l\u00e9\u010db\u011b Zenkerova divertiklu. Principem operace je vytvo\u0159en\u00ed spojen\u00ed \u2013 \u201eanastom\u00f3zy\u201c mezi divertiklem a j\u00edcnem (obr. 10).<\/p>\n

    \"Obr.<\/a>

    Obr. 10
    Endoskopick\u00e1 transor\u00e1ln\u00ed divertikulotomie<\/p><\/div>\n

    V celkov\u00e9 anestezii se zavede peror\u00e1ln\u011b speci\u00e1ln\u00ed endostapler, jeho\u017e jedna bran\u017ee se vsune do divertiklu a druh\u00e1 do j\u00edcnu. Pro\u0161it\u00edm a prot\u011bt\u00edm p\u0159ep\u00e1\u017eky mezi j\u00edcnem a divertiklem abor\u00e1ln\u011b od kr\u010dku divertiklu dojde vlastn\u011b i k prot\u011bt\u00ed HJS, a tedy myotomii a vytvo\u0159en\u00ed \u0161irok\u00e9ho spojen\u00ed mezi v\u00fdchlipkou a j\u00edcnem [63, 64,\u00a065, 66, 67].<\/p>\n

    U\u017eit\u00ed rigidn\u00edch stapler\u016f vy\u017eaduje mo\u017enost dostate\u010dn\u00e9ho z\u00e1klonu hlavy a otev\u0159en\u00ed\u00a0\u00fast. Tato mo\u017en\u00e1 omezen\u00ed pro n\u011bkter\u00e9 nemocn\u00e9 odstra\u0148uje zaveden\u00ed flexibiln\u00edch stapler\u016f [68]. K vytvo\u0159en\u00ed tohoto spojen\u00ed mezi j\u00edcnem a divertiklem je mo\u017en\u00e9 vyu\u017e\u00edt\u00a0i jin\u00e9 modern\u00ed technick\u00e9 prost\u0159edky, jako je harmonick\u00fd skalpel, elektrokoagulace\u00a0\u010di laser [69, 70, 71].<\/p>\n

    Endoskopick\u00e1 metoda l\u00e9\u010dby byla zavedena i olomouck\u00fdmi chirurgy [72, 73]. P\u016fvodn\u011b byla tato metoda doporu\u010dov\u00e1na pro pacienty, u kter\u00fdch byla kontraindikace\u00a0pro otev\u0159enou chirurgii. S p\u0159ib\u00fdvaj\u00edc\u00edmi zku\u0161enostmi s touto metodou se objevuj\u00ed\u00a0zpr\u00e1vy, \u017ee endoskopick\u00e9 \u0159e\u0161en\u00ed m\u00e1 v\u00fdhody proti otev\u0159en\u00e9 operaci v ni\u017e\u0161\u00ed frekvenci komplikac\u00ed a rychlej\u0161\u00ed rekonvalescenci p\u0159i srovnateln\u00fdch dlouhodob\u00fdch v\u00fdsledc\u00edch\u00a0[74, 75].<\/p>\n

    V\u00fdsledky chirurgick\u00e9 l\u00e9\u010dby parafarynge\u00e1ln\u00edch divertikl\u016f<\/h6>\n

    Chirurgick\u00e1 l\u00e9\u010dby Zenkerova divertiklu pro\u0161la dlouh\u00fdm a slo\u017eit\u00fdm v\u00fdvojem a vy\u00fastila v jednodobou resekci divertiklu kombinovanou s krikofarynge\u00e1ln\u00ed myotomi\u00ed (tab. 4).<\/p>\n

    Bezprost\u0159edn\u00ed klinick\u00e9 v\u00fdsledky pouh\u00e9 resekce divertiklu byly vcelku velmi dobr\u00e9, i kdy\u017e rentgenologicky byly zji\u0161\u0165ov\u00e1ny pom\u011brn\u011b \u010dast\u00e9 recidivy v\u00fdchlipky, kterou Vantrapen [76] uv\u00e1d\u00ed a\u017e v 45 %, p\u0159esto\u017ee nemocn\u00ed s rentgenologickou recidivou byli \u010dasto bez v\u011bt\u0161\u00edch obt\u00ed\u017e\u00ed. Byla analyzov\u00e1na p\u0159\u00ed\u010dina tohoto stavu [77, 55], a dal\u0161\u00ed v\u00fdvoj proto vedl k zaveden\u00ed krikofarynge\u00e1ln\u00ed myotomie odstra\u0148uj\u00edc\u00ed vlastn\u00ed p\u0159\u00ed\u010dinu vzniku divertiklu.<\/p>\n\n\n\n\n\n\n\n\n\n
    Tab. 4<\/span>
    \nZp\u016fsoby chirurgick\u00e9 l\u00e9\u010dby v minulosti navr\u017een\u00e9 a u\u017e\u00edvan\u00e9 v l\u00e9\u010db\u011b j\u00edcnov\u00fdch divertikl\u016f. Zv\u00fdrazn\u011bny postupy odpov\u00eddaj\u00edc\u00ed dne\u0161n\u00edm n\u00e1zor\u016fm na chirurgickou l\u00e9\u010dbu<\/span><\/td>\n<\/tr>\n
    Parafarynge\u00e1ln\u00ed divertikl<\/strong><\/td>\n<\/tr>\n
    \n
      \n
    1. Divertikulopexe<\/li>\n
    2. Divertikulopexe a krikofarynge\u00e1ln\u00ed myotomie<\/li>\n
    3. Divertikulectomie dvoudob\u00e1<\/li>\n
    4. Divertikulectomie jednodob\u00e1<\/li>\n
    5. Divertikulectomie jednodob\u00e1 a krikofarynge\u00e1ln\u00ed myotomie<\/li>\n
    6. Krikofarynge\u00e1ln\u00ed myotomie s ponech\u00e1n\u00edm mal\u00e9ho divertiklu<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n
    Hrudn\u00ed divertikl<\/strong><\/td>\n<\/tr>\n
    \n
      \n
    1. Inverze divertiklu<\/li>\n
    2. Diverticulektomie<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n
    Epifren\u00e1ln\u00ed divertikl<\/strong><\/td>\n<\/tr>\n
    \n
      \n
    1. Divertikulogastroanastom\u00f3za<\/li>\n
    2. Divertikulopexe<\/li>\n
    3. Divertikulopexe a ezofagokardi\u00e1ln\u00ed myotomie<\/li>\n
    4. Inverze divertiklu<\/li>\n
    5. Inverze divertiklu a ezofagokardi\u00e1ln\u00ed myotomie<\/li>\n
    6. Divertikulectomie<\/li>\n
    7. Divertikulectomie a ezofagokardi\u00e1ln\u00ed myotomie<\/li>\n
    8. Ezofagokardi\u00e1ln\u00ed myotomie s ponech\u00e1n\u00edm mal\u00e9ho divertiklu<\/li>\n
    9. Resekce j\u00edcnu s divertiklem a ezofagogastroanastom\u00f3za<\/li>\n
    10. Resekce j\u00edcnu s divertiklem a interpozice jejuna \u010di kolon<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

      .<\/span><\/p>\n

      Obdobn\u00fd v\u00fdvoj prob\u011bhl i v Olomouci. V letech 1948\u20131982 jsme operovali 51 nemocn\u00fdch se Zenkerov\u00fdm divertiklem. P\u0159i hodnocen\u00ed dlouhodob\u00fdch v\u00fdsledk\u016f chirurgick\u00e9 l\u00e9\u010dby jsme nemocn\u00e9 rozd\u011blili do dvou skupin. V s\u00e9rii prvn\u00edch 33 operovan\u00fdch do roku 1973 jsme provedli jednodobou resekci v\u00fdchlipky 29\u00d7. Dvakr\u00e1t bylo provedeno jen vchl\u00edpen\u00ed divertiklu, jednou gastrostomie pro \u0161patn\u00fd stav nemocn\u00e9 a jednou resekce j\u00edcnu s n\u00e1hradou ileokolonem u nemocn\u00e9ho s recidivou v\u00fdchlipky a strikturou kr\u010dn\u00edho j\u00edcnu po p\u0159edchoz\u00ed divertikulektomii na jin\u00e9m pracovi\u0161ti. Dlouhodob\u011b jsme sledovali 28 nemocn\u00fdch po resekci divertikl\u016f v odstupu 1\u201318 let po operaci (pr\u016fm\u011brn\u00fd odstup 5,5 rok\u016f). Nep\u0159\u00edzniv\u00fd klinick\u00fd v\u00fdsledek v podob\u011b v\u00fdrazn\u00fdch obt\u00ed\u017e\u00ed ud\u00e1vali 4 nemocn\u00ed (14,3 %) a rentgenologicky ov\u011b\u0159en\u00e1 recidiva byla u 7 kontrolovan\u00fdch (25 %). Nebyla jednozna\u010dn\u00e1 shoda klinick\u00fdch obt\u00ed\u017e\u00ed s nep\u0159\u00edzniv\u00fdm rentgenologick\u00fdm n\u00e1lezem. Od roku 1973 jsme vedle resekce v\u00fdchlipky prov\u00e1d\u011bli i krikofarynge\u00e1ln\u00ed myotomii. Poopera\u010dn\u00ed v\u00fdsledky jsme mohli hodnotit u 15 nemocn\u00fdch z 18 operovan\u00fdch v odstupu od 1 do 9 let (pr\u016fm\u011brn\u00fd odstup 3,7 rok\u016f). Do\u0161lo ke zlep\u0161en\u00ed klinick\u00fdch obt\u00ed\u017e\u00ed, nep\u0159\u00edzniv\u00fd klinick\u00fd v\u00fdsledek uvedlo jen 6 % kontrolovan\u00fdch a pr\u016fkaz rentgenologicky zji\u0161t\u011bn\u00e9 recidivy poklesl pod 20 % [22, 23, 40, 60]. Zji\u0161t\u011bn\u00e9 v\u00fdsledky ukazuj\u00ed, \u017ee p\u0159\u00eddatn\u00e1 myotomie zlep\u0161uje v\u00fdsledky chirurgick\u00e9 l\u00e9\u010dby. K obdobn\u00fdm z\u00e1v\u011br\u016fm dosp\u011bla i \u0159ada dal\u0161\u00edch autor\u016f. V literatu\u0159e je v\u00fdskyt recidivy divertikl\u016f po prost\u00e9 resekci uv\u00e1d\u011bn mezi 15\u201320 %. P\u0159i sou\u010dasn\u00e9 myotomii [78] kles\u00e1 frekvence recidivy divertikl\u016f a\u017e na 2,2 %.<\/p>\n

      Nej\u010dast\u011bj\u0161\u00ed poopera\u010dn\u00ed komplikac\u00ed je par\u00e9za n. recurrens, kterou Vantrapen [76] ud\u00e1v\u00e1 souhrn\u011b od 2,8 do 17 %. Mezi na\u0161imi operovan\u00fdmi jsme se s n\u00ed setkali \u010dty\u0159ikr\u00e1t (7,8 %) a v\u017edy se pozd\u011bji spont\u00e1nn\u011b upravila. P\u0159ed nep\u0159\u00edznivou slinnou p\u00ed\u0161t\u011bl\u00ed varuje p\u0159edev\u0161\u00edm Belsey [55]. Setkali jsme se s n\u00ed u dvou nemocn\u00fdch (3,9 %) a v\u017edy se po dren\u00e1\u017ei v pr\u016fb\u011bhu n\u011bkolika t\u00fddn\u016f uzav\u0159ela. Clagett a Payne [57] ud\u00e1vaj\u00ed mezi\u00a0478 operovan\u00fdmi s faryngoezofage\u00e1ln\u00edm divertiklem frekvenci par\u00e9zy n. recurrens v 2,3 % a ezofagokut\u00e1nn\u00ed p\u00ed\u0161t\u011bl v 0,8 %. Mortalita jejich sestavy byla 0,8 %.<\/p>\n

      Dal\u0161\u00ed v\u00fdsledky kr\u00e1tkodob\u00e9ho sledov\u00e1n\u00ed nemocn\u00fdch se Zenkerov\u00fdm divertiklem s p\u0159\u00edzniv\u00fdmi v\u00fdsledky po resekci v\u00fdchlipky a krikofarynge\u00e1ln\u00ed myotomii byly z Olomouce zve\u0159ejn\u011bny v roce 1994 u 12 nemocn\u00fdch z obdob\u00ed 1986\u20131994 [43] a posledn\u00ed pr\u00e1ce v roce 2008 hodnot\u00ed 17 operovan\u00fdch z let 2001\u20132006 [79]. Sv\u00e9 zku\u0161enosti s l\u00e9\u010dbou tohoto typu divertiklu zve\u0159ejnila v posledn\u00edch letech i dal\u0161\u00ed dv\u011b pra\u017esk\u00e1 pracovi\u0161t\u011b [80, 81].<\/p>\n

      12.5.2.2 Hrudn\u00ed divertikly<\/h5>\n

      Otev\u0159en\u00fd opera\u010dn\u00ed p\u0159\u00edstup: U hrudn\u00edho divertiklu je nejv\u00fdhodn\u011bj\u0161\u00ed p\u0159\u00edstup posterolater\u00e1ln\u00ed torakotomi\u00ed 6.\u20137. mezi\u017eeb\u0159\u00edm zprava \u010di zleva podle lateralizace v\u00fdchlipky dle p\u0159edopera\u010dn\u00edho vy\u0161et\u0159en\u00ed.<\/span><\/p>\n

      Opera\u010dn\u00ed technika: Pl\u00edci odsunujeme ventr\u00e1ln\u011b a otev\u00edr\u00e1me mediastin\u00e1ln\u00ed pleuru nad klenouc\u00ed se v\u00fdchlipkou. Podle lokalizace je nutn\u00e9 n\u011bkdy prot\u011bt\u00ed a podvaz v. azygos. Preparace divertiklu b\u00fdv\u00e1 obvykle velmi obt\u00ed\u017en\u00e1 pro t\u011b\u017ek\u00e9 z\u00e1n\u011btliv\u00e9 zm\u011bny v okol\u00ed a \u010dastou fixaci k uzlin\u00e1m a tracheobronchi\u00e1ln\u00edmu stromu. Mus\u00edme myslet na mo\u017enost rudiment\u00e1ln\u00ed p\u00ed\u0161t\u011ble s dechov\u00fdmi cestami, kterou je pak nutn\u00e9 pe\u010dliv\u011b ligovat, i kdy\u017e se jev\u00ed jako obliterovan\u00e1. Resekci v\u00fdchlipky a suturu sliznice prov\u00e1d\u00edme stejn\u00fdm zp\u016fsobem jako u kr\u010dn\u00edho divertiklu. Uz\u00e1v\u011br kr\u010dku v\u00fdchlipky je mo\u017eno prov\u00e9st i kovov\u00fdmi svorkami pomoc\u00ed \u0161ic\u00edho p\u0159\u00edstroje. Suturu sliznice dopln\u00edme v druh\u00e9 vrstv\u011b stehem j\u00edcnov\u00e9 svaloviny jednotliv\u00fdmi stehy. Mediastin\u00e1ln\u00ed pleuru ne\u0161ijeme a dutinu hrudn\u00ed dr\u00e9nujeme dv\u011bma dr\u00e9ny.<\/span><\/p>\n

      V\u00fdsledky chirurgick\u00e9 l\u00e9\u010dby hrudn\u00edch divertikl\u016f<\/h6>\n

      Pro t\u011b\u017ekou peridivertikulitidu s vysokou frekvenc\u00ed komplikac\u00ed u hrudn\u00edch v\u00fdchlipek, kter\u00e9 je nutno indikovat k operaci, pat\u0159\u00ed tyto v\u00fdkony k vysoce rizikov\u00fdm. Ze 7 hrudn\u00edch divertikl\u016f operovan\u00fdch v Olomouci v letech 1948\u20131982 byli v\u0161ichni nemocn\u00ed indikov\u00e1ni p\u0159edev\u0161\u00edm pro obt\u00ed\u017ee vypl\u00fdvaj\u00edc\u00ed z tlaku na okol\u00ed a dysfagii. Dva nemocn\u00ed po operaci zem\u0159eli (opera\u010dn\u00ed mortalita 28,6%). Jedna nemocn\u00e1 zem\u0159ela 3. poopera\u010dn\u00ed den pravd\u011bpodobn\u011b v d\u016fsledku technick\u00e9 z\u00e1vady na sac\u00edm za\u0159\u00edzen\u00ed, druh\u00fd nemocn\u00fd zem\u0159el 16. poopera\u010dn\u00ed den na kardi\u00e1ln\u00ed selh\u00e1n\u00ed. U 4 nemocn\u00fdch byla provedena resekce divertikl\u016f, u dvou invaginace v\u00fdchlipky a u jednoho resekce j\u00edcnu a kardie s n\u00e1slednou ezofagogastroanastom\u00f3zou pro podez\u0159en\u00ed na malign\u00ed infiltraci v divertiklu, kter\u00e1 v\u0161ak nebyla histologicky potvrzena. P\u011bt p\u0159e\u017e\u00edvaj\u00edc\u00edch operovan\u00fdch jsme m\u011bli mo\u017enost sledovat v intervalu 3 m\u011bs\u00edc\u016f a\u017e 7 let po proveden\u00e9 operaci (v pr\u016fm\u011bru 4,3 let). U v\u0161ech nemocn\u00fdch bylo mo\u017eno klinicky i rentgenologicky hodnotit stav jako v\u00fdborn\u00fd. Pouze jeden operovan\u00fd m\u011bl po vchl\u00edpen\u00ed divertiklu lehk\u00e9 dysfagick\u00e9 obt\u00ed\u017ee p\u0159i polyk\u00e1n\u00ed tuh\u00fdch j\u00eddel [22, 39, 40]. Divertikly st\u0159edn\u00edho j\u00edcnu (viz obr. 6) se operuj\u00ed vz\u00e1cn\u011b a v\u0161echny dal\u0161\u00ed nitrohrudn\u00ed divertikly, kter\u00e9 jsme m\u011bli mo\u017enost v posledn\u00edch desetilet\u00edch sledovat, byly klasifikov\u00e1ny jako epifren\u00e1ln\u00ed. Nepochybn\u011b by bylo mo\u017eno i tento typ nitrohrudn\u00ed v\u00fdchlipky j\u00edcnu dnes operovat torakoskopicky obdobnou technikou, jak je o tom pojedn\u00e1no u epifren\u00e1ln\u00edch divertikl\u016f.<\/p>\n

      12.5.2.3 Epifren\u00e1ln\u00ed divertikly<\/h5>\n

      Obdobn\u011b jako u Zenkerova divertiklu dnes u nitrohrudn\u00edch divertikl\u016f j\u00edcnu vedle klasick\u00e9 otev\u0159en\u00e9 operace existuje i mo\u017enost miniinvazivn\u00edho v\u00fdkonu.<\/p>\n

      Klasick\u00e1 otev\u0159en\u00e1 operace<\/h6>\n

      Opera\u010dn\u00ed p\u0159\u00edstup k doln\u00edmu hrudn\u00edmu j\u00edcnu je nejv\u00fdhodn\u011bj\u0161\u00ed l\u016f\u017ekem 8. \u017eebra vlevo. Lateralizaci torakotomie mus\u00edme v\u017edy individu\u00e1ln\u011b posoudit podle p\u0159edopera\u010dn\u00edho rentgenov\u00e9ho n\u00e1lezu.<\/p>\n

      Opera\u010dn\u00ed technika: Po otev\u0159en\u00ed dutiny hrudn\u00ed prot\u00edn\u00e1me plicn\u00ed ligamentum a pl\u00edci odsunujeme krani\u00e1ln\u011b. Po otev\u0159en\u00ed mediastin\u00e1ln\u00ed pleury ne\u010din\u00ed obvykle izolace v\u00fdchlipky v\u011bt\u0161\u00ed obt\u00ed\u017ee. Jej\u00ed resekci prov\u00e1d\u00edme podle stejn\u00fdch z\u00e1sad jako u hrudn\u00edho divertiklu. Pokud je u epifren\u00e1ln\u00edho divertiklu indikov\u00e1na sou\u010dasn\u00e1 ezofagokardi\u00e1ln\u00ed myotomie, prov\u00e1d\u00edme ji po skon\u010den\u00ed resekce v jin\u00e9 \u010d\u00e1sti cirkumference j\u00edcnu, nejl\u00e9pe ventr\u00e1ln\u011b. Technika proveden\u00ed je stejn\u00e1 jako u ezofagokardi\u00e1ln\u00ed achal\u00e1zie. U mal\u00fdch divertikl\u016f, kde dominuj\u00ed p\u0159\u00edznaky achal\u00e1zie DJS, je mo\u017eno se spokojit s pouhou myotomi\u00ed s ponech\u00e1n\u00edm v\u00fdchlipky, kter\u00e1 se m\u016f\u017ee pozd\u011bji zmen\u0161it nebo i vymizet [61, 82, 78].<\/p>\n

      V\u00fdsledky chirurgick\u00e9 l\u00e9\u010dby epifren\u00e1ln\u00edch divertikl\u016f<\/h6>\n

      V obdob\u00ed klasick\u00e9 chirurgie jsme vyhodnocovali dlouhodob\u00e9 v\u00fdsledky 14 nemocn\u00fdch s epifren\u00e1ln\u00edm divertiklem, kte\u0159\u00ed byli operov\u00e1ni v letech 1948\u20131982. Mortalita sestavy byla nulov\u00e1. U 5 operovan\u00fdch byla p\u0159\u00edtomna sou\u010dasn\u00e1 hypertonie DJS, kter\u00e1 m\u011bla u \u010dty\u0159 nemocn\u00fdch v rentgenologick\u00e9m obraze charakter ezofagokardi\u00e1ln\u00ed achal\u00e1zie. U nemocn\u00fdch s hypertoni\u00ed DJS byla dvakr\u00e1t provedena myotomie bez sou\u010dasn\u00e9 resekce divertikl\u016f. Jednou myotomie kombinovan\u00e1 s resekc\u00ed divertikl\u016f a jednou s inverz\u00ed divertikl\u016f. U jednoho nemocn\u00e9ho s pouze manometricky prok\u00e1zanou hypertoni\u00ed DJS byla provedena jen prost\u00e1 resekce v\u00fdchlipky. Po p\u016fl roce do\u0161lo k recidiv\u011b v\u00fdchlipky, ale vzhledem k minimu subjektivn\u00edch obt\u00ed\u017e\u00ed nebyla indikov\u00e1na reoperace. U zbyl\u00fdch dev\u00edti operovan\u00fdch byla provedena resekce divertikl\u016f. V\u00fdsledky operace jsme vyhodnotili u v\u0161ech 14 operovan\u00fdch v odstupu 6 m\u011bs\u00edc\u016f a\u017e 8 let (pr\u016fm\u011brn\u00fd odstup 3 roky). U v\u0161ech nemocn\u00fdch byl klinick\u00fd stav v\u00fdborn\u00fd. Rentgenologicky u jedn\u00e9 nemocn\u00e9 s mal\u00fdm divertiklem bez resekce do\u0161lo k jeho vymizen\u00ed a u druh\u00e9ho operovan\u00e9ho po pouh\u00e9 myotomii k podstatn\u00e9mu zmen\u0161en\u00ed v\u011bt\u0161\u00ed v\u00fdchlipky. U t\u0159\u00ed kontrolovan\u00fdch je patrn\u00e1 v m\u00edst\u011b proveden\u00e9 resekce, respektive inverze v\u00fdchlipky, nepatrn\u00e1 nerovnost kontury j\u00edcnu. U jednoho nemocn\u00e9ho do\u0161lo k recidiv\u011b v\u00fdchlipky. Pas\u00e1\u017e j\u00edcnem a kardi\u00ed byla u v\u0161ech kontrolovan\u00fdch voln\u00e1 [22,\u00a039, 40].<\/p>\n

      Miniivazivn\u00ed l\u00e9\u010dba<\/h6>\n

      S rozvojem laparoskopick\u00e9 a torakoskopick\u00e9 chirurgie od po\u010d\u00e1tku 90. let minul\u00e9ho stolet\u00ed se na pracovi\u0161t\u00edch s dostate\u010dnou zku\u0161enost\u00ed s t\u011bmito miniinvazivn\u00edmi technikami st\u00e1le v\u00edce prosazuje tento p\u0159\u00edstup i u nitrohrudn\u00edch divertikl\u016f. U or\u00e1ln\u011bji ulo\u017een\u00fdch divertikl\u016f m\u016f\u017ee b\u00fdt preferov\u00e1na torakoskopie [83, 84], p\u0159i \u010dast\u011bj\u0161\u00ed lokalizaci t\u011bsn\u011b nad br\u00e1nic\u00ed je preferov\u00e1n transhiat\u00e1ln\u00ed p\u0159\u00edstup z laparoskopie [52, 85, 86]. Endoskopick\u00e1 resekce nitrohrudn\u00edch v\u00fdchlipek byla zavedena i olomouck\u00fdmi chirurgy [43, 87]. Jednozna\u010dn\u00fd trend prov\u00e1d\u011bt tyto operace miniinvazivn\u011b je d\u00e1n t\u00edm, \u017ee operace je zku\u0161en\u00fdm miniinvazivn\u00edm chirurgem stejn\u011b dob\u0159e provediteln\u00e1 jako p\u0159i otev\u0159en\u00e9m p\u0159\u00edstupu.<\/p>\n

      Jak bylo podrobn\u011b vysv\u011btleno v \u010d\u00e1sti o etiopatogenezi epifren\u00e1ln\u00edch divertikl\u016f, je v sou\u010dasnosti za metodu volby pova\u017eov\u00e1na resekce v\u00fdchlipky se sou\u010dasnou ezofagokardi\u00e1ln\u00ed myotomi\u00ed [28 a\u017e 38]. Ot\u00e1zka, zda je mo\u017eno u mal\u00fdch rozm\u011br\u016f v\u00fdchlipky od resekce upustit a spokojit se jen s myotomi\u00ed, jak to bylo zva\u017eov\u00e1no ve star\u0161\u00edch prac\u00edch [61, 55, 88, 78, 89], m\u016f\u017ee b\u00fdt individu\u00e1ln\u011b posouzena. Obdobn\u011b jako u operace achal\u00e1zie, kde je o tom podrobn\u011bji pojedn\u00e1no, je ot\u00e1zka p\u0159ipojen\u00ed antirefluxn\u00ed man\u017eety st\u00e1le p\u0159edm\u011btem diskuz\u00ed a nen\u00ed jednozna\u010dn\u011b rozhodnuta.<\/p>\n

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        12.1 Definice, historie a klasifikace J\u00edcnov\u00fdm divertiklem rozum\u00edme vakovit\u00e9 vyklenut\u00ed st\u011bny j\u00edcnu do periezofage\u00e1ln\u00edho prostoru. Podle lokalizace rozli\u0161ujeme t\u0159i typy: Parafarynge\u00e1ln\u00ed divertikl na p\u0159echodu faryngu v j\u00edcen (synonyma: kr\u010dn\u00ed, hypofarynge\u00e1ln\u00ed, horn\u00ed, farynge\u00e1ln\u00ed, Zenker\u016fv). Hrudn\u00ed divertikl ve st\u0159edn\u00ed \u010d\u00e1sti j\u00edcnu (synonyma: epibronchi\u00e1ln\u00ed, parabronchi\u00e1ln\u00ed, st\u0159edn\u00ed). Epifren\u00e1ln\u00ed divertikl um\u00edst\u011bn\u00fd nad br\u00e1nic\u00ed (synonyma: doln\u00ed, parahi\u00e1tov\u00fd). Historicky prvn\u00ed popis hypofarynge\u00e1ln\u00ed […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":65,"menu_order":60,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-607","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/607","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=607"}],"version-history":[{"count":44,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/607\/revisions"}],"predecessor-version":[{"id":1184,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/607\/revisions\/1184"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/65"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=607"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}