Renal failure in Nigerian children: factors limiting access to dialysis

A 5-year clinical and laboratory study of Nigerian children with renal failure (RF) was performed to determine the factors that limited their access to dialysis treatment and what could be done to improve access. There were 48 boys and 33 girls (aged 20 days to 15 years). Of 81 RF patients, 55 were eligible for dialysis; 33 indicated ability to afford dialysis, but only 6 were dialyzed, thus giving a dialysis access rate of 10.90% (6/55). Ability to bear dialysis cost/dialysis accessibility ratio was 5.5:1 (33/6). Factors that limited access to dialysis treatment in our patients included financial restrictions from parents (33%), no parental consent for dialysis (6%), lack or failure of dialysis equipment (45%), shortage of dialysis personnel (6%), reluctance of renal staff to dialyze (6%), and late presentation in hospital (4%). More deaths were recorded among undialyzed than dialyzed patients (P<0.01); similarly, undialyzed patients had more deaths compared with RF patients who required no dialysis (P<0.025). Since most of our patients could not be dialyzed owing to a range of factors, preventive nephrology is advocated to reduce the morbidity and mortality from RF due to preventable diseases.     

手术治疗Ⅱ型锁骨外侧端骨折

目的 介绍一种治疗Ⅱ型锁骨外侧端骨折的手术方法。方法 取用锁骨与喙突间螺丝钉加压固定，喙锁韧带修复。结果 24例患术后骨折端全部愈合，关节功能恢复良好，内固定物无松脱，肩锁关节无创伤性关节炎。结论 本术式治疗成人Ⅱ型锁骨外侧端骨折，操作方便，固定可靠，效果确切，并发症少，是理想的手术方法。     

Improvements in dialysis access survival with increasing use of arteriovenous fistulas in a Veterans Administration medical center

BACKGROUND: Native arteriovenous fistulas (AVFs) have been found to exhibit higher survival rates and lower complication rates than prosthetic grafts (AVGs). METHODS: Between August 2001 and December 2003, 93 patients with end stage renal disease (ESRD) had primary dialysis access placed at a single Veterans Administration medical center. Of these 93 patients, 67 had AVFs created and 26 patients had AVGs implanted. RESULTS: The percentage of patients who did not require additional intervention was 84% (56 of 67) for AVF and 78% (21 of 26) for AVG after 4 to 31 months of follow-up evaluation. In the AVF group, repeat interventions were as follows: collateral ligation (4), angioplasty owing to central stenosis (2), AVF ligation due to arterial steal phenomenon (1), and new AVF creation owing to clotting (1). Four AVFs were later converted to AVG. In the AVG group there were 4 venous anastomosis stenosis seen in 3 patients who required angioplasty. Two patients needed thrombectomy and revision, and 1 graft was removed because of infection. AVF prevalence in our dialysis patients was 63%, with 33% AVG and 4% temporary catheter. CONCLUSIONS: The National Kidney Foundation-Dialysis Outcome Quality Initiative (NKF-DOQI) guidelines for dialysis access reawakened interest in maximizing the use of renal veins for AVF. AVFs created by using the patient's native vein provides the best vascular access for dialysis when compared with prosthetic grafts. AVF has better long-term patency with fewer complications.     

腹腔镜辅助下远端胃切除术中及术后早期并发症的原因和处理

目的：探讨腹腔镜辅助下远端胃切除（LADG）术中及术后早期并发症的原因与处理。方法：回顾性分析2007年1月—2011年9月82例行LADG术患者的临床资料。结果：中转开腹2例,术中出血6例,皮下气肿3例,高碳酸血症2例,横结肠系膜损伤4例;术后腹腔内出血2例,戳孔感染2例,戳孔血肿1例,十二指肠残端瘘4例,吻合口瘘1例,吻合口狭窄1例,吻合口出血1例,淋巴瘘1例。术中及术后并发症均经处理后痊愈。全组无死亡病例。结论：LADG手术并发症的发生与其手术难度以及术者的经验、技能有关,严格规范操作,提高术者技能和熟练度并加强手术团队的协调、配合是减少LADG术中和术后早期并发症的关键。     

远端动脉旁路移植附加动静脉吻合治疗严重下肢缺血21例

目的 探讨严重下肢动脉病变伴有远端流出道动脉不通畅的动脉旁路移植手术方法，以避免截肢或降低截肢平面。方法 分析2000年7月至2004年12月采用动脉旁路移植手术并辅助远端吻合口处的动静脉吻合治疗的21例（21条患肢）下肢远端流出道动脉不良患者的临床资料。结果 21例患者中，除1例因为远端动脉的“虚灌”而再次手术外，其余患者均一次手术成功，成功率95．2％。出院时血管通畅率100％，足部创面的愈合率33．3％。结论 伴有远端流出道动脉不良的严重缺血，在下肢动脉血流重建中采用远端吻合口的动静脉吻合可以明显提高血管的通畅率，可以达到避免截肢或降低截肢平面的目的。     

Tapered arteriovenous grafts do not provide significant advantage over nontapered grafts in upper extremity dialysis access

ObjectiveAlthough tapered dialysis access grafts are often used in an effort to prevent ischemic steal, their efficacy is uncertain. Our goal was to use real-world data to assess the performance of these grafts with respect to primary patency and ischemic steal.MethodsThe Vascular Quality Initiative database was queried from 2010 to 2017 for all patients undergoing tapered dialysis grafts in the upper arm. Multivariable analysis was performed to analyze primary patency, ischemic steal, and reinterventions.ResultsWe identified 3608 patients who received dialysis access grafts, 1473 tapered grafts and 2135 nontapered grafts. The mean age was 64.8 years, and 43.4% of the patients were male. Tapered grafts were used more often in female patients (60.5% vs 54%), nonwhite patients (53.3% vs 47.7%), patients with no previous access (28% vs 26.3%), grafts with an antecubital brachial artery origin (50% vs 44.4%), and grafts with an antecubital cephalic vein target (7.4% vs 3.7%; P < .05). Three-month outcomes between tapered and nontapered grafts were similar for wound infection (1.4% vs 2%; P = .31), ischemic steal (4.1% vs 4.6%; P = .58), and arm swelling (3.5% vs 2.9%; P = .38). Multivariable analyses revealed that in comparison to nontapered grafts, tapered grafts did not affect primary patency rates (hazard ratio [HR], 1.17; 95% confidence interval [CI], 0.96-1.42; P = .11), ischemic steal (HR, 1.03; 95% CI, 0.64-1.65; P = .92), difference in endovascular reintervention (HR, 1.08; 95% CI, 0.74-1.16; P = .5), or operative reintervention (HR, 1.25; 95% CI, 0.86-1.82; P = .24).ConclusionsTapered grafts for upper extremity arteriovenous access do not affect primary patency, development of steal, or endovascular reintervention in comparison to nontapered grafts. Our findings do not support the routine use of these grafts in dialysis access to improve outcomes.     

Vascular access malfunction due to upper extremity embolization in dialysis patients

Acute occlusions of arteries such as those of the cerebral and peripheral circulation are usually due to thrombotic or embolic events. Emboli have not been previously reported to cause arteriovenous (AV) dialysis access malfunction. We describe in this report three patients with end-stage renal disease (ESRD) and atrial fibrillation (Afib) who developed acute ischemia of an arteriovenous access-bearing extremity due to embolization. The clinical manifestations mimicked thrombotic events, but the presence of symptoms and signs of limb ischemia distinguished these cases clinically. A timely diagnosis followed by an appropriate intervention can lead to limb and access salvage.     

股骨远端骨折的手术治疗

目的探讨股骨远端骨折的手术治疗方法及合并症的预防。方法对1991年～2001年,348例股骨远端骨折手术治疗,选用螺钉、动力加压钢板(DCP)、角钢板、动力髁部螺钉(DCS)、股骨髁钢板、带锁髓内钉治疗股骨远端骨折。研究内固定物的使用、骨折复位、植骨、骨折不愈合等相关问题。结果13例发生内固定失效、钢板断裂,需要重新固定植骨。8例延迟愈合,二期植骨。其余骨折均愈合。14例术后伤口感染,18例晚期出现肢体短缩,范围1～4cm。52例因骨折愈合后膝关节屈曲小于90°需要行松解手术。结论手术治疗股骨远端骨折能够恢复解剖结构,从而最大限度地恢复肢体的功能。     

透析开始残余肾功能与维持性透析患者预后的关系

目的 评估终末期肾病患者透析开始残余肾功能与维持性透析预后的关系.方法 收集2005年1月1日至2009年9年30日新进入血透或腹透治疗的终末期肾病成年患者资料,随访至2010年3月31日.根据透析开始时估算肾小球滤过率(eGFR)分为≥10.5、8～＜10.5、6～＜8、＜6 ml· min-1·(1.73 m2)-1 4组.eGFR评估采用MDRD简化公式.终点事件为全因死亡和心脑血管死亡.结果 (1)共562例患者入选,透析开始中位eGFR为5.60(2.26～12.62) ml· min-1·(1.73 m2)-1;中位随访时间为17(0～58)个月 ;死亡141例,中位生存期为45.48(43.05 ～47.90)个月.随着透析开始eGFR下降,4组患者Scr、BUN、血尿酸(SUA)、血前白蛋白、血磷、血钙磷乘积、整段甲状旁腺激素(iPTH)、平均动脉压(MAP)逐渐升高 ;血红蛋白(Hb)、男性患者比例、并发糖尿病比例、Charison并发症指数≥5比例逐渐下降,差异均有统计学意义(均P＜ 0.05).随着透析开始eGFR下降,并发左室肥大比例有逐渐升高趋势,但差异无统计学意义.(2)Kaplan-Meier生存曲线显示4组患者总体生存率差异无统计学意义.Cox回归分析显示透析开始eGFR与透析预后无显著关系.对透析非早期(＞3个月)死亡患者进行Kaplan-Meier生存曲线分析,4组患者1年生存率差异无统计学意义.多因素Cox回归分析显示透析开始eGFR是透析1年生存预后的保护因素(HR =0.791,95％CI 0.669～0.935,P＜0.01).(3)以心脑血管死亡为终点事件,多因素Cox回归分析显示,透析开始eGFR是心脑血管生存预后(HR =0.868,95％CI 0.777～0.971,P＜0.05)和1年心脑血管生存预后(HR=0.937,95％CI 0.851～0.992,P＜0.05)的保护因素.(4)多因素Cox回归分析显示,透析开始eGFR增高1 ml·min-1·(1.73 m2)-1,腹膜透析患者死亡风险下降10％(HR=0.90,95％CI 0.81～0.99,P＜ 0.05).血液透析方式4组患者Kaplan-Meier生存率分析显示,差异有统计学意义(Log-rank检验,P=0.047),8～＜10.5组生存率最低,与6～＜8组、＜6组差异有统计学意义(Log-rank检验,P=0.033,P=0.005).多因素Cox回归分析并未显示透析开始eGFR与预后相关.多因素Cox回归分析提示透析开始eGFR增高1 ml·min-1·(1.73 m2)-1,慢性肾小球肾炎患者和慢性肾小球肾炎腹膜透析患者死亡风险分别降低16.6％(HR=0.834,95％CI 0.736～0.946,P＜0.01)和32.1％(HR=0.679,95％CI 0.535～0.862,P＜0.01).以心脑血管死亡为终点,多因素Cox回归分析显示透析开始eGFR增高1 ml·min-1·(1.73 m2)-1,慢性肾小球肾炎患者心脑血管死亡风险下降18.2％(HR=0.818,95％CI 0.669～0.999,P＜0.05).结论 本组患者透析时机明显晚于国际透析指南的标准.随着透析开始eGFR降低,并发症增多及程度加重.早期透析可能无法提高透析患者的总体生存率,但可能有助于改善患者心脑血管及1年总体生存预后和腹膜透析、慢性肾小球肾炎患者的预后.     

Proximal venous outflow obstruction in patients with upper extremity arteriovenous dialysis access

To evaluate the impact of central venous obstruction on upper extremity hemodialysis access failure, we retrospectively analyzed our recent experience in managing this problem. We reviewed 158 upper extremity hemodialysis access procedures performed in 122 patients during a 1-year period. Fourteen (11.5%) patients had central vein obstruction as the cause of severe arm swelling, graft thrombosis, or graft malfunction. All 14 patients had had bilateral temporary subclavian vein dialysis catheters and failed upper extremity arteriovenous access. Seventeen lesions were treated in 14 patients including eight subclavian vein occlusions, six subclavian vein stenoses, two internal jugular vein stenoses, and one superior vena cava stenosis. Twenty-one procedures were performed including 17 percutaneous transluminal balloon angioplasties (PTAs) with stent placement in 13, two axillary to innominate vein bypasses, and two axillary to internal jugular vein bypasses. All patients had resolution of symptoms. Thirteen (76%) PTAs were initially successful but in four (24%) cases it was impossible to recanalize the vein. Eight (47%) PTAs provided functional hemodialysis access for 2 to 9 months, two (12%) restenosed at 3 and 10 months and were successfully redilated, two occluded at 2 and 4 months and were unable to be recanalized, and one failed immediately after a successful PTA. Four PTA failures were followed by venous bypass, which remained patent and provided functional access 7 to 13 months after surgery. Of nine stenotic venous lesions six (67%) were successfully dilated without restenosis, whereas of eight occluded veins only two (25%) were successfully treated without recurrence. Temporary central hemodialysis catheters produce a significant number of symptomatic central vein obstructions in patients with upper extremity arteriovenous access. PTA with stenting and venous bypass provides early success in most patients. Transcatheter therapy is less successful in treating complete venous occlusions when compared with stenotic lesions. All effort should focus on preventing this complication by avoiding the use of temporary subclavian vein hemodialysis catheters.     

Comparison of upper extremity and transfemoral access for fenestrated-branched endovascular aortic repair

ObjectiveThe use of upper extremity (UE) access is an accepted and often implemented approach for fenestrated/branched endovascular aortic aneurysm repair (F-BEVAR). The advent of steerable sheaths has enabled the performance of F-BEVAR using a total transfemoral (TF) approach without UE access, potentially decreasing the risks of cerebral embolic events. The purpose of the present study was to assess the outcomes of F-BEVAR using UE vs TF access.MethodsProspectively collected data from nine physician-sponsored investigational device exemption studies at U.S. centers were analyzed using a standardized database. All patients were treated for complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) using industry-manufactured fenestrated and branched stent grafts between 2005 and 2020. The outcomes were compared between patients who had undergone UE vs total TF access. The primary composite outcome was stroke or transient ischemia attack (TIA) and 30-day or in-patient mortality during the perioperative period. The secondary outcomes included technical success, local access-related complications, and perioperative mortality.ResultsAmong 1681 patients (71% men; mean age, 73.43 ± 7.8 years) who had undergone F-BEVAR, 502 had had CAAAs (30%), 535 had had extent IV TAAAs (32%), and 644 had had extent I to III TAAAs (38%). UE access was used for 1103 patients (67%). The right side was used for 395 patients (24%) and the left side for 705 patients (42%). UE access was preferentially used for TAAAs (74% vs 47%; P < .001). In contrast, TF access was used more frequently for CAAAs (53% vs 26%; P < .01). A total of 38 perioperative cerebrovascular events (2.5%), including 32 strokes (1.9%) and 6 TIAs (0.4%), had occurred. Perioperative cerebrovascular events had occurred more frequently with UE access than with TF access (2.8% vs 1.2%; P = .036). An individual component analysis of the primary composite outcome revealed a trend for more frequent strokes (2.3% vs 1.2%; P = .13) and TIAs (0.54% vs 0%; P = .10) in the UE access group. On multivariable analysis, total TF access was associated with a 60% reduction in the frequency of perioperative cerebrovascular events (odds ratio, 0.39; P = .029). No significant differences were observed between UE and TF access in the technical success rate (96.5% vs 96.8%; P = .72), perioperative mortality (2.9% vs 2.6%; P = .72), or local access-related complications (6.5% vs 5.5%; P = .43).ConclusionsIn the present large, multicenter, retrospective analysis of prospectively collected data, a total TF approach for F-BEVAR was associated with a lower rate of perioperative cerebrovascular events compared with UE access. Although the cerebrovascular event rate was low with UE access, the TF approach offered a lower risk of stroke and TIA. UE access will continue to play a role for appropriately selected patients requiring more complex repairs with anatomy not amenable to the TF approach.     

Chronic upper extremity ischemia: current concepts in management

As a rule, the few innominate or subclavian obstructions that are symptomatic produce neurologic and extremity symptoms that are easily reversed by an extrathoracic surgical approach. Balloon angioplasty is seeing some utility for this problem also. Concomitant carotid disease may be more significant in that its correction may not only prevent stroke but also mitigate symptoms of subclavian steal. The reconstruction of lesions distal to the vertebral artery frequently results in dramatic and durable improvement. Sympathectomy has a valuable role to play in those cases in which restoration of perfusion cannot be complete.     

Two-stage basilic vein transposition—a new approach for pediatric dialysis access

Purpose

The fistula first initiative has led to increased efforts to create arteriovenous fistulas (AVFs) as primary dialysis access. Two-stage basilic vein transposition (BVT) allows maturation of smaller veins, often a limiting factor in the pediatric population, before elevation and use. We sought to determine whether using 2-stage BVT improves maturation, use, and patency compared with other AVFs, including arteriovenous (AV) grafts.

Methods

Thirty-one patients underwent AV access creation between 1997 and 2008. Data were collected on types of access, maturation, complications, and patency.

Results

Forty-two AV access procedures were performed: 15 (36%) 2-stage BVT, 13 (31%) 1-stage BVT, 6 (14%) radiocephalic, 3 (7%) brachiocephalic, 1 (2%) brachiobrachial, and 4 (10%) AV grafts. Follow-up averaged 20.4 ± 3.2 months for 2-stage BVT and 47.9±4.1 months for other AVFs (P < .001). All 2-stage BVT matured compared with 52% (14/27) of other AVFs (P = .001). More 2-stage BVTs (87%) were used for dialysis than other AVFs (48%, P = .024). Fistula failure occurred in 7% 2-stage BVT compared with 59% other AVFs (P = .001). One-year patency rates were 91% for 2-stage BVT vs 47% for other AVFs (P = .003).

Conclusions

Rates of fistula maturation, use, and patency are higher for 2-stage BVT with lower rates of failure. Two-stage BVT shows great promise as the preferred approach to creation of AVF in pediatric patients, especially those with smaller veins.     

Diagnosis and management of complex regional pain syndrome complicating upper extremity recovery.

Complex regional pain syndrome (CRPS) is a clinical syndrome of pain, autonomic dysfunction, trophic changes, and functional impairment. CRPS is common after hand trauma or surgery. Early diagnosis and intervention is critical for adequate recovery. The diagnosis of CRPS requires a careful history, physical examination, and supporting diagnostic testing. Optimal treatment requires a multidisciplinary approach. A large spectrum of pharmacologic interventions is efficacious in treating CRPS. Surgery may be used to relieve nociceptive foci. Patient-specific hand therapy is very important in reducing swelling, decreasing pain, and improving range of motion.     

Site of service influence on stent use for hemodialysis access interventions

ObjectiveWith rising health care spending in the United States, the Centers for Medicare and Medicaid Services (CMS) in recent years attempted to use reimbursement rates to influence use of less expensive care sites for covered patients, such as ambulatory surgery centers (ASCs) and office-based laboratories (OBLs), in lieu of hospital service sites. It has been suggested that cost savings have not been realized because of more procedures being performed by physicians with ownership interests in nonhospital facilities. CMS adopted massive reimbursement changes for 2019 OBL and ASC-based procedures, which reduced dialysis access angioplasty reimbursement in the ASC setting by 50%, whereas facility reimbursement for stenting increased by 33% above prior levels. The clinical utility of adjunctive stenting in treating dialysis access stenosis remains controversial and highly discretionary. As a vascular group performing such procedures in both a hospital and nonhospital facility in which we have equity interest, we reviewed our use of stents in dialysis access procedures both in the hospital and in the ASC/OBL to determine whether site of service affected stent use.MethodsA retrospective review of a prospectively maintained database was performed from 2014 to 2018. All patients undergoing dialysis access angiography with angioplasty and adjunctive stent placement at our OBL (later ASC) and our primary hospital were included in the study.ResultsThere were 961 angioplasty or stent procedures performed for dialysis accesses between the two sites, 564 (58.7%) in the hospital setting and 397 (41.3%) at the OBL/ASC. There was a significant difference in race and age between the two sites, with younger, minority patients more frequently being treated in the hospital and older, white patients more likely to be treated in the ambulatory setting; 153 (27.1%) underwent adjunctive stent placement in the hospital and 127 (32.0%) in the ambulatory setting (P = .09).ConclusionsWhereas financial incentives have not yet had an appreciable influence on stent use for dialysis access within previous reimbursement paradigms, the dramatic changes recently adopted by CMS may well alter this dynamic and could lead to substantially higher overall costs without proven clinical advantage. Interventionalists may be incentivized to add stents when performing balloon angioplasty in ASCs. With high failure and reintervention rates and increasingly expensive adjuncts (drug-coated balloons and stents, covered stents), the cost implications of attempts to incentivize interventionalists toward a specific type of procedure or site of care are substantial, and unintended negative consequences are likely to occur.     

Targeted sensorimotor retraining in the clinical setting: Improving patient outcomes following distal upper extremity injury

BackgroundExisting theoretical evidence indicates sensorimotor retraining is beneficial following wrist injury. However, there are no large cohort studies applying the knowledge in a clinical setting.Purpose of the StudyTo Determine the clinical benefits of sensorimotor rehabilitation following distal upper extremity injury.Study DesignProspective cohort study.MethodsA sensorimotor rehabilitation program was evaluated following distal upper extremity injury. A battery of clinical and patient-rated outcome measures (PROM) were taken before and after group completion.ResultsNinety-three patients, 49 males (53%) and 44 females (47%), completed the program. There were statistically significant improvements in 12 clinical measures. However, improvements in 11 of the clinical measures only had a small effect size (<0.5). Joint position sense had the greatest clinical change with a median improvement of 4° on the left and 3.9° on the right, and these had moderate effect sizes of 0.5 and 0.7, respectively. There were statistically significant improvements in all PROMs. PRWE had a median improvement of 21 (ES = 1.2). UEFI showed median improvements of 19.7 (ES = 1.4) and NRS (pain) median improved 2.5 (ES = 1.2). All PROM improvements had mean change greater than associated MCIDs.DiscussionThese results indicate the benefits of sensorimotor group rehabilitation and supports existing literature regarding the importance of sensorimotor control for JPS accuracy and function. Group based sensorimotor programs present an efficient and low-cost opportunity to provide intervention to patients following upper extremity injury.ConclusionA sensorimotor group rehabilitation program may improve patient outcomes following distal upper extremity injury.Level of EvidenceLevel 2b prospective cohort.     

Operative treatment for separation of distal tibiofibular syndesmosis

Objective: To study the influence of separation of distal tibiofibular syndesmosis on ankle joint and to compare various operative methods so as to find suitable stabilization for separated distal tibiofibular syndesmosis. Methods: From July 1997 to July 2002, we treated 87 patients (64 males and 23 females, aged 18-54 years) with separation of distal tibiofibular syndesmosis, among whom, 79 were combined with fracture of malleolus. Manipulative reduction, internal fixation with cancellous screws and external fixation with plaster support were performed on 37 patients, fixation with plate and screws for fibular fracture and fixation with cancellous screws for distal tibiofibular syndesmosis on 34 patients, and repair of the distal tibiofibular ligaments with tendon of peroneus longus, reduction of the separated distal tibiofibular syndesmosis, and fixation with cancellous screws on 16 patients. The ankle joint had been dorsiflexed for 30°when the distal tibiofibular syndesmosis was fixed with cancellous screws. And the cancellous screws were taken out at 8-10 weeks after operation. Results: These patients were followed up for at least two years. The curative effects were assessed according to the complaints of the patients and the contour, function and radiogram of the ankle joint: excellent in 55 patients (63%), good in 18 patients (21%) , and fair in 14 patients (16%). Separation of distal tibiofibular syndesmosis recurred in 2 patients, who underwent a reoperation for repairing the distal tibiofibular ligaments with tendon of peroneus longus and recovered. One cancellous screw was broken off. No necrosis developed in the anterior skin of the ankle mortise. Conclusions:Separation of distal tibiofibular syndesmosis can be treated with various reasonable operations. Repair with tendon of the peroneus longus can get excellent outcomes for complete separation of the distal tibiofibular syndesmosis.     

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.