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PubMed2004

Perforated duodenal diverticulum successfully diagnosed preoperatively with abdominal CT scan associated with upper gastrointestinal series.

Although duodenal diverticulum is not uncommon, precise preoperative diagnosis is occasionally difficult. We report a patient with perforated duodenal diverticulum successfully diagnosed preoperatively by an upper gastrointestinal series followed by abdominal computed tomography (CT) scanning. An 81-year-old Japanese woman visited a local hospital because of right-sided abdominal pain. Physical examination revealed diffuse muscle guarding localized in the entire right-side of the abdomen indicative of peritonitis. While plain abdominal X-ray film revealed no free air, abdominal ultrasound and abdominal CT scanning revealed fluid collection and gas in the anterior perirenal space. An emergency upper gastrointestinal series, using water-soluble contrast media, demonstrated multiple diverticula in the descending portion and the horizontal portion of the duodenum. Leakage of the contrast material was found by the upper gastrointestinal series followed by the abdominal CT scanning, suggesting that the peritonitis was caused by the perforated duodenal diverticulum, and an emergency laparotomy was performed. The diverticulum in the descending portion of the duodenum was mobilized from the retroperitoneum and complete resection and peritoneal drainage were performed. The resected specimen showed that the diverticulum was 42 x 23 mm in size, and two separate sites of perforation were identified. The present case suggests that upper gastrointestinal series followed by CT scan is useful for the preoperative diagnosis of perforated duodenal diverticulum.

Aged↗

PubMed1989

Diverticulum of the right ventricle associated with ventricular septal defect.

A true diverticulum of the ventricle is a very rare congenital cardiac lesion which is characterized by a normal myocardial wall and active participation in the ventricular contractions. Diverticula of the right ventricle may originate from the apical or anterosuperior wall. We report three patients with an anterosuperior diverticulum of the right ventricle associated with a perimembranous ventricular septal defect, one of whom additionally had obstruction of the right ventricular outflow tract. These patients presented clinically with symptoms related only to their associated defects. The right ventricular diverticulum was diagnosed by angiography in all, but was also seen on cross-sectional echocardiography in one patient. The ventricular septal defect was repaired through an incision of the diverticulum, which was reduced in size at the same time. Complete resection appears necessary only if severe endocardial fibrosis is present within the diverticulum, because such a diverticulum does not contribute to right ventricular contraction, but rather is at risk of rupture.

Child↗

PubMed2003

Role of Helicobacter pylori infection in complications from Meckel's diverticulum.

Our purpose was to evaluate the role of Helicobacter pylori in complications arising from Meckel's diverticulum in the Jewish and Arab populations of Jerusalem. Diverticular tissues were studied by hematoxylin-eosin, Giemsa, and two immunohistochemical stainings. Three groups of patients were identified: (1) 20 patients in whom Meckel's diverticulum was an incidental finding during laparotomy for other causes; (2) 7 patients with heterotopic gastric mucosa who underwent laparotomy because of bleeding from Meckel's diverticulum--3 were infected with Helicobacter pylori; and (3) 15 patients who underwent operations because of complicated Meckel's diverticulum except for bleeding--7 patients had heterotopic gastric mucosa; only 1 patient had Helicobacter pylori. Demographic, clinical, and pathological findings within the gastric mucosa were not different in patients with and without colonization with Helicobacter pylori. In conclusions, Helicobacter pylori colonizes heterotopic gastric mucosa with Meckel's diverticulum, but probably has a minor role in the complications of Meckel's diverticulum.

Adult↗

PubMed1999

Helicobacter pylori in Meckel's diverticulum with heterotopic gastric mucosa in a population with relatively high H. pylori prevalence rate.

BACKGROUND: Helicobacter pylori (H. pylori) colonize only foveolar gastric-type mucosa and are associated with active chronic gastritis and peptic ulcer. The aim of this study was to investigate whether H. pylori can also be found in Meckel's diverticulum which contains heterotopic gastric mucosa. METHODS: Biopsy specimens of Meckel's diverticulum resected in Queen Mary Hospital, University of Hong Kong, during the 10 year period 1986-1995 were retrieved and reviewed. Those containing gastric heterotopia were examined for the presence of H. pylori, using Warthin-Starry silver stain. RESULTS: In the 59 cases of Meckel's diverticula studied, 16 were found to contain heterotopic gastric mucosa. Helicobacter pylori were not identified in any of these cases. In one of the 16 patients a concomitant gastric biopsy was performed. Although the gastric mucosa of this patient was heavily colonized by H. pylori, again no H. pylori was found in the heterotopic gastric mucosa in the Meckel's diverticulum. CONCLUSIONS: The absence of H. pylori in all the Meckel's diverticula examined, even when the stomach was heavily colonized by the organisms, suggests that colonization of Meckel's diverticulum by H. pylori is a rare event. This, together with the overall rarity of H. pylori in all reported series of Meckel's diverticulum, argues against its causative role in complications of Meckel's diverticulum.

Adult↗

PubMed2004

Intraoperative catheter management during laparoscopic excision of a giant bladder diverticulum.

BACKGROUND: Massive bladder diverticula present a technical challenge to the laparoscopic surgeon. We describe a laparoscopic approach to transperitoneal diverticulectomy, using a specific catheter arrangement to allow excellent control of the various portions of the procedure. METHODS: A 49-year-old male with longstanding frequency was diagnosed with a 1000 cc bladder diverticulum and bladder neck outlet obstruction. Laparoscopic transperitoneal diverticulectomy was performed using a triple catheter arrangement: endoscopic placement of a Councill catheter in the diverticulum, fluoroscopic positioning of an occlusion balloon catheter in the renal pelvis, and placement of a Cope loop suprapubic tube. Additionally, a transurethral incision of the prostate was performed. RESULTS: The procedure was completed laparoscopically using a four port transperitoneal approach. During the procedure, the diverticulum could be filled and emptied as needed; the catheter across the diverticular neck facilitated subsequent closure of the bladder wall defect. The diverticulum was completely excised. The remaining defect in the bladder was then closed in 2 layers. The patient was discharged on postoperative day 3. CONCLUSION: Careful planning and arrangement of catheters in the bladder, ureter, and diverticulum facilitates laparoscopic transperitoneal diverticulectomy of even a very large volume diverticulum.

Cystectomy↗

PubMed1976

Meckel's diverticulum.

One hundred and ninety surgically documented cases of Meckel's diverticulum encountered at the Mayo Clinic during a 51-year period, 1920 through 1971, are reviewed. In 39 patients, the diverticulum was left undisturbed. In 51 patients, the diverticulum was the primary surgical disease, and, in 100 patients, the diverticulum was removed incidentally. The clinical features are presented as well as the surgical considerations. Meckel's diverticulum is a relatively frequent development anomaly with eccentric manifestations, and its surgical management has intrigued physicians for over 350 years. Dr. Charles W. Mayo stated, "Meckel's diverticulum is frequently suspected, often looked for, and seldom found."

Adolescent↗

PubMed2003

Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases.

OBJECTIVES/HYPOTHESIS: Several reports since the early 1990s have advocated a minimally invasive technique, endoscopic staple diverticulostomy (ESD), to treat Zenker's diverticulum. However, long-term results and comparisons with the reported experience with external or other endoscopic approaches have been lacking in the literature. We present follow-up on our experience with ESD since 1995 and compare it with the results obtained by other endoscopic or external techniques for treatment of Zenker's diverticulum. STUDY DESIGN: Retrospective review of 159 consecutive ESD procedures performed on 150 unique patients with Zenker's diverticulum between March 1995 and August 2002. Telephone interviews of patients were conducted to assess long-term treatment outcome. Review of the literature was performed by Ovid MEDLINE search for all reports on the surgical treatment of Zenker's diverticulum in the English language between January 1990 and August 2002. METHODS: Data were retrospectively reviewed and information was tabulated for age, sex, size of diverticulum, symptoms, duration of symptoms, operative time, length of hospital stay, time before oral intake, complications, and relief of symptoms at first postoperative visit. Follow-up interviews of patients were conducted to assess current status of symptoms and, if any symptoms returned, how many months after the procedure they recurred. All case series in the literature in the English language since 1990 that were found in the Ovid MEDLINE database and referenced from identified articles were also tabulated for the same information. RESULTS: At the time of initial follow-up after ESD, 98% of patients reported complete or improved symptoms. Average hospital stay was 0.76 days, with a diet started on postoperative day 0.25. There was a 2.0% significant complication rate without mortality. Further follow-up (average, 32.2 mo) identified a recurrence rate of 11.8%. On review of the literature, patients who underwent ESD had shorter perioperative courses, quicker return to diet, and lower complication and mortality rates compared with external procedures. ESD had comparable operative times and mortality rates, but fewer complications and more rapid convalescent times compared with other endoscopic procedures. Recurrence rates were found to be variable. CONCLUSIONS: Overall, ESD is an outpatient procedure with few complications. The technique has a faster operative and convalescence period with fewer complication rates compared with other endoscopic or external transcervical approaches. The results in the present study and those reported in the English language literature advocate that ESD be the initial preferred treatment for Zenker's diverticulum.

Adult↗

PubMed2001

Zenker's diverticulum associated with multilevel cervical osteomyelitis.

STUDY DESIGN: A case report of cervical osteomyelitis possibly associated with a Zenker's diverticulum perforation. OBJECTIVES: To present clinical, radiologic, and surgical findings of a cervical osteomyelitis due to a Zenker's diverticulum perforation. SUMMARY OF BACKGROUND DATA: A 56-year-old patient was in an intensive care unit for a severe head injury. He was fed via a nasogastric tube. Four months later he developed a pyogenic cervical vertebral infection. METHODS: Plain films and magnetic resonance imaging showed a diffuse cervical osteomyelitis. Investigation of his dysphagia revealed a Zenker's diverticulum. RESULTS: After administration of antibiotics and surgical treatment of the diverticulum, the cervical infection resolved. Plain films and magnetic resonance imaging showed healing with vertebral fusion. CONCLUSIONS: Cervical osteomyelitis is uncommon. Only one case of direct contamination leading to cervical vertebral osteomyelitis after esophageal perforation has been previously described. Direct contamination of the prevertebral soft tissues by bacteria traveling through the fistula may have occurred. The development of vertebral osteomyelitis in this case is consistent with the hypothesis of direct contamination. Management relies on appropriate antimicrobial therapy and surgical management of the diverticulum. The association of Zenker's diverticulum with vertebral osteomyelitis and discitis is a unique, previously undescribed situation.

Anti-Infective Agents↗

PubMed2001

Meckel's diverticulum in Crohn's disease.

Meckel's diverticulum is a congenital abnormality of the distal ileum associated with failed vitelline duct closure. Detailed pathological studies have estimated its frequency to be about 2% of the general population, and it has been anecdotally recorded in patients with Crohn's disease. Most patients with Crohn's disease have imaging studies of the small intestine during the course of their disease, and often, an intestinal resection. Thus, it seems possible to estimate the prevalence of Meckel's diverticula in Crohn's disease. In addition, patient characteristics may be important, especially if management of Crohn's disease is altered. Of 877 patients with Crohn's disease, 10 (about 1%) had a Meckel's diverticulum diagnosed, including six men and four women. All were diagnosed with Crohn's disease before age 50 years and seven were diagnosed before age 30 years. There were five with ileocolonic disease, two with colon-only disease and three with ileum-only disease. The clinical behaviour of five patients could be classified as penetrating and two as stricturing. A total of 311 patients had an ileocolonic resection, including eight (about 2%) with a Meckel's diverticulum. In contrast to some case reports, no heterotopic mucosa was detected and the Meckel's diverticulum was incidental and, apparently, an unexpected finding. In each case, the diverticulum was not involved with Crohn's disease but was included in the ileal resection. These results suggest that the overall prevalence of a Meckel's diverticulum is not increased in Crohn's disease but may result in resection of additional small intestine.

Adolescent↗

PubMed2000

[Zenker's diverticulum].

The first case of posterior pharyngooesophageal diverticulum was published in 1764 by Ludlow. Zenker's name has been attributed to the diverticulum since his description of a series of patients in 1878. The aetiology and pathogenesis of Zenker's diverticulum are not well understood. Research has mainly focused on the role of the upper oesophageal sphincter, but numerous manometric studies have produced controversial results. Also, the influence of gastrooesophageal reflux on the upper oesophageal sphincter and the development of a diverticulum is unclear. Patients with a Zenker's diverticulum typically present with a long history of slowly progressive dysphagia for solid consistencies and regurgitation of undigested food. Weight loss and nocturnal attacks of coughing may bother the patient. The diagnosis of a diverticulum needs to be confirmed by radiologic examination. The only definite therapy is surgery. The classical extramucosal cricopharyngeal myotomy by transcervical approach, with or without removal of the diverticular sac, is increasingly giving way to transmucosal myotomy through a transoral endoscopic approach. Compared to the transcervical approach the endoscopic technique avoids the risk of injuring the recurrent laryngeal nerve, substantially lowers the number of pharyngeal fistulas and, in large series, showed an equivalent outcome as far as relief of symptoms is concerned. In the light of the literature and our own experience diverticulooesophagostomy with the Endo-GIA stapler by a transoral endoscopic approach has become the therapy of choice at the ENT-Department of the University Hospital of Zurich, Switzerland. In an operating time of only 10-15 minutes the stapler cuts the wall between the diverticular sac and the oesophagus, and in the same manoeuvre closes the mucosal wound edges with tiny staples. Oral feeding is possible from the first postoperative day. With the technique described this elderly population of patients obtains rapid and safe relief of symptoms.

Disease Progression↗

PubMed2000

Abdominal disorders arising from 71 Meckel's diverticulum.

BACKGROUND AND AIMS: The study was done to investigate the frequency of Meckel's diverticulum, and its manifestations as the cause of abdominal disorders. MATERIAL AND METHODS: The material consisted of 71 patients with Meckel's diverticulum treated in our hospital during the years 1988-1998. From the material the age and sex were analyzed as well the outcome of patients. The histological findings of diverticulectomies were evaluated. RESULTS: In a retrospective analysis 46 males (65.5%) and 25 females (34.5%) were found. At the same eleven-year study period Meckel's diverticulum was found during 55 out of 3758 appendicectomies (1.5%). The age of patients ranged from 11 months to 87 years (mean 30.4 years). Preoperatively the diagnosis was made in three cases: two patients with TC-99m scanning and one patient with intestinal passage radiography. 46 Meckel's diverticles were asymptomatic, but 25 (34.5%) cases were symptomatic. Nine patients had ulcer in the diverticulum, which was perforated in five cases. Eight patients had intestinal occlusion, five patients had Meckel's diverticulitis, two patients had invagination, and in one case a sharp piece of plastic material had perforated the Meckel's diverticulum. CONCLUSION: Meckel's diverticulum should be searched in the laparotomy due to acute abdomen. It can be the cause of serious abdominal complications.

Abdominal Pain↗

PubMedDate not supplied

[Meckel's diverticulum in laparoscopic era].

A recent case of a Meckel's diverticulum diagnosed and successfully laparoscopically treated, triggered off a retrospective study on a series of 34 cases with Meckel's diverticulum admitted to the First Surgical Clinic between 1990-2003. We encountered 12 uncomplicated cases and 22 cases with a large panel of complications: 11 intestinal obstructions (volvulus 9, intussusceptions on a tumor-2), 9 cases with diverticulitis, 1 gastrointestinal bleeding and 1 case with Littre's inguinal hernia. Positive diagnosis was established intraoperatively and the surgical treatment was adapted according to the local situation (excision of the diverticulum or enterectomy). Out of 12 patients with uncomplicated Meckel's diverticulum 8 were subjected to prophylactic excision of the diverticulum. In 6 of these microscopic examinations were inclusions of gastric mucosa. Laparoscopy is safe, relatively inexpensive and efficient in the diagnosis and treatment of Meckel's diverticulum.

Adolescent↗

PubMed2005

[Endoscopic stapled esophago-diverticulostomy as a new alternative to open surgery in the treatment of Zenker's diverticulum: which operation?].

AIMS: The authors analyse the indications, contraindications, early and late results of two types of operations (resection of the diverticulum with crycopharyngeal myotomy and endoscopic stapled esophago-diverticulostomy) for the treatment of Zenker's diverticulum. PATIENTS AND METHODS: In a five year period 10 patients (5 male, 5 female, mean age 56.9 years) were operated for Zenker's diverticulum. Six open and 4 endoscopic operations were planned, although in one case the placement of the endoscope was unsuccessful. Open surgery was planned if the diverticulum was in lateral position, if it was too small or large and if endoscopic surgery was technically impossible. RESULTS: The operative time was shorter in the endoscopic group (32.3 vs. 80.7 minutes). In the open surgery group (7 patients) one saliva fistula developed caused by suture leak. The length of hospital stay was 8.1 days in the resection group and 4.7 in the endoscopic group. No recurrence developed. CONCLUSIONS: The advantages of the endoscopic oesophago-diverticulostomy are: shorter operating time and hospital stay, less complication rate and it is minimally invasive. The authors suggest endoscopic oesophago-diverticulostomy as the choice of operation in case of Zenker's diverticulum. Open surgery is indicated only if the diverticulum is in lateral position or if it is bigger than 8 cms. The technical contraindications for endoscopic surgery are: short, rigid neck and limited mouth opening.

Adult↗

PubMed1992

Manometric aspects of Zenker's diverticulum.

Zenker's diverticulum is thought to result from disordered coordination between the pharynx and upper esophageal sphincter. Manometric studies of the upper esophagus have been helpful in testing the hypothesis of dysmotility in the formation and growth of a Zenker's diverticulum; however, the data have provided conflicting evidence. Manometric studies show that resting upper esophageal sphincter pressure is normal in some patients with Zenker's diverticulum and decreased in others. Abnormal premature relaxation and contraction of the upper esophageal sphincter seen in some patients with Zenker's diverticulum may be accompanied by pharnygeal contractions against a closed sphincter. This abnormality is thought by some investigators to be the cause of Zenker's diverticulum, but not by others who have found normal upper sphincter relaxation. Future manometric studies will very likely elucidate the pathogenesis of Zenker's diverticulum.

Esophageal Diseases↗

PubMed2005

Laparoscopic resection of duodenal diverticulum. A case report.

We report the case of a laparoscopic resection of a symptomatic duodenal diverticulum. A 35 year old female with history of pain in the upper abdomen, nausea and regurgitation was diagnosed with a diverticulum of the second portion of the duodenum on the external border at upper gastrointestinal radiography. The diverticulum size was medium (2 cm in diameter). Under general anesthesia, a pneumoperitoneum was created. Four trocars were inserted into the peritoneal cavity for this intervention. After the sectioning of posterior parietal peritoneum on the external border of the second portion of duodenum, the diverticulum was dissected. The resection was performed with an endo-GIA linear stapler at the base of the diverticulum. One subhepatic drain was inserted. The operative time was 30 min. There were no intra- or postoperative complications. Postoperative gastrointestinal series revealed no signs of diverticulum or stenosis on the second portion of the duodenum. The patient was discharged in the fifth postoperative day after a normal course. The follow-up evaluation was normal.

Adult↗

PubMed1990

[A case of isolated congenital diverticulum of the left ventricule].

Congenital diverticulum of the left ventricule is rare congenital cardiac malformation and is classified as muscular and fibrous. Muscular diverticula are usually accompanied with other cardiac and extracardiac malformations. 8 years old boy involved with muscular left ventricular diverticulum with no other congenital anomalies underwent resection of diverticulum. The cardiopulmonary bypass was required because it was not feasible to apply a clamp, to the neck of the diverticulum. Congenital diverticulum of the heart should be resected as soon as possible because of crisis of spontaneous rupture and systemic embolization. However, the assessment of cardiac arrhythmias and hemodynamic changes caused by clamping of the diverticulum during operation is necessary.

Cardiopulmonary Bypass↗

PubMed1987

[A case of subtentorial ventricular diverticulum accompanied with choroid plexus papilloma in the lateral ventricle].

Marked non-communicating hydrocephalus may rarely cause ventricular rupture producing either a dilated cystic cavity (ventricular diverticulum) or communication between ventricle system and subarachnoid space (spontaneous ventriculostomy). Ventricular diverticulum has been believed to be collection of cerebrospinal fluid which escaped beneath the pia mater after rupture of ependymal layers and cerebral parenchyma. We proposed herein to report a case of subtentorial ventricular diverticulum which accompanied with choroid plexus papilloma of the lateral ventricle. A nine year-old girl admitted to our hospital complaining of clumsiness of hands and walking, disability of reading, headache and vomiting. The neurological examination revealed alexia, papilledema, anisocoria, righ hemianopsia, weakness of right upper limb, and cerebellar ataxia. CT brain scan showed a large high density area at the trigone of the left lateral ventricle with non-communicating hydrocephalus and an extra-axial low density area in the posterior fossa. The medial space of the left trigone was especially ballooned and is just shifted above incisura tentoria by the tumor. The intraventricular tumor was totally removed by operation and proved to be benign choroid plexus papilloma microscopically. The subtentorial mass was confirmed to be a cyst contiguous to the medial trigone of the lateral ventricle, namely ventricular diverticulum. Three special features were recognized in this case. The first, this was the first example of ventricular rupture accompanied with tumor in the lateral ventricle reviewing all reports of both ventricular diverticulum and spontaneous ventriculostomy. The second, this ventricular diverticulum was not produced merely by hydrocephalus alone but mainly by direct effects of the tumor.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain Diseases↗

PubMed1975

Radial distribution of esophageal peristaltic pressure in normal subjects and patients with esophageal diverticulum.

This study was designed to determine the radial profile of peristaltic pressure waves in the esophageal body of normal subjects and patients with isophageal diverticulum. We used a manometric assembly featuring four radial side hole recording orifices oriented at equidistant 90 degree angles. Each recording catheter was infused with water at a rate (6.1 ml per min) which provided high fidelity pressure recording. In normal subjects, the radially recorded peristaltic pressure complexes were similar in peak amplitude and wave form. The range of pressure differences between the four radial recordings averaged 9.0 +/- 4 SD mm Hg A range is less than or greater to 25 mm Hg occurring in 99% of observations. These variations in pressure amplitude showed no consistant spacial orientation. In 5 of the 6 patients with esophageal diverticulum, the range of radial peristaltic pressure differences exceeded 25 mm Hg in the region of the diverticulum, the lowest pressure occurring at the recording orifice facing the diverticulum mouth. In occasional peristaltic sequences abnormal wave forms featuring abrupt onsets or offsets were observed. These bizarre wave forms were probably caused by oralaboral diverticulum movement relative to the recording sensor during peristalsis. Two patients had abnormally high peristaltic pressure amplitudes, greater than 250 mm Hg. This latter finding introduces the possibility that hypertensive peristaltic contractions may contribute to diverticulum production in some patients.

Adult↗