We report a case of giant epiphrenic diverticulum in a 43-year-old woman who underwent Heller's myotomy because of achalasia 20 years earlier. She complained of heartburn and dysphagia from March of 1991 and was hospitalized in our institution. An upper gastrointestinal X-ray examination with contrast medium revealed a large hemispheric lesion (7.8 x 4.8 cm) occupying the right posterior wall of the lower thoracic and abdominal esophagus. Manometry revealed a motility disorder and high pressure of the lower esophageal sphincter due to achalasia. Therefore she was diagnosed as having a giant diverticulum with achalasia after Heller's operation. She underwent transhiatal esophagectomy and reconstruction with placement of a gastric tube on June 4, 1992. Pathology results on the resected specimen revealed a false diverticulum. She has been doing well for 4 years since the operation. It has been said that a complication of incomplete long myotomy causes pulsion diverticulum, but we could not find a case of epiphrenic diverticulum after myotomy for achalasia reported in the literature in the last 10 years.

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It is very difficult to approach the hepatic hilus safely in patients with common and/or hepatic bile duct strictures in which normal tissue has been replaced by scarred tissue with firm fibrous adhesions. In this report, we describe how eight patients with benign strictures of the bile duct underwent an operation which involved dividing the superior mesenteric and portal veins from the lower margin of the pancreas in a dorsal direction using a finger in a tunneling technique. The common bile duct, which was buried in scar tissue, was then explored, while the common and/or proper hepatic arteries in the hepatoduodenal ligament were confirmed, after transsection at the superior margin of the pancreas. Biliary reconstruction was successfully performed after resection of the constricted bile duct in all the patients, none of whom have experienced recurrence from 6 months to 5 years after the operation.

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