Resección de divertículo epifrénico por laparoscopia
Palabras clave:
divertículo esofágico, trastornos de la motilidad esofágica, acalasia del esófago, cirugía asistida por vídeoResumen
El divertículo epifrénico es infrecuente, la mayoría surge por un mecanismo de pulsión debido a un trastorno motor esofágico que determina un efecto de barrera y ocasiona la herniación de la mucosa y la submucosa a través de un punto débil de la capa muscular. Se asocia a menudo con acalasia, trastornos concomitantes de la motilidad esofágica, y una alta presión de reposo del esfínter esofágico inferior. Los principales síntomas experimentados por los pacientes son disfagia, regurgitación y broncoaspiración. El tratamiento quirúrgico sólo se recomienda en pacientes sintomáticos.
Se han utilizado técnicas mínimamente invasivas, con éxito en la mayoría de los casos. El abordaje laparoscópico es el tratamiento quirúrgico de elección. Una miotomía larga y un procedimiento antirreflujo deben asociarse para evitar las fístulas del esófago en la línea de reparación del reflujo gastroesofágico.
El objetivo de esta revisión es revisar la literatura científica de esta infrecuente enfermedad; presentamos un caso tratado por abordaje laparoscópico.
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Referencias bibliográficas
1. Rosati R, Fumagalli U, Elmore U, Pascale S, Massaron S, Pe- racchia A. Long-term results of minimally invasive surgery for symptomatic epiphrenic diverticulum. Am J Surg. 2011;201:132-5.
https://doi.org/10.1016/j.amjsurg.2010.03.016
2. Lai ST, Hsu CP. Carcinoma arising from an epiphrenic diverticu- lum: A frequently misdiagnosed disease. Ann Thorac Cardiovasc Surg. 2007;13:110-3.
3. Zamarín J, García C, Gallardo C. Resección laparoscópica de divertículo esofágico epifrénico secundario a acalasia. Revista Chilena de Cirugía. 2011;63:557-8.
https://doi.org/10.4067/S0718-40262011000600002
4. Nehra D, Lord RV, DeMeester TR. Physiologic basis for the treatment of epiphrenic diverticulum. Ann Surg. 2002; 235:346-54.
https://doi.org/10.1097/00000658-200203000-00006
5. Soares R, Herbella F. Epiphrenic diverticulum of the esopha- gus: From pathophysiology to treatment. J Gastrointest Surg. 2010;14:2009-15.
https://doi.org/10.1007/s11605-010-1216-9
6. Altorki NK, Sunagawa M, Skinner DB. Thoracic esophageal diverticula. Why is operation necessary? J Thorac Cardiovasc Surg. 1993;105:260-4.
7. Fekete F, Vonns C. Surgical management of esophageal thoracic diverticula. Hepatogastroenterology. 1992;39:97-9.
8. Zaninotto G, Portale G, Costantini M, Zanatta L, Salvador R, Ruol A. Therapeutic strategies for epiphrenic diverticula: Sys- tematic review. World J Surg . 2011;35:1447-53.
https://doi.org/10.1007/s00268-011-1065-z
9. Harrington SW. The surgical treatment of pulsion diverticula of the thoracic esophagus. Ann Surg. 1949;129:606-18.
10. Cross FS. Esophageal diverticula related neuromuscular prob- lems. Ann Otol Rhinol Laryngol. 1968;77:914-26.
https://doi.org/10.1177/000348946807700510
11. Varghese TK, Marshall B, Chang AC, Pickens A, Lau CL, Orringer MB. Surgical treatment of epiphrenic diverticula: A 30-year experience. Ann Thorac Surg. 2007;84:1801-9.
https://doi.org/10.1016/j.athoracsur.2007.06.057
12. Streitz JM, Glick ME, Ellis H. Selective use of myotomy for treatment of epiphrenic diverticula. Manometric and clinical analysis. Arch Surg. 1992;127:585- 8.
https://doi.org/10.1001/archsurg.1992.01420050109014
13. Wheeler D. Diverticula of the foregut. Radiology. 1947;49:476-81.
https://doi.org/10.1148/49.4.476
14. Dobashi Y, Goseki N, Inutake Y, Kawano T, Endou M, Nemoto T. Giant epiphrenic diverticulum with achalasia occurring 20 years after Heller's operation. J Gastroenterol. 1996;31:844-7.
https://doi.org/10.1007/BF02358612
15. Schima W, Schober E, Stacher G, Franz P, Uranitsch K, Pokiester P,et al. Association of mideesophageal diverticula with oesopha- geal motor disorders: Videofluoroscopy and manometry. Acta Radiol. 1997;38:108-14.
https://doi.org/10.1080/02841859709171252
16. Skinner DB, Belsey RH. Esophageal spasm and diverticulum. In: Skinner DB, Belsey RHR, editors. Management of esophageal disease. Philadelphia: W.B. Saunders; 1988. p. 431-52.
17. Trastek VF, Payne WS. Esophageal diverticula. In: Shields TW, ed. General thoracic surgery. Philadelphia: Lea & Febiger; 1989. p. 989-1001.
18. Mondiere JT. Notes sur quelques maladies de'loesophage. Arch Gen Med Paris. 1833;3:28-65.
19. Kausel HJ, Lindskog G. Epiphrenic diverticulum of the esopha- gus: A review of its surgical treatment and report of a case. Chest. 1952;21:334-45.
https://doi.org/10.1378/chest.21.3.334
20. Pérez R, Encinas JM. Divertículo epifrénico asociado a acalasia. Rev Hosp Jua Mex. 1999;3:55-8.
21. Janes RA. Diverticula of the lower esophagus. Ann Surg. 1948;124:637-49.
https://doi.org/10.1097/00000658-194610000-00003
22. Rodríguez J, García J, Gironés J., Codina A, Francescha M, Ferrán H, et al. Divertículo epifrénico de grandes dimensiones: resolución mediante toracotomía y sutura mecánica. Cir Esp. 2002;72:240-3.
https://doi.org/10.1016/S0009-739X(02)72047-2
23. Effler DB, Barr D, Groves LK. Epiphrenic diverticulum of the esophagus -surgical treatment. Arch Surg. 1959;79:459-67.
https://doi.org/10.1001/archsurg.1959.04320090107016
24. Belsey R. Functional disease of the esophagus. J Thorac Car- diovasc Surg. 1966;52:164-88.
25. Tedesco P, Fisichella PM, Way LW, Patti MG. Cause and treat- ment of epiphrenic diverticula. Am J Surg. 2005;190:902-5.
https://doi.org/10.1016/j.amjsurg.2005.08.016
26. Fernando HC, Luketich JD, Samphire J, Alvelo-Rivera M, Chris- tie NA, Buenaventura PO, et al. Minimally invasive operation for esophageal diverticula. Ann Thorac Surg. 2005;80:2076-81.
https://doi.org/10.1016/j.athoracsur.2005.06.007
27. Ruiz J, Castillo A, González L, Barinaga R, Maldonado A, Cor- nejo A, et al. Esófago en cascanueces y divertículo epifrénico. Cirugía Endoscópica. 2010;11:32-5.
28. Fasano NC, Levine MS, Rubesin SE, Redfen RO, Laufer I. Epiphrenic diverticula: Clinical and radiographic findings. Dysphagia. 2003;18:9-15.
https://doi.org/10.1007/s00455-002-0075-2
29. Vega K, Andrade R, Alegre F, Lambraño L. Divertículo epifré- nico. Descripción de un caso clínico y revisión de la literatura. Revista Colombiana de Cirugía. 2006;21:63-7.
30. Melman L, Quinlan J, Robertson B, Brunt LM, Halpin VJ, Eagon JC, et al. Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula. Surg Endosc. 2009;23:1337-41.
https://doi.org/10.1007/s00464-008-0165-9
31. Braghetto I, Owen Kb, Valladares H. Divertículos esofági- cos. Tratamiento quirúrgico. Gastrointestinal Latinoamerica. 2005;16:122-6.
32. Del Genio A, Rossetti G, Maffettone V, Renzi A, Brusciano L, Limongelli P, et al. Laparoscopic approach in the treatment of epiphrenic diverticula: Long-term results. Surg Endosc. 2004;18:741-5.
https://doi.org/10.1007/s00464-003-9044-6
33. D'Journo XB, Ferraro P, Martin J, Chen LQ, Duranceau A. Lower oesophageal sphincter dysfunction is part of the functional abnor- mality in epiphrenic diverticulum. Br J Surg. 2009;96:892-900.
https://doi.org/10.1002/bjs.6652
34 Patti MG, Gorodner MV, Galvani C, Tedesco P, Fisichella PM, Ostroff JW, et al. Spectrum of esophageal motility dis- orders: Implications for diagnosis and treatment. Arch Surg. 2005;140:442-9.
https://doi.org/10.1001/archsurg.140.5.442
35. Hung JJ, Hsieh CC, Lin SC, Wang LS. Squamous cell carcinoma in a large epiphrenic esophageal diverticulum. Dig Dis Sci. 2009;54:1365-8.
https://doi.org/10.1007/s10620-009-0727-2
36. Lee JH, Chae HS, Kim KH, Kim JW, Wang YP, Lee SH, et al. Delayed primary repair of perforated epiphrenic diverticulum. J Korean Med Sci. 2004;19:887-90.
https://doi.org/10.3346/jkms.2004.19.6.887
37. Abul-Khair MH, Khalil A, Mohsen A. Bleeding from an epi- phrenic oesophageal diverticulum. Eur J Surg. 1992;158:377-8.
38. Debas HT, Payne WS, Cameron AJ, Carlson HC, Physiopathol- ogy of lower esophageal diverticulum and its implications for treatment. Surg Gynecol Obstet. 1980;151:593-600.
39. Conrad C, Nissen F. Giant epiphrenic diverticula. Eur J Radiol. 1982;2:48-9.
40. Rosati R, Fumagalli U, Bona S, Zago M, Celotti S, Bisagni P, et al. Laparoscopic treatment of epiphrenic diverticula. JSLS. 2001;11:371-5.
https://doi.org/10.1089/10926420152761897
41. Clark SC, Norton SA, Jeyasingham K, Ridley PD. Oesophageal epiphrenic diverticulum: An unusual presentation and review. Ann R Coll Surg Engl. 1995;77:342-5.
42. DeMeester TR, Wang CI, Wernly JA, Pellegrini CA, Little AG, Klementschitsch P, et al. Technique, indications and clinical use of 24-hour esophageal pH monitoring. J Thorac Cardiovas Surg. 1980;79:656-70.
43. Peracchia A, Bonavina L, Rosati R, Bona S. Thoracoscopic resection of epiphrenic diverticula. In: Peters J, DeMeester TR, editors. Minimally invasive surgery of the foregut. St. Louis: QMP Inc.; 1994. p. 110-6.
44. van der Peet DL, Klinkenberg-Knol EC, Berends FJ, Cuesta MA. Epiphrenic diverticula: Minimally invasive approach and repair in five patients. Dis Esophagus. 2001;14:60-2.
https://doi.org/10.1111/j.1442-2050.2001.00151.x
45. Devaney EJ, Iannettoni MD, Orringer MB, Marshall B. Esopha- gectomy for achalasia: Patient selection and clinical experience. Ann Thorac Surg. 2001;72:854-8.
https://doi.org/10.1016/S0003-4975(01)02890-9
46. Rebecchi F, Giaccone C, Farinella E, Campaci R, Morino M. Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for acha- lasia: Long-term results. Ann Surg. 2008;248:1023-30.
https://doi.org/10.1097/SLA.0b013e318190a776
47. Richards WO, Torquati A, Holzman MD, Khaitan L, ByrneD, Lutfi R, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia. A prospective randomized double- blind clinical trial. Ann Surg. 2004;240:405-15.
https://doi.org/10.1097/01.sla.0000136940.32255.51
48. Vallés M, Reyes OR, Gaetano C, Rey S. Divertículo epifrénico. Rev Cubana Cir. 2011;50:223-8.
49. Klaus A, Hinder RA, Swain J, Achem SR. Management of epi- phrenic diverticula. J Gastrointest Surg. 2003;7:906-11.
https://doi.org/10.1007/s11605-003-0038-4
50. Brian E, Weiser K. Esophageal motility disorders; medical therapy. J Clin Gastroenterol. 2008;42:652-8.
https://doi.org/10.1097/MCG.0b013e31815bd223
51. Fraiji E Jr, Bloomston M, Carey L, Zervos E, Goldin S, Ba- nasiak M, et al. Laparoscopic management of symptomatic achalasia associated with epiphrenic diverticulum. Surg Endosc. 2003;17:1600-3.
https://doi.org/10.1007/s00464-002-8959-7
52. Müller A, Halbfass HJ. Laparoscopic esophagotomy without diverticular resection for treating epiphrenic diverticulum in hypertonic lower esophageal sphincter. Chirurg. 2004;75:302-6.
https://doi.org/10.1016/j.amjsurg.2010.03.016
2. Lai ST, Hsu CP. Carcinoma arising from an epiphrenic diverticu- lum: A frequently misdiagnosed disease. Ann Thorac Cardiovasc Surg. 2007;13:110-3.
3. Zamarín J, García C, Gallardo C. Resección laparoscópica de divertículo esofágico epifrénico secundario a acalasia. Revista Chilena de Cirugía. 2011;63:557-8.
https://doi.org/10.4067/S0718-40262011000600002
4. Nehra D, Lord RV, DeMeester TR. Physiologic basis for the treatment of epiphrenic diverticulum. Ann Surg. 2002; 235:346-54.
https://doi.org/10.1097/00000658-200203000-00006
5. Soares R, Herbella F. Epiphrenic diverticulum of the esopha- gus: From pathophysiology to treatment. J Gastrointest Surg. 2010;14:2009-15.
https://doi.org/10.1007/s11605-010-1216-9
6. Altorki NK, Sunagawa M, Skinner DB. Thoracic esophageal diverticula. Why is operation necessary? J Thorac Cardiovasc Surg. 1993;105:260-4.
7. Fekete F, Vonns C. Surgical management of esophageal thoracic diverticula. Hepatogastroenterology. 1992;39:97-9.
8. Zaninotto G, Portale G, Costantini M, Zanatta L, Salvador R, Ruol A. Therapeutic strategies for epiphrenic diverticula: Sys- tematic review. World J Surg . 2011;35:1447-53.
https://doi.org/10.1007/s00268-011-1065-z
9. Harrington SW. The surgical treatment of pulsion diverticula of the thoracic esophagus. Ann Surg. 1949;129:606-18.
10. Cross FS. Esophageal diverticula related neuromuscular prob- lems. Ann Otol Rhinol Laryngol. 1968;77:914-26.
https://doi.org/10.1177/000348946807700510
11. Varghese TK, Marshall B, Chang AC, Pickens A, Lau CL, Orringer MB. Surgical treatment of epiphrenic diverticula: A 30-year experience. Ann Thorac Surg. 2007;84:1801-9.
https://doi.org/10.1016/j.athoracsur.2007.06.057
12. Streitz JM, Glick ME, Ellis H. Selective use of myotomy for treatment of epiphrenic diverticula. Manometric and clinical analysis. Arch Surg. 1992;127:585- 8.
https://doi.org/10.1001/archsurg.1992.01420050109014
13. Wheeler D. Diverticula of the foregut. Radiology. 1947;49:476-81.
https://doi.org/10.1148/49.4.476
14. Dobashi Y, Goseki N, Inutake Y, Kawano T, Endou M, Nemoto T. Giant epiphrenic diverticulum with achalasia occurring 20 years after Heller's operation. J Gastroenterol. 1996;31:844-7.
https://doi.org/10.1007/BF02358612
15. Schima W, Schober E, Stacher G, Franz P, Uranitsch K, Pokiester P,et al. Association of mideesophageal diverticula with oesopha- geal motor disorders: Videofluoroscopy and manometry. Acta Radiol. 1997;38:108-14.
https://doi.org/10.1080/02841859709171252
16. Skinner DB, Belsey RH. Esophageal spasm and diverticulum. In: Skinner DB, Belsey RHR, editors. Management of esophageal disease. Philadelphia: W.B. Saunders; 1988. p. 431-52.
17. Trastek VF, Payne WS. Esophageal diverticula. In: Shields TW, ed. General thoracic surgery. Philadelphia: Lea & Febiger; 1989. p. 989-1001.
18. Mondiere JT. Notes sur quelques maladies de'loesophage. Arch Gen Med Paris. 1833;3:28-65.
19. Kausel HJ, Lindskog G. Epiphrenic diverticulum of the esopha- gus: A review of its surgical treatment and report of a case. Chest. 1952;21:334-45.
https://doi.org/10.1378/chest.21.3.334
20. Pérez R, Encinas JM. Divertículo epifrénico asociado a acalasia. Rev Hosp Jua Mex. 1999;3:55-8.
21. Janes RA. Diverticula of the lower esophagus. Ann Surg. 1948;124:637-49.
https://doi.org/10.1097/00000658-194610000-00003
22. Rodríguez J, García J, Gironés J., Codina A, Francescha M, Ferrán H, et al. Divertículo epifrénico de grandes dimensiones: resolución mediante toracotomía y sutura mecánica. Cir Esp. 2002;72:240-3.
https://doi.org/10.1016/S0009-739X(02)72047-2
23. Effler DB, Barr D, Groves LK. Epiphrenic diverticulum of the esophagus -surgical treatment. Arch Surg. 1959;79:459-67.
https://doi.org/10.1001/archsurg.1959.04320090107016
24. Belsey R. Functional disease of the esophagus. J Thorac Car- diovasc Surg. 1966;52:164-88.
25. Tedesco P, Fisichella PM, Way LW, Patti MG. Cause and treat- ment of epiphrenic diverticula. Am J Surg. 2005;190:902-5.
https://doi.org/10.1016/j.amjsurg.2005.08.016
26. Fernando HC, Luketich JD, Samphire J, Alvelo-Rivera M, Chris- tie NA, Buenaventura PO, et al. Minimally invasive operation for esophageal diverticula. Ann Thorac Surg. 2005;80:2076-81.
https://doi.org/10.1016/j.athoracsur.2005.06.007
27. Ruiz J, Castillo A, González L, Barinaga R, Maldonado A, Cor- nejo A, et al. Esófago en cascanueces y divertículo epifrénico. Cirugía Endoscópica. 2010;11:32-5.
28. Fasano NC, Levine MS, Rubesin SE, Redfen RO, Laufer I. Epiphrenic diverticula: Clinical and radiographic findings. Dysphagia. 2003;18:9-15.
https://doi.org/10.1007/s00455-002-0075-2
29. Vega K, Andrade R, Alegre F, Lambraño L. Divertículo epifré- nico. Descripción de un caso clínico y revisión de la literatura. Revista Colombiana de Cirugía. 2006;21:63-7.
30. Melman L, Quinlan J, Robertson B, Brunt LM, Halpin VJ, Eagon JC, et al. Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula. Surg Endosc. 2009;23:1337-41.
https://doi.org/10.1007/s00464-008-0165-9
31. Braghetto I, Owen Kb, Valladares H. Divertículos esofági- cos. Tratamiento quirúrgico. Gastrointestinal Latinoamerica. 2005;16:122-6.
32. Del Genio A, Rossetti G, Maffettone V, Renzi A, Brusciano L, Limongelli P, et al. Laparoscopic approach in the treatment of epiphrenic diverticula: Long-term results. Surg Endosc. 2004;18:741-5.
https://doi.org/10.1007/s00464-003-9044-6
33. D'Journo XB, Ferraro P, Martin J, Chen LQ, Duranceau A. Lower oesophageal sphincter dysfunction is part of the functional abnor- mality in epiphrenic diverticulum. Br J Surg. 2009;96:892-900.
https://doi.org/10.1002/bjs.6652
34 Patti MG, Gorodner MV, Galvani C, Tedesco P, Fisichella PM, Ostroff JW, et al. Spectrum of esophageal motility dis- orders: Implications for diagnosis and treatment. Arch Surg. 2005;140:442-9.
https://doi.org/10.1001/archsurg.140.5.442
35. Hung JJ, Hsieh CC, Lin SC, Wang LS. Squamous cell carcinoma in a large epiphrenic esophageal diverticulum. Dig Dis Sci. 2009;54:1365-8.
https://doi.org/10.1007/s10620-009-0727-2
36. Lee JH, Chae HS, Kim KH, Kim JW, Wang YP, Lee SH, et al. Delayed primary repair of perforated epiphrenic diverticulum. J Korean Med Sci. 2004;19:887-90.
https://doi.org/10.3346/jkms.2004.19.6.887
37. Abul-Khair MH, Khalil A, Mohsen A. Bleeding from an epi- phrenic oesophageal diverticulum. Eur J Surg. 1992;158:377-8.
38. Debas HT, Payne WS, Cameron AJ, Carlson HC, Physiopathol- ogy of lower esophageal diverticulum and its implications for treatment. Surg Gynecol Obstet. 1980;151:593-600.
39. Conrad C, Nissen F. Giant epiphrenic diverticula. Eur J Radiol. 1982;2:48-9.
40. Rosati R, Fumagalli U, Bona S, Zago M, Celotti S, Bisagni P, et al. Laparoscopic treatment of epiphrenic diverticula. JSLS. 2001;11:371-5.
https://doi.org/10.1089/10926420152761897
41. Clark SC, Norton SA, Jeyasingham K, Ridley PD. Oesophageal epiphrenic diverticulum: An unusual presentation and review. Ann R Coll Surg Engl. 1995;77:342-5.
42. DeMeester TR, Wang CI, Wernly JA, Pellegrini CA, Little AG, Klementschitsch P, et al. Technique, indications and clinical use of 24-hour esophageal pH monitoring. J Thorac Cardiovas Surg. 1980;79:656-70.
43. Peracchia A, Bonavina L, Rosati R, Bona S. Thoracoscopic resection of epiphrenic diverticula. In: Peters J, DeMeester TR, editors. Minimally invasive surgery of the foregut. St. Louis: QMP Inc.; 1994. p. 110-6.
44. van der Peet DL, Klinkenberg-Knol EC, Berends FJ, Cuesta MA. Epiphrenic diverticula: Minimally invasive approach and repair in five patients. Dis Esophagus. 2001;14:60-2.
https://doi.org/10.1111/j.1442-2050.2001.00151.x
45. Devaney EJ, Iannettoni MD, Orringer MB, Marshall B. Esopha- gectomy for achalasia: Patient selection and clinical experience. Ann Thorac Surg. 2001;72:854-8.
https://doi.org/10.1016/S0003-4975(01)02890-9
46. Rebecchi F, Giaccone C, Farinella E, Campaci R, Morino M. Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for acha- lasia: Long-term results. Ann Surg. 2008;248:1023-30.
https://doi.org/10.1097/SLA.0b013e318190a776
47. Richards WO, Torquati A, Holzman MD, Khaitan L, ByrneD, Lutfi R, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia. A prospective randomized double- blind clinical trial. Ann Surg. 2004;240:405-15.
https://doi.org/10.1097/01.sla.0000136940.32255.51
48. Vallés M, Reyes OR, Gaetano C, Rey S. Divertículo epifrénico. Rev Cubana Cir. 2011;50:223-8.
49. Klaus A, Hinder RA, Swain J, Achem SR. Management of epi- phrenic diverticula. J Gastrointest Surg. 2003;7:906-11.
https://doi.org/10.1007/s11605-003-0038-4
50. Brian E, Weiser K. Esophageal motility disorders; medical therapy. J Clin Gastroenterol. 2008;42:652-8.
https://doi.org/10.1097/MCG.0b013e31815bd223
51. Fraiji E Jr, Bloomston M, Carey L, Zervos E, Goldin S, Ba- nasiak M, et al. Laparoscopic management of symptomatic achalasia associated with epiphrenic diverticulum. Surg Endosc. 2003;17:1600-3.
https://doi.org/10.1007/s00464-002-8959-7
52. Müller A, Halbfass HJ. Laparoscopic esophagotomy without diverticular resection for treating epiphrenic diverticulum in hypertonic lower esophageal sphincter. Chirurg. 2004;75:302-6.
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2012-10-01
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Olarte, P.; Padrón, O. L.; Arboleda, D. Resección De divertículo epifrénico Por Laparoscopia. Rev Colomb Cir 2012, 27, 306-313.
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