Endoscopic rendez-vous after damage control surgery in treatment of retroperitoneal abscess from perforated duodenal diverticulum: a techinal note and literature review

Perforated Duodenal Diverticulum With Postoperative Diverticulum Bleeding Successfully Treated Using Transcatheter Arterial Embolization

A diverticulum is a relatively common finding that is generally discovered incidentally; it is most commonly observed in the colon, followed by the duodenum. However, duodenal diverticulum perforation (DDP) is a rare complication. Due to its rarity, its diagnosis is often challenging and the appropriate treatment remains unclear, possibly contributing to its high mortality rate. Traditionally, surgical repair is the primary mode of treatment. However, with the recent advancements in medical technology, conservative management such as bowel rest and endoscopic drainage help successfully manage DDP. Duodenal diverticulum bleeding (DDB) is a rare cause of upper gastrointestinal bleeding. While endoscopic, angiographical, and surgical treatments have been performed to achieve hemostasis, there is no consensus regarding the optimal treatment for DDB. We describe a case of a perforated duodenal diverticulum (DD) with postoperative diverticulum bleeding. Our patient, an elderly female, complained of abdominal pain. Computed tomography images revealed free air in the retroperitoneum, and gastrointestinal perforation was suspected. During the emergency surgery, a perforated DD was detected in the third portion of the duodenum. Due to severe inflammation, diverticulectomy was not performed as it was deemed risky. Instead, we directly sutured the orifice using an omental patch. Duodenal leakage was observed from postoperative day (POD) 3 with bleeding from the remnant DD occurred on PODs 6 and 13. An attempt at endoscopic hemostasis failed, but transcatheter arterial embolization (TAE) was successfully performed. The postoperative course was complicated, and the patient died on POD 54. To the best of our knowledge, this is the first report on DD perforation with postoperative DDB. The remnant DD may be damaged by the digestive juices and result in bleeding. Precautionary measures for duodenal leakage should be undertaken when the DD is unresectable. Additionally, TAE is effective for postoperative DDB.

A systematic review of the perforated duodenal diverticula: lessons learned from the last decade

Background

The perforated duodenal diverticulum remains a rare clinical entity, the optimal management of which has not been well established. Historically, primary surgery has been the preferred treatment modality. This was called into question during the last decade, with the successful application of non-operative therapy in selected patients. The aim of this systematic review is to identify cases of perforated duodenal diverticula published over the past decade and to assess any subsequent evolution in treatment.

Methods

A systematic review of English and non-English articles reporting on perforated duodenal diverticula using MEDLINE (2008–2020) was performed. Only cases of perforated duodenal diverticula in adults (> 18 years) that reported on diagnosis and treatment were included.

Results

Some 328 studies were identified, of which 31 articles met the inclusion criteria. These studies included a total of 47 patients with perforated duodenal diverticula. This series suggests a trend towards conservative management with 34% (16/47) of patients managed non-operatively. In 31% (5/16) patients initially managed conservatively, a step-up approach to surgical intervention was required.

Conclusion

Conservative treatment of perforated duodenal diverticula appears to be an acceptable and safe treatment strategy in stable patients without signs of peritonitis under careful observation. For patients who fail to respond to conservative treatment, a step-up approach to percutaneous drainage or surgery can be applied. If surgery is required, competence in techniques ranging from simple diverticulectomy to Roux-en-Y gastric diversion or even Whipple’s procedure may be required depending on tissue friability and diverticular collar size.

Indications and benefits of intraoperative esophagogastroduodenoscopy

Introduction

Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy.

Aim

To evaluate the indications, benefits and risks of IOG.

Material and methods

A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed.

Results

The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG.

Conclusions

The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.

Perforated Duodenal Diverticulum Treated Conservatively: Another Two Successful Cases

Diverticula of the duodenum proceed those of the colon in respect to frequency of location. Incidence at times of autopsy ranges from 15 to 23%. Despite the fact that more than 90% of duodenal diverticulum cases are asymptomatic, complications if they do occur can be calamitous. Perforation is one of these rare complications. Surgical intervention has always been the mainstay for symptomatic/complicated duodenal diverticula, but with the advancement of imaging, medical treatment, and proper intensive observation, conservative treatment came forth. We hereby present two cases of duodenal diverticula, complicated by perforation and fistulization into the retroperitoneal cavity, both treated conservatively by Taylor's approach of upper gastrointestinal tract perforation. Review of other cases of duodenal diverticulum perforation has also been presented.

Laparoscopic resection of perforated duodenal diverticulum - A case report and literature review

BACKGROUND

Duodenum diverticulum is the most common site for diverticular disease of small intestine. Most of duodenal diverticulum are asymptomatic, but complicated or perforated duodenal diverticulum is rare. Nonoperative management is attractive in selected patients, because of higher surgical complications. We suggest the use of a minimally invasive operative method as an alternative approach for the management of complicated duodenal diverticulum, especially when conservative treatment has failed.

CASE PRESENTATION

A 67-year-old female was admitted to Emergency Department with sudden onset of severe right upper abdominal pain and fever (38.2°C) lasted 8h. Abdominal computed tomographic imaging was performed and a perforated duodenal diverticulum with right-sided anterior pararenal space free air and fluid retention was identified. After assessment and resuscitation, proper treatment modality was selected taking in consideration type, location and complication of duodenal diverticulum. A emergency laparoscopic duodenal diverticulectomy with intraabdominal drainage was performed. Postoperative period was uneventful and patient was discharged on the 10th postoperative day. English literatures discussing laparoscopic management for complicated duodenal diverticulum were carefully reviewed.

CONCLUSIONS

Laparoscopic approach showed less complication, shorted hospital stay and better outcome in comparison to conservative, or open surgery. Laparoscopic approach is safe and feasible in selected cases of complicated duodenal diverticulum (laterally located and protruding duodenal diverticulum). With advances in laparoscopic instruments and techniques, complicated duodenal diverticulums can be managed safely by laparoscopically.

Management of Perforated Duodenal Diverticulum: Report of Two Cases

Duodenal diverticula are common, but perforated duodenal diverticulum is rare. Because of the disease rarity, there is no standard management protocol for perforated duodenal diverticulum. To properly manage this rare complication, a clear preoperative diagnosis and clinical disease severity assessment are important. An abdomino-pelvic CT is an unquestionably crucial diagnostic tool. Perforation is considered a surgical emergency, although conservative treatment based on fasting and broad-spectrum antibiotics may be offered in some selected cases. Herein, we report two cases of perforated duodenal diverticulum, one case managed with surgical treatment and one with conservative treatment.