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PubMed2005

Large diverticulum and volvulus of the small bowel in adults.

The purpose of this study was to evaluate the relationship of large diverticulum (>3 cm) and volvulus of the small bowel (SB) in adults. A computer search of the medical records between January 1995 and December 2002 revealed 94 surgically proved cases of small bowel volvulus in adults. We reviewed the surgical records and recorded any specific condition found during laparotomy. The control group included 107 consecutive patients receiving a laparotomy with a diagnosis other than SB volvulus. In the 94 surgically proved cases of SB volvulus, the surgical records described presence of adhesion in 47 cases, adhesions around large SB diverticulum (>3 cm) in 5 cases, coexistence of large SB diverticulum and adhesions around the narrowed mesenteric root in 4 cases, large SB diverticulum without a specific description of the presence of adhesion or narrowed mesenteric root in 24 cases, narrowed mesenteric root without large SB diverticulum in 3 cases, internal hernia in 4 cases, tumors in 3 cases, and absence of any specific lesion in 4 cases. Only one case was found to have a large SB diverticulum in the control group. The incidence of large SB diverticulum in SB volvulus of adults was 35% (33/94), significantly higher than that of the control group (1%, 1/107) (p < 0.01). Large diverticulum of the small bowel might play a contributing role in the occurrence of SB volvulus in adults.

Adult↗

PubMed2002

Resection of Kommerell's diverticulum and left subclavian artery transfer for recurrent symptoms after vascular ring division.

OBJECTIVES: A Kommerell's diverticulum in patients with a right aortic arch may become aneurysmal and be an independent cause of tracheoesophageal compression, even after ligation and division of a left ligamentum. We review the indications for and results of Kommerell's diverticulum resection and left subclavian artery transfer in children with a right aortic arch who previously underwent vascular ring (ligamentum) division. METHODS: From 1998 through 2001, eight children have been referred with recurrent respiratory symptoms (n=8) and/or recurrent dysphagia (n=4) after vascular ring division. Each child had a right aortic arch with a left ligamentum and had undergone division of the ligamentum elsewhere. All had a Kommerell's diverticulum that was not addressed at the initial operation. All patients had a repeat left thoracotomy with resection of the diverticulum. Five patients had division and reimplantation of the left subclavian artery into the left carotid artery to relieve the sling-like effect of the retroesophageal left subclavian artery on the right aortic arch. One other patient had primary Kommerell's diverticulum resection and transfer of the left subclavian artery to the left carotid artery. RESULTS: The mean age at the initial operation was 1.7+/-0.9 years, and the mean age at reoperation was 8.0+/-3.7 years. In all patients postoperative bronchoscopy confirmed relief of the tracheal compression. There were no complications related to the subclavian artery transfer. Two patients developed postoperative chylothorax, one requiring thoracic duct ligation. The median hospital stay was 5 days. All patients had dramatic resolution of their preoperative symptoms. CONCLUSIONS: Kommerell's diverticulum is an important anatomic structure that can cause recurrent symptoms in patients with a right aortic arch after ligamentum division. In selected patients, reoperation with resection of the Kommerell's diverticulum and transfer of a retroesophageal left subclavian artery results in relief of symptoms. This technique has become our procedure of choice as a primary operation for children with a right aortic arch and a significant Kommerell's diverticulum.

Adolescent↗

PubMed2000

Endoscopic staple-assisted esophagodiverticulostomy: an excellent treatment of choice for Zenker's diverticulum.

OBJECTIVES: The objectives of the present study are to review the technique of endoscopic staple-assisted esophagodiverticulostomy (ESED) for the treatment of Zenker's diverticulum and to describe our experience and modifications with ESED and the advantages of ESED over previous treatments of Zenker's diverticulum. STUDY DESIGN: Retrospective review of 74 cases of ESED performed for the treatment of Zenker's diverticulum. METHODS: Patient's records were retrospectively reviewed and tabulated for age, sex, size of diverticulum, symptoms, duration of symptoms, operative time, length of postoperative hospital stay, oral intake, complications, and relief of symptoms. RESULTS: The senior author (R.L.S) previously reported results in 36 cases of ESED performed in 34 patients with Zenker's diverticulum. We have performed an additional 38 cases of ESED in 37 patients between March 1997 and August 1999. The rate of success of ESED was similar between the two series The average perioperative time, time until oral intake, and length of postoperative hospital stay decreased in the second series. Overall, there were no mortalities and few complications with ESED. Compared with other forms of treatment of Zenker's diverticulum, such as Dohlman's procedure, diverticulectomy, and diverticulopexy, ESED has a similar rate of success, decreased perioperative time, decreased convalescence, and decreased mortality and complications. CONCLUSIONS: Cost-effectiveness, safety, and efficacy of ESED offer new advantages over previously used treatments for Zenker's diverticulum. These results continue to support the use of ESED as the initial treatment of choice for patients with Zenker's diverticulum.

Aged↗

PubMed2003

Surgical management of the calyceal diverticulum.

PURPOSE OF REVIEW: The management of calyceal diverticulum has evolved from an open surgical approach to a minimally invasive approach. Currently, the percutaneous, ureteroscopic and laparoscopic techniques are recommended by individual investigators. Recent studies have helped establish patient selection criteria for each of the above procedures. This review will discuss technique and results and suggest a treatment algorithm for the patient with a symptomatic calyceal diverticulum. RECENT FINDINGS: Excellent long-term success has been reported with all three minimally invasive modalities. Percutaneous ablation of the calyceal diverticulum is the most established minimally invasive technique for this disorder. A direct puncture into the calyceal diverticulum is recommended. Limitations exist primarily for an anteriorly located diverticulum. In this situation, if the diverticulum is in a superior anterior calyx, a ureteroscopic approach is recommended while if the diverticulum is in a middle or lower pole calyx, a laparoscopic approach is recommended. SUMMARY: This review suggests that experience and expertise in percutaneous, ureteroscopic and laparoscopic techniques provide the urologist with the best opportunity to individualize treatment approach based on location and size of the diverticulum. A treatment algorithm based on these parameters may be helpful in patient counseling and decision-making.

Clinical Trials as Topic↗

PubMed1999

[Three cases of transitional cell carcinoma in bladder diverticulum treated by a bladder-preserving approach].

Three cases of transitional cell carcinoma (TCC) in the urinary bladder diverticulum were encountered during a period of 12 years and bladder preserving treatments were performed. Case 1: A 78-year-old man was admitted with a chief complaint of hematuria. Papillary tumors in the diverticulum of the right bladder wall were revealed (TCC, G3, T3N0M0). Intraarterial infusion chemotherapy was performed and complete remission was achieved. When a recurrent bladder tumor appeared 22 months later, transurethral resection was performed and there was no evidence of recurrence for 50 months. Case 2: A 60-year-old man was admitted with a chief complaint of gross hematuria. Cystoscopic examination revealed papillary tumors in a bladder diverticulum near the ureteral left orifice. Transurethral resection revealed TCC G2 and carcinoma in situ. Partial cystectomy, including the bladder diverticulum, and vesicoureteral neostomy was performed. The histological stage of the tumor was pTis and the wall of diverticulum possessed a thin muscle layer histopathologically. Twenty two months later, recurrence in the left bladder wall developed and transurethral resection and bladder instillation therapy were performed. For 21 months he had no evidence of recurrence. Case 3: A 59-year-old man was admitted with a chief complaint of hematuria. A solid tumor in the diverticulum of the bladder left wall was revealed. After 4 courses of intraarterial infusion chemotherapy, 41% remission was achieved and partial cystectomy was performed. Histopathological diagnosis was TCC G3, pT3b, INF-alpha, v (-), ly (-), and no muscle layer was found in the diverticulum. There was no evidence of recurrence 16 months after operation. By using the combination therapy, bladder preserving treatment is possible in the cases of bladder cancer arising in the diverticulum.

Aged↗

PubMed1991

Esophageal diverticulum associated with carcinoma of the esophagus--a report of four cases.

During a 25-year period, four patients with esophageal diverticulum associated with carcinoma of the esophagus underwent surgery. The results were satisfactory. The clinical features included a long history of diverticulum and the presence of a carcinoma of the esophagus in close proximity to the former. Inflammation within the diverticulum and in the mucosa around the diverticulum was noted. The closer the diverticulum to the carcinoma, the more severe the inflammation. Therefore, diverticulitis and esophagitis may be important factors leading to the development of carcinoma of the esophagus, and patients with esophageal diverticulum should be followed up regularly and the diverticulum resected as early as possible if inflammation within the diverticulum or peri-diverticular esophagitis is found.

Diverticulum, Esophageal↗

PubMed1991

[Esophageal diverticulum].

During a 25-year period, nineteen patients with esophageal diverticulum were treated surgically in PUMC Hospital. Of them, eleven cases underwent resection of the diverticulum (10 pulsion type and 1 traction type); and four cases were treated by inversion suturing of the diverticulum (all traction type). The results of follow-up showed that pulsion diverticulum resection was satisfactory, and the resection was better than inversion suturing for traction-type diverticula. In this series, diverticulitis and esophagitis were present in all cases. Carcinoma of the esophagus developed at site near the diverticulum in 4 cases. Pathologic examination demonstrated severe submucosal inflammatory infiltration and epithelial hyperplasia of the esophagus associated with the diverticulum, with these changes being increasingly severe with the precondition of the carcinoma to the diverticulum. Carcinoma of the esophagus as a complication of diverticulum may be associated with chronic diverticulitis and esophagitis.

Adult↗

PubMed1980

Physiopathology of lower esophageal diverticulum and its implications for treatment.

This study attempted to define the esophageal motor disturbances and pathogenesis of symptoms in patients with lower esophageal diverticulum. Sixty-five patients were investigated by manometry in addition to roentgenography and endoscopy. Fifty had manometric evidence of abnormal motility, most often diffuse spasm or achalasia. Of the 15 patients with normal esophageal motility, 13 had hiatal hernia, and five of these had a high grade distal esophageal stricture. Pressures in the lower esophagus and lower esophageal sphincter in patients with lower esophageal diverticulum and motor disturbance were the same as for those in matched patients with motor disturbances but no diverticulum. Dysphagia, chest pain and regurgitation were common presenting symptoms. Of 46 patients with dysphagia, only ten had mechanical obstruction to explain this symptom. Of 32 patients with chest pain, only two had ulceration in the diverticulum as a possible cause of pain. We conclude that the development of lower esophageal diverticulum and its symptoms are associated with a motor disturbance of the esophagus in the majority of patients and with an organic obstruction in the minority of patients. The diverticulum itself is usually not the sole cause of the esophageal symptoms, although diverticula can produce symptoms in the absence of other definable conditions. When surgical treatment is indicated, the diverticulum should be excised and the underlying motor or mechanical obstruction should be corrected to prevent serious postoperative complications and recurrence of the diverticulum and its symptoms.

Adult↗

PubMed1993

Axial volvulus of the small bowel caused by Meckel's diverticulum.

BACKGROUND: A mechanism where the presence of a Meckel's diverticulum might cause bowel obstruction by twisting the small bowel along its long axis has been described. The developmental anatomy of the Meckel's diverticulum and its blood supply has been traced. Various other ways a Meckel's diverticulum can cause an obstruction have been enumerated. METHODS: We have reported two cases where the presence of a Meckel's diverticulum was the cause of bowel obstruction in a fashion hitherto not described. One patient had intermittent bouts of obstruction; the second patient had an acute obstruction. RESULTS: Preoperative investigations for a Meckel's diverticulum are not always fruitful, and most of the time the diagnosis is made at operation. When a Meckel's diverticulum is encountered at operation, division of its mesentery, the mesodiverticular band, rather than diverticulectomy, to relieve the volvulus described might devitalize the Meckel's diverticulum and should be avoided. CONCLUSIONS: A new mechanism by which the presence of a Meckel's diverticulum can cause an obstruction has been described. A short mesodiverticular band causes the bowel to twist along its long axis, precipitating the obstruction. This condition should be kept in mind in patients with a bowel obstruction who have not undergone any previous abdominal operation.

Acute Disease↗

PubMedDate not supplied

Symptomatic duodenal diverticulum.

To determine management guidelines for symptomatic duodenal diverticulum, we reviewed medical records of 26 patients. Complicated duodenal diverticulum was the only possible cause of symptoms-abdominal pain, fever and chills, melena, vomiting-in 18 patients. Ten patients improved with conservative management, and eight patients underwent diverticulectomy with or without various other procedures. Among the eight patients, one patient who had duodenal fistula died of respiratory complications on the second postoperative day. Symptoms recurred in two patients: One had a distal common bile duct (CBD) stricture and underwent choledochojejunostomy. In the other patient a CBD stone developed 3 years later, and choledocholithotomy and choledochojejunostomy were performed. Eight patients had associated gallstone disease as well as the diverticulum. Five of the eight had a history of operation for gallstone disease; four improved with conservative treatment, and one underwent choledochojejunostomy. Two patients were thought to have an innocent diverticulum and underwent cholecystectomy and choledocholithotomy only. One patient underwent diverticulectomy and sphincteroplasty for a CBD stone and pervaterian diverticulum. In conclusion, operations for duodenal diverticulum should be reserved for seriously complicated diverticula, and the surgeon should be aware that pervaterian diverticulum can be a cause of choledocholithiasis.

Aged↗

PubMed2004

A large renal pelvic diverticulum, presenting incomplete excretion during tc-99m MAG-3 scintigraphy and tracer accumulation on tc-99m DMSA scintigraphy; a case report.

This case report illustrates the dynamic and static renal scintigraphic images of a patient with an unusual large diverticulum of the renal pelvis. The initial diagnosis by intravenous pyelography (IVP) and ultrasonographic (US) examination was a renal pelvic diverticulum of the left kidney, and the patient was referred to the nuclear medicine department for exploration of the effect of the pelvic diverticulum on renal functions. We performed dynamic renal scintigraphy with technetium-99m (Tc-99m) labeled mercaptoacetyl triglycine (MAG-3) and static renal scintigraphy with Tc-99m labeled dimercaptosuccinic acid (DMSA). In dynamic renal scintigraphy, bilaterally normal concentration function was observed. While right kidney excretion function was normal, an incomplete excretion pattern was seen on the left side. Complete urinary flow obstruction occurred approximately at the 10th minute of the acquisition, which did not seem to respond to the i.v. furosemide application. However, when only the renal cortex was included in the region of interest, the obstructive pattern disappeared. In static renal scintigraphy, a large renal pelvic diverticulum localized antero-medially was clearly visualized in the left-anterior oblique projection, most probably due to accumulation of radiopharmaceutical inside it. This case showed that a renal pelvic diverticulum should be thought of when an incomplete excretion pattern is seen on dynamic renal scintigraphy. Using only a cortical region of interest may also help to distinguish other types of obstructive pattern from diverticulum. Additionally, Tc-99m DMSA scintigraphy may show diverticulum localization with antero-oblique projections in addition to routine projections.

Adult↗

PubMed2004

[Laparoscopic esophagotomy without diverticular resection for treating epiphrenic diverticulum in hypertonic lower esophageal sphincter].

INTRODUCTION: As a rule, epiphrenic diverticulum occurs in combination with most diverse forms of dysfunction in the lower esophageal sphincter (LES) and/or in the esophagus itself. The main symptoms are dysphagia, pain, and regurgitation. The operation consists in myotomy, diverticulum resection, and partial fundoplication via abdominal or thoracic approach using conventional or minimally invasive technique. The main risk is postoperative suture dehiscence after diverticular resection. The present study was therefore undertaken to establish whether the operation succeeds in risk patients even without resection of the diverticulum. PATIENTS AND METHODS: In the period from 1998 to 2001, six patients were investigated preoperatively by means of esophageal manometry, endoscopy, and radiological barium swallow. The four risk patients underwent only myotomy of the LES, if appropriate, in combination with laparoscopic partial fundoplication. Resection of the diverticulum by thoracoscopy or with conventional thoracic technique was also performed in the two patients with normal risk. RESULTS: Three of the four risk patients showed normal postoperative courses after laparoscopic myotomy and rapidly became free of symptoms and were able to eat normally. One patient died perioperatively of pulmonary complications. After thoracic diverticulum resection, both patients developed postoperative suture dehiscence with a complicated course. Altogether, freedom from symptoms with regard to dysphagia and regurgitation could be attained in five out of six patients over a follow-up period of 6 to 25 months. CONCLUSION: In patients with epiphrenic diverticulum and disorder of LES function, myotomy alone without resection of the diverticulum may be sufficient to relieve or eliminate symptoms. Laparoscopy and the combination with partial fundoplication are the preferred techniques. In our opinion, this method must be considered in order to reduce the surgical risk in multimorbid and elderly patients.

Aged↗

PubMed1988

The coronary sinus diverticulum: a pathologic entity associated with the Wolff-Parkinson-White syndrome.

Of 65 patients with posterior septal accessory pathways, 6 were found intraoperatively to have a previously unrecognized pathologic entity: a coronary sinus (CS) diverticulum in the posterior septal region. The CS diverticulum is a venous pouch within the left ventricular wall, with a neck opening into the CS. The pouch, 2 to 5 cm in diameter, has a deep wall corresponding to the left ventricular wall, with venous channel openings and a thin superficial wall made of myocardium. The CS diverticulum neck is 5 to 10-mm wide, opens into the CS and is proximal to the midcardiac vein. Using an epicardial approach during normothermic bypass, the neck of the CS diverticulum was identified, separated from the left ventricle and then closed. Accessory pathway conduction disappeared only after separation of the CS diverticulum neck. The accessory pathway is intimately related to the diverticulum. The latter is a bridge between the left ventricle and the right or left atrium. The accessory pathways associated with CS diverticula had short anterograde refractory periods and were associated with potentially malignant arrhythmias. An epicardial operative approach with division of the neck of the diverticulum is recommended when surgery is indicated.

Adult↗

PubMedDate not supplied

Pharyngeal diverticulum as a sequela of anterior cervical fusion.

A rarely diagnosed etiology of dysphagia is a pharyngeal diverticula occurring after anterior cervical fusion. Here we review 2 cases where patients developed pharyngeal diverticula following anterior cervical fusion. The first patient was a 28-year-old female who presented with regurgitation following C5 through C6 cervical fusion. She was diagnosed with a pharyngeal diverticulum and underwent open repair, but began to experience symptoms again a few months later. A barium swallow showed a recurrent pharyngeal diverticulum. Endoscopic repair was attempted; however, because of the thick scar band between the diverticulum and the esophagus, the operation had to be converted to an open repair with cricopharyngeal myotomy. The second case involved a 63-year-old male who presented with dysphagia and regurgitation 6 months after anterior cervical fusion. Esophagram demonstrated a small diverticulum at the right lateral border of the upper esophagus. Open repair of the diverticulum with cricopharyngeal myotomy was successfully performed. Pharyngeal diverticula after anterior cevical fusion have only been reported in 2 prior cases in the literature. Here we describe 2 additional cases at our institution, both requiring open repair. Radiographic studies demonstrate the diverticulum at the site of scarring from the cervical fusion. Because of the thick scar band and the atypical location of these diverticula, endoscopic repair with stapping (as done for Zenker's diverticula) may not be feasible. These cases highlight the importance of considering a diverticulum in the differential of posoperative patients presenting to the otolaryngologists with complaints of dysphagia following cevical spine surgery.

Adult↗

PubMed2005

[Endoscopic assisted endoluminal stapler-diverticulotomy of Zenker diverticulum].

INTRODUCTION: One of the advantages of endoluminal diverticolotomy in Zenker's diverticulum with the staple is the possibility of early rehabilitation. As the stapler allows to close the cut wound margins of the diverticulum threshold simultaneously with a clip suture, the patient can start oral food intake as early as 24 hours after surgery. The overview for the surgeon for correct placement of the clip device is limited due to the physiological narrowness of the pharyngeal tube. PATIENTS AND METHODS: We reduced the danger of malplacement by placing a temporary stomach tube as well as endoscopic control of the position of the stapler at the diverticulum threshold. RESULTS: 61 patients with Zenker's diverticulum stage Brombart I - IV have been successfully treated with this surgery technique since 1998. In two other patients a transcervical diverticulotomy was done because the diverticulum threshold could not be exposed clearly with the spread laryngoscope. In 10 patients a clinically symptomatical recurrent diverticulum (Brombart stage II) could be safely removed by a repeated endoscopically assisted stapler diverticulotomy. CONCLUSION: The advanced endoscopically assisted endoluminal stapler diverticulotomy in Zenker's diverticulum is convenient for the patient allowing prompt food intake and showing low morbidity and no mortality.

Adult↗

PubMed1989

[Cancer in a hypopharynx diverticulum].

The development of a carcinoma in a hypopharyngeal diverticulum is reported as a rare complication in a 74-year-old female. The carcinoma was neither radiologically nor endoscopically detected. The left part of the diverticulum was resected. Histology showed a moderately differentiated squamous cell carcinoma in the wall of the diverticulum. The patient died postoperatively from thrombo-embolism of the lung. At autopsy the right part of the diverticulum showed a carcinoma which had originated from the bottom of the diverticulum, had spread polypously into the lumen and had infiltrated all layers of the wall of the diverticulum (pT1N0M0). Diagnostic problems are discussed which are posed by a carcinoma in a hypopharyngeal diverticulum.

Aged↗

PubMed1999

Laparoscopic resection of gastric diverticulum.

Gastric diverticulum is a rare disorder. The laparoscopic approach may be ideal for the resection of gastric diverticulum in some cases. The authors believe this to be the first reported case of gastric diverticulum resected laparoscopically. A 59-year-old woman was admitted with indigestion and epigastric pain. Upper gastrointestinal series showed a single diverticulum (3 x 2 cm) on the posterior wall of the upper part of the stomach. The neck of the diverticulum was relatively narrow. Gastroduodenoscopy revealed that food residues were impacted within the diverticular pouch. Other areas of the stomach and the duodenum were normal. Abdominal ultrasonography showed no other pathologic conditions in the upper part of abdomen. On operation, the lesser sac was entered by division of the greater omentum along the avascular plane of the transverse colonic attachment. The location of the diverticulum was confirmed by intraoperative gastroscopy. Using a 5-cannula techniques, the diverticulum was resected with an endoscopic linear stapler device. Pathologic examination of the resected specimen demonstrated chronic superficial gastritis. Flatus was passed out on the first postoperative day, diet was started from the second day, and the patient was discharged on the fifth day without problems.

Diverticulum, Stomach↗

PubMed2001

Feasibility and outcome of endoscopic staple-assisted esophagodiverticulostomy for Zenker's diverticulum.

OBJECTIVES/HYPOTHESIS: Endoscopic staple-assisted esophagodiverticulostomy (ESED) is a newly described method of surgically correcting Zenker's diverticulum. Initial reports on the ease and success of the surgery have been quite enthusiastic, making it seem the procedure of choice. We initiated the procedure in an algorithm of treatment of Zenker's diverticulum, to further explore the feasibility and outcome of this new technique. STUDY DESIGN: This is a case series of 23 patients with Zenker's diverticulum who have undergone surgical repair. For each patient, an attempt at ESED was made. If unsuccessful, an open approach was then taken. RESULTS: Seven of 23 patients (30%) were unable to be treated with ESED because of inability to expose the diverticulum or unfavorable anatomy of the diverticulum itself. Of the remaining 16 patients, ESED was successful in resolving the symptoms of diverticulum in 14 (87%). Two patients (13%) were somewhat improved but had persistent dysphagia. No significant complications occurred. All patients resumed oral diet within the first 24 hours after surgery. CONCLUSION: Esophagodiverticulostomy is an excellent method of surgically correcting Zenker's diverticulum in many patients, but anatomical considerations may prevent its use, making open approaches of continued importance in a surgeon's armamentarium.

Adult↗