The association of biliary and pancreatic anomalies with periampullary duodenal diverticula. Correlation with clinical presentations

Fifty-eight symptomatic patients with periampullary duodenal diverticula (PDD) were examined for pancreatic and biliary anomalies using endoscopic retrograde cholangiopancreatography (ERCP), ultrasonography, and other imaging modalities. The pathologic findings in these patients were compared with those in a matched group of 58 patients without PDD, who were simultaneously undergoing a similar investigation for the same clinical presentations. Pathologic findings in the pancreas and/or biliary tree were detected in 70.7% of all patients with PDD, compared with 39.7% in the control group. In patients with PDD, pancreatobiliary anomalies were detected in all patients who presented with jaundice, 85% of patients with pancreatitis, and 27.8% of patients with abdominal pain, as compared with 60%, 40%, and 17%, respectively, in the control group. In 23 patients, ERCP findings demonstrated pancreatobiliary abnormalities that were not detected by other imaging modalities. Fifteen of the patients with PDD and pancreatobiliary anomalies had undergone cholecystectomy between six months and five years previously. We conclude that ERCP is essential in the investigation of all patients with PDD, especially those presenting with jaundice or pancreatitis. Biliary surgery in patients with PDD and a dilated bile duct should include a biliary drainage procedure to prevent recurrence of pancreatobiliary disease.     

Ampullary but not periampullary duodenal diverticula are an etiologic factor for chronic pancreatitis

BACKGROUND: Duodenal diverticula are common incidental findings. Although a definite treatment is rarely required, an association with biliary and pancreatic diseases is often suggested. Our aim was to determine the frequency of complications in relation to the location of the diverticulum. METHODS: We reviewed 64 patients with extraluminal duodenal diverticula. In 24 of these patients the diverticulum was treated surgically. The incidence of symptoms and complications is analyzed and follow-up in 88% of operated patients is presented. RESULTS: Thirty-one patients presented with ampullary, 36 patients with periampullary diverticula. Three patients had both types of diverticula. The indication for surgery in 24 patients was chronic pancreatitis (n = 12), chronic pain (n = 6), diverticular perforation (n = 3), bleeding (n = 2), or jaundice (n = 1). In 7 out of 31 patients with ampullary and none out of 36 patients with periampullary diverticula, chronic pancreatitis was considered to be induced by the diverticulum. Morbidity in 24 operated patients was 17%, no patient died. At follow-up all patients were free of symptoms. CONCLUSION: Extraluminal duodenal diverticula are frequently found. They rarely cause symptoms and need no surgical treatment. While ampullary duodenal diverticula can cause chronic pancreatitis, periampullary duodenal diverticula are no etiologic factor.     

十二指肠乳头旁憩室与胆结石的关系（附92例分析）

目的 探讨十二指肠憩室在胆结石发病中的作用。方法 回顾性分析广州市番禺中心医院行逆行胰胆管造影检查的462例患者,其中合并乳头憩室92例（憩室组）,无合并乳头憩室370例（非憩室组）。分析比较两组患者年龄、胆结石的发病率、结石发生部位及结石成分方面的差异。结果 本组462例患者中,憩室组92例,占19.9%。憩室组平均年龄61.8岁,明显高于非憩室组(61.8 vs 51.2岁,P<0.O1),且憩室发生率随年龄的增大而增高(P<0.01)。本组发现患者中,72例十二指肠憩室合并胆结石,憩室合并胆结石发生率78.3%,而非憩室组370例中仅97例合并胆结石,占26.2%。十二指肠憩室组并结石的发生率明显高于非憩室组。本组中乳头旁憩室胆结石发生率明显高于乳头周围型憩室者,有显著性差异。乳头旁憩室患者的原发性胆总管结石发生率明显高于继发性胆总管结石及胆囊结石,且结石成分主要为胆色素结石。结论 十二指肠乳头旁憩室患者胆结石发病率显著增高,且主要与原发性胆总管结石相关。     

Operative management of symptomatic duodenal diverticula

BACKGROUND: Duodenal diverticula are common but rarely cause symptoms that require operative intervention. METHODS: The charts of 34 patients who underwent a laparotomy at a single institution for complications of a duodenal diverticulum between the years of 1969 and 2001 were reviewed. RESULTS: The indications for operation included perforation (n = 10), gastrointestinal bleeding (7), intractable pain (6), biliary or pancreatic obstruction (4), gastrointestinal obstruction (2), steatorrhea (2), questionable malignancy (2), and cholecystodiverticular fistula (1). The operation consisted of diverticulectomy in 27 patients, duodenal resection in 4, diverticular inversion in 2, and a controlled duodenal fistula in 1. An additional drainage procedure was performed in 7 patients. Perioperative mortality rate was 3%. Early (15%) and late (12%) morbidity rates were significant. CONCLUSIONS: Operative treatment of duodenal diverticula is safe but should be reserved for those with emergent presentations or intractable symptoms.     

Endoscopic sphincterotomy in patients with gallbladder in situ: the influence of periampullary duodenal diverticula

Forty-four elderly patients (mean age, 77.2 years; range, 65 to 95) with acute bile duct obstruction, with gallbladder in situ, underwent endoscopic sphincterotomy without subsequent cholecystectomy during the same hospitalization. Thirty patients had periampullary duodenal diverticula, and 14 had no diverticula. Because periampullary diverticula were associated with biliary and pancreatic complications, possibly as a result of stasis in the diverticula, the clinical course in patients with and without diverticula was compared. Endoscopic sphincterotomy was well tolerated and resulted in a rapid clinical improvement in all patients. There were four complications related to the procedure (pancreatitis, two, and cholangitis, two), all were treated conservatively, and there were no deaths. The clinical outcome was similar in both groups of patients. During a mean follow-up of 25 months (range, 6 to 58), only two patients (one of each group) underwent elective cholecystectomy 2 and 3 months after initial presentation. It is concluded that endoscopic sphincterotomy is a safe and effective alternative to surgery as an initial treatment in elderly patients with choledocholithiasis and gallbladder in situ. Periampullary duodenal diverticulum does not interfere with the favorable results of endoscopic sphincterotomy in patients with gallbladder in situ.     

The relationship between juxtapapillary duodenal diverticula and the presence of bacteria in the bile

A total of 432 patients with gallstone disease were studied with respect to the existence of juxtapapillary duodenal diverticula and their relationship to the presence of bacteria in the bile. A total of 63 patients were found to have diverticula with an incidence of 14.6 per cent, being significantly higher in the elderly group aged 60 years or older (p<0.01), and no sex difference was noted. Among the patients with diverticula, positive bacterial cultures of bile were recognized at a significantly higher frequency, being found in 49 of the 63 patients (77.8 per cent; p<0.01), and the probability of bilirubinate stones was also higher, being found in 35 of 37 patients (94.6 per cent; p<0.01). The presence of a diverticulum bore significant relation to a higher positive bile bacterial culture (p<0.05), dilatation of the common bile duct (p<0.05), and elevation of the bile duct pressure (p<0.05), even when the conditions were divided into cholecystolithiasis or choledocholithiasis. It was suggested that the presence of a diverticulum affected the flow in the bile duct by narrowing it from the outside and chronically stimulating the papilla, inducing biliary tract infection and/or the formation of gallstones. As the surgical procedures for juxtapapillary duodenal diverticula, including its indications, have not been established, long term follow up investigations seem necessary.     

The relationship between juxtapapillary duodenal diverticula and the presence of bacteria in the bile

A total of 432 patients with gallstone disease were studied with respect to the existence of juxtapapillary duodenal diverticula and their relationship to the presence of bacteria in the bile. A total of 63 patients were found to have diverticula with an incidence of 14.6 per cent, being significantly higher in the elderly group aged 60 years or older (p less than 0.01), and no sex difference was noted. Among the patients with diverticula, positive bacterial cultures of bile were recognized at a significantly higher frequency, being found in 49 of the 63 patients (77.8 per cent; p less than 0.01), and the probability of bilirubinate stones was also higher, being found in 35 of 37 patients (94.6 per cent; p less than 0.01). The presence of a diverticulum bore significant relation to a higher positive bile bacterial culture (p less than 0.05), dilation of the common bile duct (p less than 0.05), and elevation of the bile duct pressure (p less than 0.05), even when the conditions were divided into cholecystolithiasis or choledocholithiasis. It was suggested that the presence of a diverticulum affected the flow in the bile duct by narrowing it from the outside and chronically stimulating the papilla, inducing biliary tract infection and/or the formation of gallstones. As the surgical procedures for juxtapapillary duodenal diverticula, including its indications, have not been established, long term follow up investigations seem necessary.     

Juxtapapillary duodenal diverticula and cholelithiasis

One hundred and thirteen cases of juxtapapillary duodenal diverticula were found in 5573 cases which were examined by upper gastrointestinal barium meal X-ray examination. Seventy-nine percent of those 113 cases had complications, while 21% of the cases were suffered from juxtapapillary duodenal diverticula alone. Among the complications, cholelithiasis showed the highest incidence. (33 cases out of 113 cases, 29.2%). Twenty-four cases of juxtapapillary duodenal diverticula of which serum amylase and serum bilirubin values were found to be over the normal range, were subjected to the ERCP and hepatocholedocal RI scintigraphy using 99mTcPI. Fourteen cases out of the 24 cases had complication of cholelithiasis. In 4 cases (28.6%) in this group, delaying of bile-flow was observed. While in 3 cases (30%) out of 10 cases without cholelithiasis, bile-flow disturbance was found. According to above mentioned observations, the following steps were recommended for the treatment of juxtapapillary duodenal diverticula: When juxtapapillary duodenal diverticula is revealed, examinations should be carefully done in order to find out other complications. Treatment for juxtapapillary duodenal diverticula may be done simultaneously with operation of the complications. Surgical indication of the juxtapapillary duodenal diverticula alone should be decided by the result of bile-flow examination.     

Juxta-papillary duodenal diverticula in patients with primary common duct stones

Incidence of juxta papillary duodenal diverticula (JPDD) was studied in 182 patients with benign biliary diseases. Incidences of JPDD were 11.1% in cholecystolithiasis, 23.4% in cholecystocholedocholithiasis and 54.5% in choledocholithiasis. Concerning to the patients with common duct stones, average of age was significantly higher in the group with diverticulum than in the group without diverticulum (65.9 +/- 7.6 vs 55.9 +/- 13.7, p less than 0.01). Diameter of the common duct was also significantly larger in the group with diverticulum. To exclude the effect of aging, the same comparison was performed in patients older than 60 years. Here again, the group with diverticulum showed significantly greater dilatation of the common duct. Incidences of JPDD in the primary and secondary common duct stones were 73.1% and 19.7%, respectively. The difference was highly significant. JPDD seemed to play an important role in the pathogenesis of cholestasis in the aged patients which may result in formation of primary common duct stones.     

十二指肠乳头旁憩室致胆道梗阻的外科诊治

目的:探讨十二指肠乳头旁憩室(JPPD)引起的胆道梗阻的合理诊断与治疗方法。方法:结合文献资料,回顾分析昆明医科大学第一附属医院近年来收治的22例JPPD导致胆道梗阻的患者的临床资料。结果:22例患者中,14例通过内镜逆行胰胆管造影(ERCP)检查确诊,8例通过磁共振胰胆管造影(MRCP)检查确诊;1例行单纯憩室切除术,2例行憩室切除+胆道探查术+T管引流术,15例行Billroth Ⅱ式胃大部切除术+胆道探查术+T管引流术,3例行胆总管-空肠Roux-en-Y吻合术,1例行胰十二指肠切除术。20例获随访1.5~10年,恢复良好。结论:对于JPPD引起的胆道梗阻,MRCP是目前确诊最佳方法,单纯憩室切除术最为理想;Billroth Ⅱ胃大部切除术+胆道探查+T管引流术简单、安全、有效、应用最为广泛;Oddi括约肌狭窄者,可行胆总管-空肠Roux-en-Y吻合术。     

Periampullary diverticula and technical success of endoscopic retrograde cholangiopancreatography

Introduction/aim  Periampullary diverticula (PAD) discovered incidentally during endoscopic retrograde cholangiopancreatography are usually asymptomatic, but can be a source of significant morbidity. The size of the diverticula and position of the papilla in relation to the diverticula are variable. The twofold aim of this study was to determine the prevalence of PAD in adult Indian patients and technical success of endoscopic retrograde cholangiopancreatography (ERCP). Methods  Patients with PAD (group I) were prospectively entered into a database from May 2006 to May 2007. Diverticula were categorized based on size into small (<1.5 cm) and large (>1.5 cm). Papilla was arbitrarily defined as type A when located outside the diverticulum and type B when the position was intradiverticular. Requirement of needle knife papillotomy (NKP), sphincterotomy, and overall success/failure of the procedure were recorded. One hundred consecutive patients without PAD undergoing ERCP served as controls (group II). Results  PAD were present in 46 (7.5%) of the 600 patients undergoing ERCP for various indications (group I). Mean age of patients with PAD (51 ± 15 years) was significantly higher than control group (39 ± 17 years) (p < 0.001). Of the 46 diverticula, 26 diverticula (56.5%) were large. In small diverticula, the papilla was extradiverticular (type A) in all 20 (100%) patients, whereas in the group with diverticula >1.5 cm only 57% was extradiverticular. Successful cannulation was achieved in 97% (45/46). NKP was done in six patients, five of whom had type A papilla. There was a significant high rate of NKP inpatients without PAD compared with patients with PAD (p = 0.001), whereas the rate of endoscopic papillotomy (EPT) was similar in both groups. Complete common bile duct (CBD) clearance was achieved in 93% patients in PAD group as compared with 96% in the non-PAD group (p = nonsignificant). Complications after ERCP were similar in both groups. Conclusion  PAD were present in 7.5% of patients. Fifty-six percent of PAD were large and in the vast majority (76%) papilla was extradiverticular in location. PAD were not associated with an increased risk of EPT-related complications.     

壶腹周围憩室和胆道结石的关系探讨

目的 探讨壶腹周围憩室（PAD）与胆道结石的关系以及内镜诊断PAD的应用价值。方法选择284例经内窥镜逆行胰胆管造影（ERCP）检查确诊合并有PAD的患者（PAD组）与同期经ERCP检查无PAD的患者（对照组）作为对照研究。胆道疾病根据病史、体征、给合实验室检查上超、CT以及ERCP等确诊。结果PAD组合并胆囊结石、胆总管结石、胆总管下端括约肌功能不良患者明显多于对照组,尤以胆总管结石增多为主（P<0.01）。结论PAD与胆道结石有着密切关系,PAD可能是胆道结石发生或复发的一个重要因素。     

Surgical choices in peptic ulcer associated with duodenal diverticula

The work analyzes surgeon's tactics for associated ulcer disease with duodenal diverticula. Operations were performed on 51 patients with these diseases. The operation of choice is gastric resection after Hofmeister-Finsterer which is sufficiently effective in treatment of ulcer disease and when excluding the duodenum creates conditions for the prevention of inflammation of the diverticulum.     

Periampullary diverticula: consequences of failed ERCP.

Periampullary diverticula (PAD) are associated with biliary disease and contribute to failure of endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. The presence of PAD and causes of failure to cannulate the ampulla were noted in 1211 consecutive patients undergoing ERCP. Case notes of 100 consecutive patients with PAD were reviewed retrospectively. Overall prevalence of PAD was 9%. Prevalence was higher in patients > or = 75 years when compared with those < 75 years (19.2% vs 4.8%, P < 0.0001). Ampullary cannulation was successful in 62.4% of patients with PAD and 92.7% without PAD (P < 0.0001). Success rates were lower in patients with intradiverticular papillae than in those with juxtapapillary diverticula (38.1% vs 77.6%; P < 0.0001). Of 19 patients with PAD who did not have any imaging other than ultrasound, 16 were asymptomatic over a median follow-up of 20 months. Biliary surgery was performed on 35 patients, with no major complication. PAD are a major cause of failed ERCP. Failure rates are higher in patients with intradiverticular papillae than juxtapapillary diverticula. Though a large proportion of patients not imaged remain asymptomatic on follow-up, it is difficult to predict which patients may form this group. Surgery, when indicated, is safe and effective in elderly patients in whom ERCP has failed.     

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目的 探讨壶腹周围憩室（PAD）与胆道疾病的关系以及内镜诊断PAD铁应用价值。方法 选择284例经内镜逆行胰胆管造影（ERCP）检查确诊合并有PAD的病人（PAD组）与同期经ERCP检查无PAD的病人（对照组）作为对照研究。胆道疾病根据病史，体征，结合实验室检查，B超，CT以及ERCP等确诊。结果 PAD组合并胆囊结石，胆总管结石，胆总管下端括约肌功能不良病人明显多于对照组，尤以胆总管结石增多为著（P＜0．01）。结论 PAD与胆道疾病，尤其是胆管结石存在着密切关系，PAD可能是胆道疾病发生或复发的一个重要因素，对胆道疾病病人行ERCP检查以了解PAD与胆道的关系，从而选择合适的治疗方案，对提高胆道疾病的治愈率有重要意义。     

Surgical management of perforated duodenal diverticula

A patient is described who had acute perforation of a duodenal diverticulum and survived after surgical intervention. Various technics for the surgical management of perforated duodenal diverticula are detailed. Choledochotomy, with passage of a catheter or sound into the duodenum, permits identification of the ampulla and safe excision and closure of the diverticulum. T tube drainage seems to be useful, and postoperative cholangiography confirms the integrity of the duodenum prior to feeding. Drainage of the retroduodenal area is recommended.     

The clinical importance of different localizations of the papilla associated with juxtapapillary duodenal diverticula

Background

Previous studies have evaluated the presence of juxtapapillary duodenal diverticula (JPDD) and the association with pancreatobiliary disease, but not the association of the papilla with an existing JPDD. We investigated the association of different localizations of the papilla with JPDD.

Methods

We studied patients in whom JPDD was detected during endoscopic retrograde cholangiopancreatography. Patients were classified into 3 groups: 1) papilla located inside the diverticulum, 2) papilla located at the edge of the diverticulum and 3) papilla located closer than 3 cm to the diverticulum. The patients were examined with respect to localization of papilla–diverticula and to the association of the localization with pancreaticobiliary disease.

Results

We enrolled 274 patients in our study. Biliary stone disease more frequently existed in group 3. The number of patients presenting with obstructive jaundice was higher in groups 2 (83.6%) and 3 (83.3%) than group 1 (66%). Cholangitis was more common in group 1 (21.3%) than in groups 2 (6.7%) and 3 (2.3%). The presence of biliary stone disease among patients presenting with pancreatitis was significantly different between groups 1 and 3 (p = 0.013) and between groups 2 and 3 (p = 0.017). The common bile duct more frequently contained stones or sludge in group 3 than in groups 1 and 2.

Conclusion

When the papilla is located close to the JPDD, the incidence of biliary stone disease decreases, and pancreatobiliary diseases are caused mostly in the absence of biliary stone disease.     

十二指肠憩室与胆胰疾病的关系以及对ERCP的影响

目的 探讨十二指肠乳头憩室的发生率与胆胰疾病的关系以及对ERCP手术的影响方法 回顾性分析广州市增城区人民医院2020年7月1日至2020年10月1日全院各科室包括门急诊、住院部曾经进行了腹部CT的所有患者,共1203人,女性475人,男性728人,其中,因胆总管结石胆管炎、或胆源性胰腺炎行ERCP手术的患者23例.观...     

十二指肠乳头旁憩室切除32例分析

目的探讨十二指肠乳头旁憩室切除的疗效及安全性。方法对1979年1月至1999年12月间施行乳头旁憩室切除的32例患者的临床资料进行回顾性分析。结果32例中单纯行憩室切除18例,另14例同时加行胆道手术。术中损伤胆总管和主胰管各1例,均经手术修补后治愈。全组29例获得随访,随访期2～10年,有效率达89.7%。结论憩室切除术是治疗十二指肠乳头旁憩室合理的术式。术中胆胰管损伤是乳头旁憩室切除的主要并发症。憩室切除术宜由有胆胰十二指肠手术经验的医师施行。     

超高龄胆胰壶腹周围疾病行治疗性内镜逆行胰胆管造影的临床特征分析

目的探讨超高龄胆胰壶腹周围病变行内镜逆行胰胆管造影（ERCP）治疗的可行性及患者的临床特征。 方法回顾性分析2014年5月至2018年5月川北医学院附属医院收治的307例行ERCP治疗的患者临床资料。根据患者年龄分为超高龄组（≥80岁）和非超高龄组（<80岁），探讨两组患者的临床特征。 结果92例超高龄组患者年龄（85.29±7.32）岁，215例非超高龄组患者年龄（57.81±14.26）岁。超高龄组患者原发病以壶腹部癌为主（P<0.01），ASA Ⅲ、Ⅳ级患者以及合并高血压、冠心病、糖尿病、慢性阻塞性肺疾病、十二指肠乳头旁憩室的比例明显高于非超高龄组（P<0.05）。超高龄组支架植入指征为胆管恶性狭窄以及采取支架植入或更换的患者比例明显更高（P=0.023、<0.001），而胆总管结石内镜取石比例更低（P=0.005），术后出血的发生率明显升高（P=0.021）。单因素分析显示原发疾病为壶腹部癌（P=0.044），合并十二指肠乳头旁憩室（P<0.001）、高血压（P=0.022）及冠心病（P=0.012），内镜下乳头括约肌切开术进行十二指肠乳头处理（P=0.012）为ERCP术后出血的危险因素。 结论超高龄胆胰壶腹周围病变患者恶性疾病患病率高、合并疾病多，但并非治疗性ERCP术的绝对禁忌证，临床需防范术后出血的风险。