Malignant colo-duodenal fistula: management based on proposed classification

Duodenal involvement in colonic malignancy is a rare event and poses challenge to surgeons as it may entail major resection in a malnourished patient. Nine patients with malignant colo-duodenal fistula were reviewed retrospectively. Depending on the pattern of duodenal involvement, it was classified as-type I involving lateral duodenal wall less than half circumference; type II involving more than half circumference away from papilla; type III involving more than half circumference close to papilla. Type I was managed with sleeve resection, type II with segmental and type III with pancreaticoduodenectomy. Median age was 47 years, with male to female ratio of 2:1. Eight patients had anemia and seven had hypoproteinemia. Tumor was located in right colon in eight patients and distal transverse colon in one. Diagnosis of fistula was established by CT abdomen in seven (78%), foregut endoscopy in three and intraoperatively in two patients. Two patients had metastatic disease. Elective resection was done in seven while two required emergence surgery. Five patients underwent sleeve resection of the duodenum, two underwent segmental resection and two required pancreaticoduodenectomy. All patients had negative resection margin. One patient died. Median survival was 14 months in eight survivors. Duodenal resection in malignant colo-duodenal fistula should be tailored based on the extent and pattern of duodenal involvement. Negative margin can be achieved even with sleeve resection. En bloc pancreaticoduodenectomy is sometimes required due to extensive involvement. Resection with negative margin can achieve good survival.

Duodenal pathologies in children: a single-center experience

OBJECTIVE

Several studies have been performed concerning pathologies of the stomach and esophagus in the pediatric age group. However, there have been very few studies of duodenal pathologies in children. The authors aimed to examine the clinical, endoscopic, and histopathological characteristics, as well as the etiology of duodenal pathologies in children.

METHOD

Patients aged between 1 and 17 years undergoing esophagogastroduodenoscopy during two years at this unit, were investigated retrospectively. Demographic, clinical, endoscopic data, and the presence of duodenal pathologies, gastritis, and esophagitis were recorded in all of the children.

RESULTS

Out of 747 children who underwent endoscopy, duodenal pathology was observed in 226 (30.3%) patients. Pathology was also present in the esophagus in 31.6% of patients and in the stomach in 58.4%. The level of chronic diarrhea was higher in patients with duodenal pathology when compared with those without duodenal pathology (p=0.002, OR: 3.91, 95% CI: 1.59-9.57). Helicobacter pylori infection was more common in patients with pathology in the duodenum (59.3%).

CONCLUSION

Duodenal pathology was detected in 30.3% of the present patients. A significantly higher level of chronic diarrhea was observed in subjects with duodenal pathologies compared to those with no such pathology. The rate of Helicobacter pylori infection was considerably higher than that in previous studies. In addition, there is a weak correlation between endoscopic appearance and histology of duodenitis.

Juxtapapillary duodenal diverticula: MDCT findings in 1010 patients and proposal for a new classification

The aim of this study is to analyze the MDCT findings of juxtapapillary duodenal diverticula (JPDD) and to propose a new radiological classification. CT-examinations of 1010 consecutive patients, all examined by 16-row MDCT of the abdomen over a time period of 20 months were retrospectively analyzed. All study patients were examined by triple phase CT (native, arterial and portal venous CT scan) of the abdomen and all recieved positive oral contrast prior to the examination. Thirty-three patients showed a juxtapapillary duodenal diverticulum, which could be seen on all CT scans, but jusually was depicted most clearly on the thin collimated arterial phase CT images. Size of diverticula range from 4 mm to 4.5 cm (mean 1.7 cm). In 17 cases the diverticulum was located ventrally to the vaterian sphincter complex, extending less or more into the pancreas at the site where the dorsal and the ventral anlage of the pancreas have fused (type I). 12 diverticula were located dorsally to the sphincter complex (type II). Three patients presented with a bilobated juxtapapillary diverticulum extending to both sides, ventrally and dorsally (type III) and one patient showed a little diverticulum ventrally to the minor papilla (type IV).Three patients presented with food impaction in the diverticulum but only one of these patients with a large IPDD showed a Lemmel-syndrome, whereas the other three patients with non-calculous extrahepatic cholostasis showed larger diverticula without food impaction. MDCT allows to identify four different types of juxtapapillary duodenal diverticula and using the proposed classification may be helpful for a more exact, anatomy based radiological description of this CT finding.

Development of a rating system for digestive system impairments: Korean Academy of Medical Sciences Guideline

A systematic and effective welfare system for people with digestive system impairments is required. In Korea, an objective and scientific rating guideline does not exist to judge the digestive system impairments. Whether the impairments exist or not and the degree of it need to be examined. Thus, with these considerations we need a scientific rating guideline for digestive system impairments to fit our cultural and social background. In 2007, a research team, for the development of rating impairment guidelines, was organized under the supervision of Korean Academy of Medical Sciences. The rating guidelines for digestive system impairments was classified into upper and lower gastrointestinal tracts impairments and liver impairment. We developed objective rating guidelines for the upper gastrointestinal tract, the impairment generated after surgery for the stomach, duodenum, esophagus, and for the lower gastrointestinal tract, the impairment generated after construction and surgery for colon, rectum, anus, and intestinal stomas. We tried to make the rating impairment guidelines to include science, objectivity, convenience, rationality, and actuality. We especially emphasized objectivity as the most important value. We worked to make it easy and convenient to use for both the subjects who received the impairment ratings and the doctors who will give the ratings.

Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula

BACKGROUND/AIMS

To propose a classification schema to describe periampullary duodenal diverticula (PDD) found at endoscopic retrograde cholangiopancreatography (ERCP), and to study the characteristics of these diverticula.

MATERIALS AND METHODS

Among 400 consecutive patients in whom an ERCP was performed, PDD were present in 131 (32.8%), being these patients significantly older than the remaining, served as controls.

RESULTS

PDD were classified in 3 different types according to the position of the major duodenal papilla: type I (16.3%), inside the diverticulum; type II (10.2%), in the margin of the diverticulum; and type III (6.5%), near the diverticulum. PDD were not associated with a more difficult cannulation of the biliary tract.

CONCLUSIONS

PDD are common, especially in older patients, and do not significantly increase the difficulty of deep cannulation.

Positive predictive value of ICD-9th codes for upper gastrointestinal bleeding and perforation in the Sistema Informativo Sanitario Regionale database

We identified patients whose records in the Sistema Informativo Sanitario Regionale database in the Italian region of Friuli-Venezia Giulia showed a code of upper gastrointestinal bleeding (UGIB) and perforation according to codes of the International Classification of Diseases (ICD)-9th revision. The validity of site- and lesion-specific codes (531 to 534) and nonspecific codes (5780, 5781, and 5789) was ascertained through manual review of hospital clinical records. The initial group was made of 1779 potential cases of UGIB identified with one of these codes recorded. First, the positive predictive values (PPV) were calculated in a random sample. As a result of the observed high PPV of 531 and 532 codes, additional hospital charts were solely requested for all remaining potential cases with 533, 534, and 578 ICD-9 codes. The overall PPV reached a high of 97% for 531 and 532 site-specific codes, 84% for 534 site-specific codes, and 80% for 533 lesion-specific codes, and a low of 59% for nonspecific codes. These data suggest a considerable research potential for this new computerized health care database in Southern Europe.

Clinical analysis of choledochoduodenal fistula with cholelithiasis in Taiwan: assessment by endoscopic retrograde cholangiopancreatography

OBJECTIVES

Choledochoduodenal fistula (CDF) is occasionally found during endoscopic retrograde cholangiopancreatography (ERCP). Cholelithiasis is suspected to be the leading cause in some endemic areas. We focus on this cause of CDF to determine which clinical characteristics are relevant to formation of fistulas and to learn whether CDF of various types would imply different clinical significance.

METHODS

In 1882 ERCP studies from 1988 to 1993, we found 27 CDF with cholelithiasis in 1066 patients. Their clinical backgrounds and ERCP findings were compared with those of 492 patients who had cholelithiasis but no CDF.

RESULTS

The prevalence of CDF was 2.53%. A longer past history of biliary stones, recurrent biliary tract infection (BTI), and the presence of common bile duct stones (CBS) were factors relevant to the formation of fistula. In the case of 24 distal fistulas, including seven of type I and 17 of type II, there was concurrent distal CBS. Three cardinal features of fistula of the distal type were: 1) the length of CDF was less than 1.5 cm, 2) its orifice was just around or on the papillary fold, and 3) all cases of distal type II had prominent pneumobilia, less jaundice, and larger CBS than type I. Aggressive endoscopic or surgical treatment of distal type CDF decreased the recurrence of BTI, as indicated by surveillance for 1 yr. Three fistulas of the proximal type were longer and drained into the duodenum far from the papilla. All of these cases deserved early surgical intervention.

CONCLUSIONS

CDF really serves as a chronic sequel of cholelithiasis. Different clinical features of CDF of various types help one to establish diagnosis and treatment. To avoid recurrence of BTI, aggressive therapy to correct CDF is mandatory.

Review of duodenal diverticula

Duodenal diverticula occur in 2-5% of patients undergoing barium studies of the upper intestinal tract. Duodenal diverticula are classified into two types: extraluminal or intraluminal. Usually of little clinical significance, they can cause obstruction, cholelithiasis, ascending cholangitis, ulcers, and hemorrhage, and may perforate. Associated intestinal tract malformations have been reported in 40% of patients with intraluminal duodenal diverticula. Diagnosis is made by endoscopy or upper gastrointestinal series. In symptomatic cases, extraluminal diverticula are amenable to surgery, whereas intraluminal diverticula may be either surgically or endoscopically resected. Imaging of the biliary tree should be performed prior to any intervention.

Chronic nonspecific duodenitis (bulbitis)

"Bulbitis" was classified by fiberoptic endoscopy in: superficial, erosive and pseudopolypoid. Endoscopic diagnosis of "bulbitis" is reliable, as good agreement was obtained in 100 cases tabulated according to histological grading. Erosive "bulbitis" implies a severe histopathological compromise.

Anatomic relationship of insertion of the common bile duct into primary duodenal diverticula

Examination of 96 postmortem specimens disclosed six diverticula of the second portion of the duodenum. In every instance, the common bile duct either emptied into, or immediately adjacent to, the diverticulum. The pancreatic duct was opacified twice; it was also intimately associated with the diverticulum on both occasions. This relationship is almost constant and should be considered in the management of patients with biliary and pancreatic disease who have primary duodenal diverticula.