MR Venous Flow in Sigmoid Sinus Diverticulum

BACKGROUND AND PURPOSE

Case reports demonstrate that coiling of a sigmoid sinus diverticulum can treat pulsatile tinnitus. We hypothesized that MR imaging 4D flow and computational fluid dynamics would reveal distinct blood flow patterns in the venous outflow tract in these patients.

MATERIALS AND METHODS

Patients with pulsatile tinnitus of suspected venous etiology underwent MR imaging at 3T, using venous phase contrast-enhanced MR angiography, 4D flow, and 2D phase contrast. The contrast-enhanced MRA contours were evaluated to determine the presence and extent of a sigmoid sinus diverticulum. Computational fluid dynamics analysis was performed using the 4D flow inlet flow and the luminal contours from contrast-enhanced MRA as boundary conditions. In addition, computational fluid dynamics was performed for the expected post treatment conditions by smoothing the venous geometry to exclude the sigmoid sinus diverticulum from the anatomic boundary conditions. Streamlines were generated from the 4D flow and computational fluid dynamics velocity maps, and flow patterns were examined for the presence of rotational components.

RESULTS

Twenty-five patients with pulsatile tinnitus of suspected venous etiology and 10 control subjects were enrolled. Five (20%) of the symptomatic subjects had sigmoid sinus diverticula, all associated with an upstream stenosis. In each of these patients, but none of the controls, a stenosis-related flow jet was directed toward the opening of the sigmoid sinus diverticulum with rotational flow patterns in the sigmoid sinus diverticulum and parent sigmoid sinus on both 4D flow and computational fluid dynamics.

CONCLUSIONS

Consistent patterns of blood flow can be visualized in a sigmoid sinus diverticulum and the parent sinus using 4D flow and computational fluid dynamics. Strong components of rotational blood flow were seen in subjects with sigmoid sinus diverticula that were absent in controls.

Role of urodynamics in management of urethral diverticulum in females

BACKGROUND

Few studies have focused on the urodynamic findings of urethral diverticula (UD). We characterized the symptoms and urodynamic findings in women with UD.

METHODS

A retrospective review of all women in a single center having surgical treatment for symptomatic UD between May 2004 and September 2014 was done. Lower urinary tract symptoms were evaluated with International Prostate Symptom Score and Overactive Bladder Symptom Score questionnaires. All patients underwent magnetic resonance imaging and videourodynamic study (VUDS) prior to surgery, and postoperative evaluation with VUDS.

RESULTS

A total of 20 female patients were enrolled into the study. 12 (60%) UD patients presented with symptoms of stress urinary incontinence (SUI). However, there were merely 3 (15%) patients diagnosed as urodynamic SUI. 15 (75%) patients exhibited low catheter-free uroflow. Detrusor overactivity was demonstrated in 4 (20%) patients. Bladder outlet obstruction (BOO) was diagnosed in 8 (40%) cases. Postoperative VUDS revealed persistent BOO in 50% of patients with preoperative BOO. Of these, residual diverticulum was noted by VUDS in one patient.

CONCLUSION

For UD patients with urinary incontinence or voiding dysfunction, VUDS is helpful in accurately characterizing these symptoms.

No neuronal loss, but alterations of the GDNF system in asymptomatic diverticulosis

Background

Glial cell line-derived neurotrophic factor (GDNF) is a potent neurotrophic factor known to promote the survival and maintenance of neurons not only in the developing but also in the adult enteric nervous system. As diverticular disease (DD) is associated with reduced myenteric neurons, alterations of the GDNF system were studied in asymptomatic diverticulosis (diverticulosis) and DD.

Methods

Morphometric analysis for quantifying myenteric ganglia and neurons were assessed in colonic full-thickness sections of patients with diverticulosis and controls. Samples of tunica muscularis (TM) and laser-microdissected myenteric ganglia from patients with diverticulosis, DD and controls were analyzed for mRNA expression levels of GDNF, GFRA1, and RET by RT-qPCR. Myenteric protein expression of both receptors was quantified by fluorescence-immunohistochemistry of patients with diverticulosis, DD, and controls.

Results

Although no myenteric morphometric alterations were found in patients with diverticulosis, GDNF, GFRA1 and RET mRNA expression was down-regulated in the TM of patients with diverticulosis as well as DD. Furthermore GFRA1 and RET myenteric plexus mRNA expression of patients with diverticulosis and DD was down-regulated, whereas GDNF remained unaltered. Myenteric immunoreactivity of the receptors GFRα1 and RET was decreased in both asymptomatic diverticulosis and DD patients.

Conclusion

Our data provide evidence for an impaired GDNF system at gene and protein level not only in DD but also during early stages of diverticula formation. Thus, the results strengthen the idea of a disturbed GDNF-responsiveness as contributive factor for a primary enteric neuropathy involved in the pathogenesis and disturbed intestinal motility observed in DD.

The effect of bladder diverticula on bladder function: An experimental study in rabbits

OBJECTIVE

This study aims to evaluate the effect of bladder diverticula (BD) on bladder function using a rabbit model, based on urodynamic findings.

METHODS

A total of 32 New Zealand white rabbits were randomly assigned to four groups: (1) sham surgery; (2) a single, 1-cm-diameter BD; (3) a single, large, 3-cm-diameter BD; and (4) four (multi) 1-cm-diameter BD. Urodynamic evaluations were performed preoperatively, and 1week and 1month postoperatively, to measure the postmicturition residual (PMR), maximum bladder capacity (MBC), filling and voiding detrusor pressure (Pdet), compliance, and unstable detrusor contractions. At the end of the study, the animals were sacrificed and assessed for pathologic evaluation and stone formation.

RESULTS

In groups 3 and 4, the rabbits all had PMR. At 30days postsurgery, the MBC was found to be 28% and 31% lower than the reference range in groups 3 and 4 and compliance was decreased (p<0.05). Further, the filling Pdet was significantly higher for large and multiple BD than in the 1-cm diverticula or sham groups (6.33±1.73, 4±1.26, p=0.0001). Groups 3 (62%) and 4 (50%) had unstable detrusor contractions. There was also a muscular/collagen ratio increase in the large and multiple BD groups. Four rabbits in the large group and one rabbit in the multiple BD group exhibited stone formation.

CONCLUSIONS

Large or multiple BD can alter bladder storage and emptying, and can decrease the capacity of the bladder and reduce its elasticity. Large or multiple bladder diverticula can lead to involuntary contractions, causing dysfunctional voiding.

Temporal Bone Pneumatization and Pulsatile Tinnitus Caused by Sigmoid Sinus Diverticulum and/or Dehiscence

BACKGROUND

Although air cells within temporal bone may play an important role in the transmission of pulsatile tinnitus (PT) noise, it has not been studied systematically.

PURPOSE

To evaluate the difference in temporal bone pneumatization between PT patients with sigmoid sinus diverticulum and/or dehiscence (SSDD) and healthy people.

MATERIAL AND METHODS

A total of 199 unilateral persistent PT patients with SSDD and 302 control subjects underwent dual-phase contrast-enhanced CT (DP-CECT), to assess the grade of temporal bone pneumatization in each ear.

RESULTS

In the bilateral temporal bone of 302 controls, 16 ears were grade I, 53 were grade II, 141 were grade III, and 394 were grade IV. Among the affected ears of 199 PT cases, 1 ear was grade I, 18 were grade II, 53 were grade III, and 127 were grade IV. There was no significant difference in the pneumatization grade between the affected PT ear and either ear in the healthy subjects (p > 0.05).

CONCLUSION

Although air cells within the temporal bone are an important factor in the occurrence of PT, its severity does not differ significantly from the pneumatization of healthy people.

Asymptomatic large bladder diverticulum

The authors report a case of a 61-year-old woman diagnosed with large bladder diverticulum. Diagnosis was performed only after a series of investigations carried out for the occasional finding of hypercreatininaemia. Although the significant volumes of post void residual (PVR) and the relevant urine stagnation in the diverticulum, subjective symptomatology was absent and urinalysis and urine culture were negative. The scheduled therapeutic plan consisted of fosfomycin three grams every ten days for sixmonths, self-catheterization twice a day, voiding on a time schedule, and adequate fluid intake. The monthly scheduled follow-up at one year showed good general health, good compliance with the therapy, no urinary tract infections, a decrease in creatininemia to 1.2 mg/dl, and regression of nephrohydrosis to a mild stage. In conclusion, the absence of symptoms and negative urinalysis or urine culture allows expectant management despite the considerable size of the bladder diverticulum.

Acquired male urethral diverticulum: a complication following artificial urethral sphincter implantation

The authors report a case of a 72-year-old patient who underwent radical prostatectomy in 2003 due to prostate cancer. During follow-up, he presented with permanent and severe urinary stress incontinence for which he underwent an artificial urinary sphincter implantation in 2009. After infection of the device, followed by the development of a urinary fistula, the artificial urinary sphincter was removed. He presented no new signs or symptoms for 2 years, during which he remained completely incontinent. In April 2012, he developed a painless scrotal swelling close to the median raphe. On manual compression, it showed urinary leakage and disappeared completely, only to reappear several hours later. Auxiliary examinations revealed a bulbar urethral diverticulum which was subsequently excised. A urethroplasty was performed during the same procedure. The patient presented with no further complications. Although still suffering from complete urinary incontinence, he refused any kind of surgery for the time being.

The GDNF System Is Altered in Diverticular Disease - Implications for Pathogenesis

Background & Aims

Absence of glial cell line-derived neurotrophic factor (GDNF) leads to intestinal aganglionosis. We recently demonstrated that patients with diverticular disease (DD) exhibit hypoganglionosis suggesting neurotrophic factor deprivation. Thus, we screened mRNA expression pattern of the GDNF system in DD and examined the effects of GDNF on cultured enteric neurons.

Methods

Colonic specimens obtained from patients with DD (n = 21) and controls (n = 20) were assessed for mRNA expression levels of the GDNF system (GDNF, GDNF receptors GFRα1 and RET). To identify the tissue source of GDNF and its receptors, laser-microdissected (LMD) samples of human myenteric ganglia and intestinal muscle layers were analyzed separately by qPCR. Furthermore, the effects of GDNF treatment on cultured enteric neurons (receptor expression, neuronal differentiation and plasticity) were monitored.

Results

mRNA expression of GDNF and its receptors was significantly down-regulated in the muscularis propria of patients with DD. LMD samples revealed high expression of GDNF in circular and longitudinal muscle layers, whereas GDNF receptors were also expressed in myenteric ganglia. GDNF treatment of cultured enteric neurons increased mRNA expression of its receptors and promoted neuronal differentiation and plasticity revealed by synaptophysin mRNA and protein expression.

Conclusions

Our results suggest that the GDNF system is compromised in DD. In vitro studies demonstrate that GDNF enhances expression of its receptors and promotes enteric neuronal differentiation and plasticity. Since patients with DD exhibit hypoganglionosis, we propose that the observed enteric neuronal loss in DD may be due to lacking neurotrophic support mediated by the GDNF system.

Duodenal switch operation for juxtapapillary duodenal diverticula

BACKGROUND/AIMS

Since the first case of juxtapapillary diverticlum reported by Lemmel, several reports have demonstrated an association between periampullary diverticulum and gallstone disease. Thus, we compared the efficiency of the duodenal switch operation and choledchojejunostomy for patients who underwent surgery for cholangitis with juxtapapillary duodenal diverticula.

METHODOLOGY

We retrospectively studied 17 patients who had cholangitis associated with juxtapapillary duodenal diverticula. These patients were divided into 2 groups on the basis of the operative procedure: the duodenal switch operation group (DS group) and the choledochojejunostomy group (CJ group).

RESULTS

The mean operative time and blood loss were significantly lesser in the DS group than in the CJ group (p<0.0001 and p<0.0005, respectively); however, the duration of nasogastric suction requirement and time after which oral ingestion of solid diet could be safely resumed after surgery were significantly longer in the DS group than in the CJ group (p<0.0001 and p<0.0001, respectively). Gallstone formation after the surgery did not occur in both groups.

CONCLUSIONS

Duodenal switch operation is useful and less invasive for cholangitis associated with juxtapapillary duodenal diverticula and for preventing cholangitis for a long period after the operation; however, gastric stasis still remains a problem with this procedure.

[Female urethral diverticula--clinical and surgical aspects]

Urethral diverticula are a common cause of chronic genitourinary symptoms in women. They occur in 5% of women overall, with higher frequencies in selected populations of symptomatic women. The classical presentation is with recurrent urinary tract infections and post-micturition dribbling but almost any urinary symptom may be a presenting feature. Newer imaging modalities such as magnetic resonance imaging and perineal ultrasound are now widely available and urethral diverticula, that were previously unrecognized, can now be more easily detected. However, despite the availability of effective diagnostic techniques, diagnosis is often delayed. This is due to a lack of awareness among clinicians. These patients are often inappropriately treated for other conditions, significantly delaying the proper management of their condition. A high index of suspicion, a careful examination and referral for appropriate investigation will improve the number correctly diagnosed and lead to considerable benefit since most symptomatic cases can be cured by appropriate surgery. This review aims to summarize the presentation, investigation and management of female urethral diverticulum. Hopefully, greater awareness will lead to more timely diagnosis and appropriate treatment.

Mounier-Kuhn syndrome: a rare cause of bronchial dilation

Mounier-Kuhn syndrome, or tracheobronchomegaly, is a rare clinical and radiologic condition characterized by marked tracheobronchial dilation and recurrent lower respiratory tract infections. Diagnosis is typically accomplished with the use of computed tomography and bronchoscopy, as well as pulmonary function testing. Patients may be asymptomatic; however, symptoms can range from minimal with preserved lung function to severe respiratory failure. Therapy, if any, is supportive but minimal. Surgery rarely has a place in the treatment of Mounier-Kuhn syndrome.Herein, we report the case of a 58-year-old man with chronic obstructive pulmonary disease who had a chronic cough, increased sputum production, and chest pain. Thoracic computed tomography showed tracheal dilation (diameter, 34 mm) and multiple diverticula in the posterior region of the trachea. Fiberoptic bronchoscopy revealed enlarged main bronchi, the dilated trachea, and prominent tracheal diverticula. Pulmonary function testing disclosed impaired respiratory function. Histopathologic examination of biopsy specimens from the bronchi and the tracheal wall supported the diagnosis of Mounier-Kuhn syndrome. The patient was released from the hospital and his condition was monitored for 2 years, during which time he developed no lower respiratory tract infections.Regardless of radiologic findings that suggest recurrent lower respiratory tract infection, we recommend that Mounier-Kuhn syndrome be considered in the differential diagnosis.

Urethral diverticula: a review and an update

Likely originating from the periurethral glands, female urethral diverticula (UD) are an uncommon but fascinating clinical entity. UD are variable in their presentation and the diagnosis is sometimes difficult and delayed. Modern imaging modalities such as surface coil and endoluminal magnetic resonance imaging (MRI) have added to the diagnostic armamentarium but have also furthered our understanding of UD. Accurate preoperative characterization of the often complex anatomical patterns seen on these imaging studies including saddlebag and circumferential urethral involvement, as well as complete evaluation of associated voiding dysfunction such as complete evaluation of associated voiding dysfunction such as urinary incontinence often impacts contemporary surgical management.

Lumbar radiculopathy in ankylosing spondylitis with dural ectasia

We present a 57-year-old man with ankylosing spondylitis (AS) and significant dorsal lumbar dural ectasia (diverticulum). An L5 nerve root monoradiculopathy associated with AS has not been previously reported. The quantity and extent of such ectasia is variable but may be related to cauda equina syndrome. Long-term follow-up of these cases may reveal whether or not solitary nerve lesions gradually lead to cauda equina syndrome. We recommend that asymptomatic or symptomatic patients with dural ectasia should be closely observed without need for immediate surgical intervention.

Giant bladder diverticulum as a rare cause of intestinal obstruction: report of a case

We report a case of intestinal obstruction as an unusual manifestation of bladder diverticulum. To our knowledge, this is the first report of a giant bladder diverticulum causing acute abdomen as a result of mechanical bowel obstruction.

Congenital Right Ventricular Diverticulum Associated With a Ventricular Septal Defect: A Rare Echocardiographic Finding

A neonate presented on the first day of life with tachypnea and poor feeding. The infant's initial echocardiogram demonstrated outpouching of the lateral wall of the right ventricle (RV) associated with a large ventricular septal defect (VSD). At 9 days of age he was diagnosed with osteogenesis imperfecta (OI). Despite treatment with digoxin, diuretics, and captopril he required hospitalization twice during his first 2 months of life for congestive heart failure (CHF). The VSD was closed at three and one-half months of age without resection of the diverticulum and CHF symptoms resolved. At 26 months of age he is doing well despite the residual RV diverticulum. Congenital cardiac diverticula are rare forms of cardiac malformations and their echo-Doppler features are herein discussed.

Neural contractions in colonic strips from patients with diverticular disease: role of endocannabinoids and substance P

BACKGROUND AND AIMS

Diverticulosis is a common disease of not completely defined pathogenesis. Motor abnormalities of the intestinal wall have been frequently described but very little is known about their mechanisms. We investigated in vitro the neural response of colonic longitudinal muscle strips from patients undergoing surgery for complicated diverticular disease (diverticulitis).

METHODS

The neural contractile response to electrical field stimulation of longitudinal muscle strips from the colon of patients undergoing surgery for colonic cancer or diverticulitis was challenged by different receptor agonists and antagonists.

RESULTS

Contractions of colonic strips from healthy controls and diverticulitis specimens were abolished by atropine. The beta adrenergic agonist (-) isoprenaline and the tachykinin NK1 receptor antagonist SR140333 had similar potency in reducing the electrical twitch response in controls and diseased tissues, while the cannabinoid receptor agonist (+)WIN 55,212-2 was 100 times more potent in inhibiting contractions in controls (IC50 42 nmol/l) than in diverticulitis strips. SR141716, a selective antagonist of the cannabinoid CB1 receptor, had no intrinsic activity in control preparations but potentiated the neural twitch in diseased tissues by up to 196% in a concentration dependent manner. SR141716 inhibited (+)WIN 55,212-2 induced relaxation in control strips but had no efficacy on (+)WIN 55,212-2 responses in strips from diverticular disease patients. Colonic levels of the endogenous ligand of cannabinoid and vanilloid TRPV1 receptors anandamide were more than twice those of control tissues (54 v 27 pmol/g tissue). The axonal conduction blocker tetrodotoxin had opposite effects in the two preparations, completely inhibiting the contractions of control strips but potentiating those in diverticular preparations, an effect selectively inhibited by SR140333.

CONCLUSIONS

Neural control of colon motility is profoundly altered in patients with diverticulitis. Their raised levels of anandamide, apparent desensitisation of the presynaptic neural cannabinoid CB1 receptor, and the SR141716 induced intrinsic response, suggest that endocannabinoids may be involved in the pathophysiology of complications of colonic diverticular disease.

[Urodynamics of the bladder diverticulum in the adult male]

OBJECTIVES

To evaluate the clinical and urodynamic characteristics of a series of adult males with BPH and bladder diverticula, and to analyze the changes in urodynamics in patients undergoing lower urinary tract surgery to relieve obstruction, with or without associated diverticulectomy.

METHODS

We studied 91 patients in two groups: Group 1- BPH: 67 cases (73.6%) and Group 2-BPH + diverticulum: 24 cases (25%). Mean age was 65.04 years. All patients underwent urological physical examination and complete urodynamic study including cystogram. In addition, we studied 19 patients with BPH and bladder diverticula (mean age 64.58 years) who underwent either endoscopic surgery (1 I cases; 57.9%) or endoscopic surgery plus diverticulectomy (8 cases, 42. 1%). Complete clinical study and urodynamics (including cystogram) were performed preoperative and three months after surgery. Statistical significance was established at 0.05.

RESULTS

Comparative study between group 1 (BPH) and group 2 (BPH with diverticulum): there were significant differences in clinical data: acute urinary retention (6.1% vs. 25%;p<0.01), and urinary tract infection (3.1% vs. 21.7%;p=0,004). All evaluated cases had single diverticula (8 cases). Urodynamic studies showed: 1) Post-void residual after free flowmetry: 45.9 ml vs. 221.4 ml, p = 0.008. 2) Bladder capacity on cystometrogram: 211.2 ml vs. 350.8 ml, p = 0.024. 3) Voiding pressure/flow study: a) Voiding with abdominal press 23.9% vs. 50%, p = 0.02. b) URA 36.5 cm H2O vs. 48.5 cm H2O, p= 0.04, c) post void residual 70.7ml vs. 210.3 ml, p= 0.004. d) Bladder contractility measurements (Wmax- isometric contractility- and W80, W20- isotonic contractility) did not show significant differences between groups. Bladder contractility duration was significantly decreased in group 2. In the analysis of patients undergoing surgery to relieve obstruction (Group A- Surgery without diverticulectomy; Group B Surgery with diverticulectomy) there were not differences between groups in clinical data. Urethral resistance parameters (URA) decreased in both groups. Group A: from 43 cm H20 to 26.3 cm H2O. Group B: from 60.6 cm H2O to 48 cm H2O. This decrease was similar after either TURP or myocapsulotomy. Post void residual diminished in both groups. There were no statistical differences between groups in Wmax, W 80-20, or volume, number and site of the diverticula. On the contrary, bladder contractility duration diminished after diverticulectomy.

CONCLUSIONS

Bladder diverticula appear in the cases with highest ureteral resistance values (lower urinary tract obstruction). Standard bladder contractility parameters were not diminished. Duration of detrusor contraction was the only contractility parameter significantly affected in cases of bladder diverticula and presented a significant association with the use of abdominal press while voiding. Diverticulectomy showed an improvement of bladder contractility with longer detrusor contraction duration, which supports its use in cases of BPH-associated diverticula. Both TURP and transurethral incision of the prostate diminished urethral resistance in a similar way, so that they may be considered alternative options. Our data should be confirmed with a bigger sample size.

Smoothelin-a is essential for functional intestinal smooth muscle contractility in mice

BACKGROUND & AIMS

In patients with chronic intestinal pseudo-obstruction, intestinal motility is disturbed by either nervous or myogenic aberrations. The cause of the myogenic form is unknown, but it is likely to originate in the contractile apparatus of the smooth muscle cells. Smoothelins are actin-binding proteins that are expressed abundantly in visceral (smoothelin-A) and vascular (smoothelin-B) smooth muscle. Experimental data indicate a role for smoothelins in smooth muscle contraction. A smoothelin-deficient mouse model may help to establish the role of smoothelin-A in intestinal contraction and provide a model for myogenic chronic intestinal pseudo-obstruction.

METHODS

We used gene targeting to investigate the function of smoothelin-A in intestinal tissues. By deletion of exons 18, 19, and 20 from the smoothelin gene, the expression of both smoothelin isoforms was disrupted. The effects of the deficiency were evaluated by pathologic and physiologic analyses.

RESULTS

In smoothelin-A/B knockout mice, the intestine was fragile and less flexible compared with wild-type littermates. The circular and longitudinal muscle layers of the intestine were hypertrophic. Deficiency of smoothelin-A led to irregular slow wave patterns and impaired contraction of intestinal smooth muscle, leading to hampered transport in vivo. This caused obstructions that provoked intestinal diverticulosis and occasionally intestinal rupture.

CONCLUSIONS

Smoothelin-A is essential for functional contractility of intestinal smooth muscle. Hampered intestinal transit in smoothelin-A/B knockout mice causes obstruction, starvation, and, ultimately, premature death. The pathology of mice lacking smoothelin-A is reminiscent of that seen in patients with chronic intestinal pseudo-obstruction.

Stacked Proximal Aortic Cuffs:An “Off-the-Shelf” Solution for Treating Focal Thoracic Aortic Pathology

PURPOSE

To report our early experience with the endovascular placement of stacked Zenith main body extensions (cuffs) in the treatment of focal thoracic aortic pathology in high-risk patients.

METHODS

Between January 2003 and May 2004, 6 patients (3 men; mean age 59 years, range 37-82) with focal aortic pathology underwent endovascular repair using stacked 30 and 32-mm-diameter Zenith main body extensions. The setting was a university tertiary referral center for vascular disease. Indication for treatment included 2 descending thoracic aneurysms and individual cases of traumatic thoracic tear, diverticulum of Kommerell, thoracic pseudoaneurysm, and aortoesophageal fistula.

RESULTS

All procedures were performed successfully, with a mean of 3 cuffs used. The patient with an aortoesophageal fistula expired after successful cuff placement due to sequela of massive pretreatment hemorrhage; fistula coverage was confirmed at autopsy. There were no type I endoleaks. Morbidity included an occluded right subclavian artery from traumatic passage of the device through the artery. No left subclavian arteries were covered. No neurological deficits or paraplegia was observed. The cuffs were patent in all surviving patients at an average follow-up of 7 months (range 3-12). Computed tomography in all survivors confirmed adequate cuff placement, absence of endoleak, and lack of cuff migration. Based on this experience, the following technical recommendations are offered: (1) right subclavian cutdown when needed to reach a lesion beyond the range of the sheath, (2) Dacron chimney placement, (3) stiff guidewire usage, (4) wire placement from the right subclavian artery through the common femoral artery if necessary to ease a sharp bend in the arch, and (5) cuff overlap of 25% to 50%.

CONCLUSIONS

In high-risk patients, focal aortic pathology can be successfully treated with off-the-shelf commercially available cuffs using a stacking technique with acceptable mortality, morbidity, and short-term durability.

Isolated large true contractile left ventricular diverticulum mimicking ischemia in an adult patient: a case report

Congenital diverticulum of the ventricle is a rare cardiac abnormality that is characterized by local embryologic development failure of the ventricular muscle. It can be found as an isolated form or associated with other cardiac abnormalities. Clinically, it has been reported that it can lead to heart failure, arrhythmia, or chest pain, although frequently the course is asymptomatic. We present a patient who was referred to our clinic with chest pain due to isolated left ventricular diverticulum mimicking myocardial ischemia.

Perugia urodynamic method of analysis (PUMA): a new advanced method of urodynamic analysis applied clinically and compared with other advanced methods

AIMS

The aim of this study is to compare PUMA curves with different pathologic conditions causing bladder dysfunction in 158 men and 83 women.

METHODS

PUMA results in terms of bladder outlet obstruction and detrusor contractility were compared in 92 men with benign prostatic hypertrophy (BPH) and p(ves) congruent with p(det) (i.e., p(abd) congruent with 0) with the results of the urodynamics operator's opinion, the provisional International Continence Society method, Abrams and Griffith's diagram, urethral resistence factor (URA), Schäfer's diagram, and Watt factor. PUMA curves correlated reliably with different pathologic conditions such as obstructive BPH, orthotopic bladder, cystocele, the neurological bladder, and bladder diverticulum. Statistical analysis indicated excellent agreement between PUMA and URA; agreement with other methods was good in cases of obstruction and nonobstruction. In doubtful cases, as diagnosed by standard methods, PUMA agreed only with the Abrams and Griffith's diagram. PUMA and Wmax were in good agreement on detrusor con traction force. Agreement between PUMA and Schäfer's diagram was excellent for patients with detrusor hypercontractility and good for patients with detrusor hypocontractility and normocontractility. PUMA is the only method applicable to women. It is easy to perform. When integrated with other diagnostic tests, it provides realistic data for diagnosis, medical or surgical therapy, and outcome.

Accessory pathway in left inferoposterior diverticulum masquerading as left posterior pathway due to conduction over coronary sinus to left atrium connection

We report the case of an accessory pathway in a left inferoposterior diverticulum. The pathway masqueraded as a true left lateral pathway due to the direction of activation over a coronary sinus to left atrium connection. The patient had undergone four prior failed ablation attempts at other institutions using both a transseptal and retrograde approach.

Coronary sinus-ventricular accessory connections producing posteroseptal and left posterior accessory pathways: incidence and electrophysiological identification

BACKGROUND

The coronary sinus (CS) has a myocardial coat (CSMC) with extensive connections to the left and right atria. We postulated that some posteroseptal and left posterior accessory pathways (CSAPs) result from connections between a cuff of CSMC extending along the middle cardiac vein (MCV) or posterior coronary vein (PCV) and the ventricle. The purpose of the present study was to use CS angiography and mapping to define and determine the incidence of CSAPs and determine the relationship to CS anatomy.

METHODS AND RESULTS

CSAP was defined by accessory pathway (AP) potential or earliest activation in the MCV or PCV and late activation at anular endocardial sites. A CSAP was identified in 171 of 480 patients undergoing ablation of a posteroseptal or left posterior AP. CS angiography revealed a CS diverticulum in 36 (21%) and fusiform or bulbous enlargement of the small cardiac vein, MCV, or CS in 15 (9%) patients. The remaining 120 (70%) patients had an angiographically normal CS. A CSMC extension potential (CSE), like an AP potential, was recorded in the MCV in 98 (82%), in the PCV in 13 (11%), in both the MCV and PCV in 6 (5%), and in the CS in 3 (2%) of 120 patients. CSMC potentials were recorded between the timing of atrial and CSE potentials.

CONCLUSIONS

CSAPs result from a connection between a CSMC extension (along the MCV or PCV) and the ventricle. The CS is angiographically normal in most patients.

[Diverticular disease of the colon in peritoneal dialysis]

Colon diverticular disease is a very common pathology in western countries and represents a risk factor for septic-type complications, especially in peritoneal dialysis patients. We examined both diagnostic procedure and therapeutics options, either pharmacological or surgical. Ultrasonography, which is useful for the diagnosis of diverticulosis and diverticular disease, has been supported in the last few years by new imaging techniques, such as NMR and CT, that also find applications in the treatment of diverticulitis complications like peritoneal abscesses. Our emphasis is on the therapeutic perspective, either dietetic - based on the use of a fibre-rich diet and the infusion of liquids by intravenous injection - or surgical, such as the Hartmann procedure, single anastomosis with stomia conservation and laparoscopic and endoscopic treatment. These therapeutic approaches have reduced both morbidity and mortality rate and have emphasized how the reduction of surgical stress on the mesothelium promotes the recovery of the functional integrity and, consequently, faster resumption of peritoneal dialysis. In conclusion, diverticulosis alone is not a contraindication for peritoneal dialysis, but constitutes a risk factor for the continuation of this alternative treatment.

Congenital diverticulum of the right ventricle associated with coarctation of aorta, atrial and ventricular septal defect and ductus

Congenital right ventricular muscular diverticula are extremely rare and are usually associated with other congenital cardiac anomalies, (in half of the cases tetralogy of Fallot). They functionally behave like an accessory ventricular chamber which contracts synchronously with the normal ventricles. Less than 30 patients with a right ventricular diverticulum have been reported in literature. An apical right ventricular diverticulum occurs in patients with thoraco-abdominal midline defects or abnormalities of the cardiac position([1]). However, an antero-superior diverticulum is usually associated with other congenital cardiac defects, such as a ventricular septal defect, tetralogy of Fallot, double outlet right ventricle and pulmonary stenosis([2--9]). We report an 11-year-old boy with an antero-superior diverticulum of the right ventricle associated with a coarctation of aorta, ductus arteriosus, and atrial and ventricular septum defects. To the best of our knowledge, such an association has not been reported before.

Evaluation of spontaneous intracranial hypotension: assessment on ICP monitoring and radiological imaging

We describe two recent cases of spontaneous intracranial hypotension. A 38-year-old woman developed a severe postural headache. Magnetic resonance imaging (MRI) showed marked dural enhancement. Histopathological findings of dural biopsy showed numerous dilated vessels in the dura, rather than hypertrophic change. Lumber CSF pressure was 5 cmH2O and RI cisternography suggested CSF leakage. A 58-year-old woman with postural headache and vertigo had bilateral subdural haematoma associated with diffuse dural enhancement on MRI. Lumber CSF monitoring confirmed persistent low pressure ranging from 0-5 cm H2O. MRI myelography revealed multiple CSF pouches along the whole spinal axis. CSF leakage was demonstrated on Radioisotope (RI) cisternography. Both cases described in this report were diagnosed as spontaneous intracranial hypotension caused by CSF leakage from spinal meningeal diverticula and were successfully treated by intravenous Factor XIII administration.

[Hydronephrosis caused spontaneous evacuation of many small calculi in a caliceal diverticulum: a case report]

We experienced a curious case that hydronephrosis had caused spontaneous evacuation of calculi in a caliceal diverticulum. A 50-year-old woman was visited to our department complaining of right lower abdominal pain. Several right ureteral stones, right hydronephrosis and a great numbers of small round-shaped calculi in a right caliceal diverticulum were diagnosed. Many of the calculi moved from the diverticulum to ureter, and were evacuated spontaneously. The month after, the right hydronephrosis had already subsided and almost all of the calculi had disappeared. It was supposed that a hydronephrosis had widened the narrow channel between the diverticulum and the calyx and enabled the small calculi to pass through. Recent reports show that effectiveness of ESWL for symptomatic caliceal diverticular calculi is doubtful, because the narrow channel hinders the passage of stone fragments. However, this case suggests that an artificial hydronephrosis created by retrograde occlusion ureteral balloon catheter may lead to good drainage of gravel and better stone-free rate of caliceal diverticular calculi treated by ESWL.

Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement

PURPOSE

We describe various clinical presentations of urethral diverticulum, which may mimic other pelvic floor disorders and result in diagnostic delay. Management and outcome results are reported.

MATERIALS AND METHODS

We reviewed retrospectively 46 consecutive cases of urethral diverticulum. Patient characteristics, history, clinical evaluation, management and long-term followup are reported.

RESULTS

Mean patient age plus or minus standard deviation was 36.3 +/- 11.7 years. Most (83%) cases were referred as diagnostic dilemmas with symptoms present for 3 months to 27 years. Mean interval between onset of symptoms to diagnosis was 5.2 years. The most common symptoms were pain (48% of cases), urinary incontinence (35%), dyspareunia (24%) and frequency/urgency (22%). The number of physicians previously consulted ranged from 3 to 20 and prior therapies included oral and/or vaginal medications, anti-incontinence surgery and psychotherapy. The diverticulum was palpable on examination in 24 patients (52%), in only 6 of whom was it possible to "milk" contents per meatus. Of these 24 palpable diverticula 2 contained malignancy, and 2 others contained endometriosis and stones, respectively. Diagnosis was made by voiding cystourethrography in 30 cases (65%), double balloon urethrography in 5 (11%) and transvaginal ultrasound or magnetic resonance imaging in 7 (15%). Diverticula were incidental findings during vaginal surgery in 4 cases (9%). Treatment consisted of diverticulectomy and/or Martius flap, pubovaginal sling and urethral reconstructive procedures when indicated in 35 cases (76%), and 2 other patients underwent radical surgery for diverticular malignancy. Subsequently all but 2 patients with pain were cured. In another patient de novo stress incontinence developed postoperatively. None of the patients who underwent concomitant pubovaginal sling had postoperative incontinence.

CONCLUSIONS

The symptoms of urethral diverticulum may mimic other disorders. This condition should be considered in women with pelvic pain, urinary incontinence and irritative voiding symptoms not responding to therapy. Surgical treatment is usually effective in alleviating associated symptoms.

Intestinal motility in small bowel diverticulosis: a case report and review of the literature

Small bowel diverticulosis is a rare disease that is usually associated with recurrent pseudo-obstruction, bacterial overgrowth, and malabsorption. The more severe complications include hemorrhage and perforation. There is evidence to suggest that this entity is a result of small bowel motor dysfunction. For this reason, it has been associated with disorders in which a myopathic or neuropathic process is involved, such as scleroderma. The majority of patients with jejunal diverticulosis do not require surgery and can be managed medically. We report a case of jejunal diverticulosis in a 63-year-old gentleman who presented with symptoms of pseudo-obstruction. Ambulatory duodenojejunal manometry revealed several abnormalities suggestive of small bowel motor dysfunction. Enteroclysis, however, did not find evidence of mechanical obstruction, and the patient had marked improvement with cisapride and antibiotics.

Long-term follow-up of a true contractile left ventricular diverticulum

The natural history of contractile left ventricular diverticulum in the adult is not known. Serial left ventricular angiography in an adult revealed that a left ventricular diverticulum did not increase in size over a 13-year period, suggesting that the clinical course may be benign.

Urethral diverticulectomy and pubovaginal sling for simultaneous treatment of urethral diverticulum and intrinsic sphincter deficiency

The purpose of this article is to determine the efficacy and safety of simultaneous urethral diverticulectomy and placement of a pubovaginal sling in patients with concomitant urethral diverticula and intrinsic sphincter deficiency (ISD). Sixteen women (mean age of 53 years) underwent simultaneous urethral diverticulectomy and pubovaginal sling. ISD was determined by fluorourodynamic evaluation and Valsalva leak point pressures. Treatment outcome was determined by resolution of the diverticula and change in individual incontinence grades before and after surgical repair. All 16 who underwent urethral diverticulectomy had symptomatic resolution at a mean follow-up of 25 months. Fourteen of 16 patients (88%) had no physical or radiologic evidence of residual or recurrent diverticula, while 2 of 16 (12%) had small, stable residual diverticula. All 16 patients reported significant improvement in incontinence status after placement of the pubovaginal sling, with 14 of 16 (88%) cured and 2 of 16 (12%) significantly improved. Five of 16 (31%) had mixed incontinence preoperatively: 2 of 5 had resolution of detrusor instability (DI) after surgery, 3 of 5 had persistent DI. De novo DI developed in two patients. No patient had erosion of the sling despite its close proximity to the urethral mucosal suture line. The average time to complete bladder emptying was approximately 5 weeks, and no patient developed permanent urinary retention. Simultaneous pubovaginal sling and urethral diverticulectomy can be performed safely without increased risk to the urethral reconstruction, yet with excellent continence rates.

Catheter ablation for ventricular tachycardia from a diverticulum at the right ventricular outflow tract

A case is presented of a 73-year-old man with drug resistant ventricular tachycardia that originated from the right ventricular outflow tract. A right ventriculogram showed a diverticulum in the interventricular septum at the right ventricular outflow tract. Low energy radiofrequency catheter ablation within the diverticulum was performed successfully and safely.

Gallbladder diverticulum: a case report and review of the literature

Gallbladder diverticulum is an unusual and uncommon disease process rarely discussed in the literature. This disorder may not be diagnosed until surgically resected. The presentation may entail nonspecific complaints over a prolonged period as highlighted in a case report of a 17-year-old woman with this disease. The incidence and pathophysiology of this disease process is correlated to the symptoms and signs of this patient. The surgical findings, procedure, and outcome are described.

Surgical treatment of spontaneous spinal cerebrospinal fluid leaks

OBJECT

Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension and may require neurosurgical intervention. In the present report the authors review their experience with the surgical management of spontaneous spinal CSF leaks.

METHODS

Between 1992 and 1997, 10 patients with spontaneous spinal CSF leaks and intracranial hypotension were treated surgically. The mean age of the seven women and three men was 42.3 years (range 22-61 years). Preoperative imaging showed a single meningeal diverticulum in two patients, a complex of diverticula in one patient, and a focal CSF leak alone in seven patients. Surgical exploration in these seven patients demonstrated meningeal diverticula in one patient; no clear source of CSF leakage could be identified in the remaining six patients. Treatment consisted of ligation of the diverticula or packing of the epidural space with muscle or Gelfoam. Multiple simultaneous spinal CSF leaks were identified in three patients.

CONCLUSIONS

All patients experienced complete relief of their headaches postoperatively. There has been no recurrence of symptoms in any of the patients during a mean follow-up period of 19 months (range 3-58 months; 16 person-years of cumulative follow up). Complications consisted of transient intracranial hypertension in one patient and leg numbness in another patient. Although the disease is often self-limiting, surgical treatment has an important role in the management of spontaneous spinal CSF leaks. Surgery is effective in eliminating the headaches and the morbidity is generally low. Surgical exploration for a focal CSF leak, as demonstrated on radiographic studies, usually does not reveal a clear source of the leak. Some patients may have multiple simultaneous CSF leaks.

Topographic evaluation of lateral hypopharyngeal pouches using electron beam tomography

BACKGROUND

To evaluate the exact topography of lateral hypopharyngeal pouches using electron beam tomography.

METHODS

Seventeen patients, nine female, eight male, aged 28-72 years, who showed lateral hypopharyngeal pouches in the videofluorographic swallowing examination were studied using electron beam tomography. Upon swallowing a 20-ml bolus of water, the region of the thyrohyoid membrane was scanned 20 times per level. Scan parameters: single slice cine mode (exposure time 100 ms, slice thickness 3 mm, 620 mA, 130 KV).

RESULTS

The lateral hypopharyngeal pouches appeared air-filled in the posterior aspect of the thyrohyoid membrane closely attached to the upper horn of the thyroid cartilage, just below the hyoid bone.

CONCLUSIONS

With electron beam tomography it was possible to define the topographic location of the pouches more accurately, compared with the prior assumption of position.

[Functional changes in the bladder of children with primary bladder diverticulum]

OBJECTIVE

Primary vesical diverticulum is generally diagnosed during urological evaluation for recurrent urinary tract infection that are frequently associated with the symptoms of urinary dysfunction. A urodynamic study was performed in children with primary vesical diverticulum to confirm or discard the presence of vesicourethal dysfunction, its relationship with vesicoureteral reflux, which is associated with diverticulum, and the results achieved by surgical versus medical treatment.

METHODS/RESULTS

A urodynamic study was carried out in 11 children (7 boys and 4 girls), aged 6 to 13 years, with primary vesical diverticulum. The diverticulum was parameatal in 7 cases (4 with reflux), posterolateral in 2 cases (1 with reflux), anterolateral in 1 patient and 1 patient had multiple bladder diverticula without neurological disorder. Surgery was indicated in 8 cases and 3 were managed conservatively. Vesicourethral function, at the time the diverticulum was diagnosed, was normal in 3 (27%) and pathological in 8 (73%) patients. The urodynamic study disclosed uncoordinated vesicosphincteric function (4 pts), vesical instability (3 pts) and vesical hypotony (1 pt). Of these 4 cases with urodynamic disorders, diverticulum was associated with vesicoureteral reflux. Of the 8 children submitted to surgery, 6 had a functional pathology preoperatively; following surgical treatment of the diverticulum, vesicourethral function returned to normal in all cases. Of the 3 cases managed conservatively, 2 had persistent urodynamic disorders despite drug therapy; one of them had clinical features of urinary incontinence.

CONCLUSIONS

These fundings suggest that alterations of bladder function might arise from the anatomic changes in the detrusor muscle causing the diverticulum and contribute to the onset or persistence of reflux, and should be considered an additional criterion for indicating surgery. It is therefore suggested that a urodynamic study for its diagnosis be included in the protocol for evaluation of children with primary vesical diverticulum.

Clinical behavior of complicated right-sided and left-sided diverticulosis

PURPOSE

The aim of the study was to characterize the clinical entity of multiple right-sided (RS) diverticular disease, which is uniquely common in Asians.

METHODS

Patients hospitalized with proven diverticular disease from June 1989 to January 1996 were reviewed. Data were retrieved from a prospectively collected computerized database.

RESULTS

One hundred eighty consecutive patients were admitted to the Department of Colorectal Surgery, Singapore General Hospital, with multiple diverticular disease. Average age was 65.1 (standard error of the mean, 13.9) years. There were 96 men and 84 women. Women presented, on average, 8.4 years later than men (P < 0.005). Eighty-five patients (47 percent) had massive rectal bleeding, 65 (36 percent) had diverticulitis, 21 (12 percent) had obstructive symptoms, and 9 (15 percent) had enteric fistulas. The diverticula were RS in 76 patients(42 percent), left-sided (LS) in 62 patients (34 percent), and on both sides in 42 patients (24 percent). RS diverticulosis tended to present with massive rectal bleeding (42/76; 55 percent) more often than LS disease (14/62; 23 percent; P < 0.005). Surgery for bleeding was also required more often for RS (17/42; 41 percent) than for LS disease (1/14; 7 percent; P < 0.05); however, diverticulitis was more common on the left (RS, 25/76, 33 percent; LS, 32/62, 52 percent; P < 0.05). Seventy-eight patients (43 percent) required surgery for these complications of diverticular disease. At a mean follow-up of 15.2 (standard error of the mean, 2) months, mortality was 2 in 78 patients who underwent surgery (3 percent), and morbidity was 15 percent.

CONCLUSIONS

In comparison with LS, RS diverticular disease tended to present more often with massive bleeding than with diverticulitis and fistulation. This bleeding was often more severe and required surgical intervention.

Diverticulum of the left ventricle associated with subvalvar aortic stenosis

Diverticula of the left ventricle are rare and only a few cases have been documented in adults. They may be asymptomatic or may present with embolization, pain, endocarditis, or sudden death. We report the case of a 34-year-old woman who presented a cardiac arrest with ventricular fibrillation which required electrical cardioversion. She was found to have a left ventricular diverticulum associated with a subvalvar aortic stenosis. The diverticulum arose from the apex with a narrow connection to the ventricular cavity. A subvalvar fibrous ridge stenosis with a systolic pressure gradient of 115 mmHg was observed. Coronary angiography revealed normal coronary arteries. The diverticulum and the subvalvar fibrous ridge were resected. Histologic examination of the diverticulum wall demonstrated the presence of the three normal layers with marked muscle cell hypertrophy, atypical plexiform structure and fibrous endocardium. The pathophysioloy of diverticula associated with subvalvar aortic stenosis are discussed.

Female urethral diverticulum. Clinical aspects and a presentation of 15 cases

OBJECTIVE

Fifteen patients with female urethral diverticulum (FUD) were referred during nine years. In order to point out the symptomatology and findings and to evaluate the treatment we have reviewed these patients.

METHODS

A retrospective analysis of 15 women treated with transvaginal diverticulectomy. The technique is described.

RESULTS

The median age was 54 years. All the patients had symptoms of lower urinary tract disorder. The time from the first appearance of symptoms to referral was median 2 years (range, 4 days 30 years). Seventy-five percent of the cases had a pronounced tenderness. In 14 patients a suburethral mass could be found. Purulent material could be expressed in twelve cases. Three patients with symptoms for more than 10 years were characterized by stress incontinence and frequency and recurrent cystitis. No single diagnostic test proved to be specific for FUD. In eight patients (53%) the indication for operation was based only on symptomatology and the presence of a suburethral mass.

CONCLUSION

Diverticulum of the urethra is to be suspected in women with unexplained lower urinary tract symptoms. We recommend a collaboration of the two specialties: Gynaecology and Urology.

Intrabiliary pressure measurement by duodenal pressure loading for the evaluation of duodenal parapapillary diverticulum

BACKGROUND/AIMS

We report a method of intrabiliary pressure measurement by duodenal pressure loading for evaluating the effects of duodenal parapapillary diverticulum.

MATERIAL AND METHODS

Forty-eight patients with primary choledocholithiasis were investigated based on usual intrabiliary pressure measurement developed at our department.

RESULTS

Ten of these patients with parapapillary diverticulum showed higher intrabiliary residual pressure (P) and biliary resistance (R) values than the remaining patients without diverticulum, but the difference were not significant. There were no significant differences in the frequency of patterns of the B zone angulation of the pressure curve between the two groups with and without parapapillary diverticulum. Intrabiliary pressure was measured while maintaining a manometer pressure of 250 mm H2O by infusing or aspirating physiologic saline.

CONCLUSION

From the results of this measurement for 6 patients, when P and R values show increases of 50 mm H2O or more and 3.5 units or more, respectively, additional surgery for parapapillary diverticulum was considered to be indicated.