Double-balloon enteroscopy-assisted closure of perforated duodenal diverticulum using polyglycolic acid sheets

Duodenal diverticula perforation caused by an impacted bezoar successfully treated by endoscopic drainage and lithotripsy: A case report and literature review

Duodenal diverticula perforation due to an impacted bezoar is a rare disease. Surgical treatment is associated with high rates of complications and mortality; therefore, treatment strategies must be carefully decided. Endoscopic treatment offers significant benefits to patients over surgery.

Spontaneous perforation of a primary duodenal diverticulum stepped treatment model: A 10-patient case report

After colonic diverticula, a duodenal diverticulum (DD) is the second most common type of gastrointestinal diverticulum. DD is mainly caused by poor congenital development, resulting in a limited outward protrusion of the duodenal wall in a sac (primary diverticula). Perforation is one of the infrequent but most severe complications of DD, most commonly in the second segment of the duodenum (D2, 58%), followed by the third segment (D3, 30%). In the current case reports on the treatment of DD perforation, preoperative diagnosis is rare, with most patients being diagnosed and treated by laparotomy; the surgical approach is complex and varied, with artificial choices; and there is a high rate of complications and mortality (6%–34%) after surgical treatment. This study aimed to review our experience treating spontaneous perforation of the primary duodenal diverticulum, focusing on the surgical treatment model. A retrospective review of all spontaneous perforations of primary DD was conducted at one center between January 2010 and January 2022. We identified 10 patients with spontaneous perforation of primary DD (6 women and 4 men; median age: 51.5 years; range: 24–87 years). The patients had a median American Society of Anesthesiologists (ASA) score of 2. All patients underwent surgical treatment, of which six had percutaneous retroperitoneal drainage, two had diverticulectomy, one had distal gastrectomy + gastrojejunostomy + diverticuloplasty, and one had diverticulum repair. No patients died. The median length of stay was 12 days (range: 3–21 days). There were no long-term complications during the follow-up period (median follow-up of 12 months). A stepwise treatment model for spontaneous perforation of primary DD appears to have more advantages, and transabdominal exploratory surgery should probably not be the preferred treatment modality.

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.

Endoscopic Closure of an Acute Duodenal Perforation Occurring during Endoscopic Ultrasound Using Endoclips and Polyglycolic Acid Sheets with Fibrin Glue

Acute duodenal perforation during endoscopic ultrasound (EUS) is a serious complication. The conventional endoscopic treatment for duodenal perforations such as endoscopic clipping is unsatisfactory; recently, the effectiveness of over-the-scope clipping (OTSC) has been reported. A 91-year-old woman was referred to our hospital with the chief complaint of jaundice. Contrast-enhanced computed tomography showed a 2-cm mass in the pancreatic head; we planned EUS-guided fine-needle aspiration. During exploration for a puncture route from the duodenal bulb using a linear echoendoscope under carbon dioxide insufflation, the duodenal lumen was suddenly filled with blood. A perforation <15 mm was identified in the superior duodenal horn. We attempted an endoscopic closure with multiple endoclips but could not completely close the perforation site. Strips of bioabsorbable polyglycolic acid (PGA) sheets were placed over the gaps between the endoclips with biopsy forceps and fixed in place with fibrin glue, completely covering the perforation site. Two days after the procedure, the perforation site had closed. Nine days later, endoscopic biliary stenting was performed. The patient was diagnosed with pancreatic cancer through bile cytology, and the optimal supportive care for her age was selected. Endoscopic tissue shielding with PGA sheets and fibrin glue is increasingly being reported for use during gastrointestinal endoscopic procedures. In this case, surgery was avoided due to successful endoscopic treatment using endoclips and PGA sheets with fibrin glue without OTSC. This method may be useful for repairing acute duodenal perforations during EUS and should therefore be known to pancreatobiliary endoscopists.