Overview
Definition:
A duodenal diverticulum is an outpouching or sac-like protrusion from the wall of the duodenum
Resection, or diverticulectomy, involves the surgical removal of such a diverticulum when it causes symptoms or complications.
Epidemiology:
Duodenal diverticula are found in 2-10% of individuals undergoing upper gastrointestinal endoscopy or surgery
Most are asymptomatic and discovered incidentally
Peripapillary diverticula, located within 2 cm of the ampulla of Vater, are the most common and are associated with higher complication rates.
Clinical Significance:
While most duodenal diverticula are benign, symptomatic diverticula can lead to a spectrum of gastrointestinal issues including pain, nausea, vomiting, dysphagia, bleeding, obstruction, perforation, and pancreatitis
Surgical resection is indicated in select cases to alleviate symptoms and prevent serious complications, making it a relevant topic for surgical residents preparing for examinations.
Indications
Symptomatic Diverticulum:
Persistent abdominal pain, nausea, vomiting, or early satiety attributable to the diverticulum after conservative management fails
Factors suggesting symptomatic nature include diverticulum size, location, and association with inflammation.
Complications Of Diverticulum:
Bleeding (hematemesis, melena), obstruction (gastric outlet obstruction, small bowel obstruction), perforation, fistula formation, pancreatitis or cholangitis (especially with peripapillary diverticula), and suspected malignancy within the diverticulum.
Failed Conservative Management:
Trial of proton pump inhibitors, dietary modifications, and prokinetic agents that do not resolve symptoms
Recurrent complications despite medical therapy.
Diagnostic Uncertainty:
When imaging studies (CT, MRI) or endoscopy are equivocal regarding the nature of the diverticulum or to rule out associated pathologies like malignancy.
Preoperative Preparation
Diagnostic Workup:
Upper GI endoscopy for visualization and biopsy if needed
Barium swallow or CT enterography for better anatomical assessment and evaluation of adjacent structures
ERCP may be considered for peripapillary diverticula to assess biliary and pancreatic ductal systems.
Nutritional Assessment:
Evaluation of the patient's nutritional status, especially if symptoms have led to poor oral intake or weight loss
Correction of electrolyte imbalances.
Optimization Of Co-morbidities:
Management of any pre-existing medical conditions such as diabetes, hypertension, or cardiac disease
Smoking cessation counseling.
Bowel Preparation:
Depending on the surgical approach, bowel preparation may be required
Antibiotic prophylaxis according to standard surgical protocols is essential to reduce surgical site infection risk.
Procedure Steps
Surgical Approach:
Laparoscopic or open surgical resection
Laparoscopic approach is preferred when feasible due to faster recovery, reduced pain, and smaller scars
Open surgery may be necessary for large, complex, or inflamed diverticula, or if malignancy is suspected.
Diverticulum Identification And Mobilization:
Careful identification of the diverticulum and its neck
The diverticulum is mobilized from surrounding tissues, with meticulous attention to preserve adjacent vital structures like the superior mesenteric artery and vein, and the pancreas.
Excision Of Diverticulum:
The diverticulum is excised at its base
Depending on the size and location, the resulting defect in the duodenal wall may be closed primarily with sutures, often in two layers
For larger defects, a patch or flap may be used.
Management Of Peripapillary Diverticula:
Special care is required for peripapillary diverticula to avoid injury to the common bile duct or pancreatic duct
If the diverticulum is very close to or involves the ampulla, a transduodenal approach or even pancreaticoduodenectomy (Whipple procedure) might be necessary for severe complications or malignancy.
Closure And Hemostasis:
Secure closure of the duodenal defect to prevent leaks
Thorough hemostasis is crucial to minimize postoperative bleeding
Placement of a drain may be considered depending on the complexity and surgeon's preference.
Postoperative Care
Pain Management:
Effective analgesia is vital, often a multimodal approach including IV opioids initially, transitioning to oral analgesics
Epidural analgesia may be used for open procedures.
Fluid And Electrolyte Management:
Intravenous fluid therapy to maintain hydration and electrolyte balance
Monitoring urine output and serum electrolytes closely.
Nutritional Support:
Nil by mouth initially, with gradual advancement of diet as tolerated, starting with clear liquids
Parenteral nutrition may be required if oral intake is significantly delayed.
Monitoring For Complications:
Close monitoring for signs of complications such as fever, tachycardia, abdominal distension, decreased urine output, or bile/pancreatic fluid drainage
Regular vital sign assessment and abdominal examination.
Complications
Early Complications:
Anastomotic leak (duodenal fistula), bleeding from the staple line or surrounding vessels, pancreatitis, cholangitis, intra-abdominal abscess, ileus, deep vein thrombosis, pulmonary embolism, and wound infection.
Late Complications:
Stricture formation at the repair site leading to obstruction, recurrent diverticulitis, chronic abdominal pain, and rarely, development of malignancy within a residual diverticular remnant or at the suture line.
Prevention Strategies:
Meticulous surgical technique, careful mobilization, secure closure of the duodenal defect, appropriate antibiotic prophylaxis, and vigilant postoperative monitoring
For peripapillary diverticula, avoidance of ampullary injury is paramount
Early recognition and prompt management of any leak are critical.
Prognosis
Factors Affecting Prognosis:
The presence and severity of symptoms prior to surgery, the extent of the diverticulum, the presence of complications, the patient's overall health status, and the experience of the surgical team
Successful resection of symptomatic diverticula generally leads to significant symptom relief.
Outcomes:
Most patients experience resolution of symptoms after successful resection
However, some may have residual discomfort or develop new issues related to the altered anatomy
The risk of major complications from surgery is generally low but can be significant.
Follow Up:
Routine follow-up with the surgeon is recommended to monitor recovery and assess for any late complications
Patients may require periodic evaluations, particularly if they had peripapillary diverticula or if there are concerns for recurrence or stricture formation
Lifestyle and dietary advice may be provided.
Key Points
Exam Focus:
Distinguish between symptomatic and asymptomatic duodenal diverticula
Know indications for surgery: bleeding, obstruction, perforation, recurrent pancreatitis/cholangitis
Understand surgical approaches: laparoscopic vs
open
Peripapillary diverticula require special attention due to proximity to biliary and pancreatic ducts.
Clinical Pearls:
Always consider duodenal diverticula in the differential diagnosis of upper GI symptoms, especially in older patients
Look for the characteristic "collar button" appearance on barium studies
Be mindful of the potential for malignancy within large or atypical diverticula
Intraoperative leak testing is advisable.
Common Mistakes:
Underestimating the risk of complications with peripapillary diverticula
Inadequate closure of the duodenal defect, leading to leaks
Failure to consider malignancy in the differential diagnosis
Insufficient mobilization leading to tension on sutures.