Síndrome biliar obstructivo no litiásico o de Lemmel. ¿Es tan infrecuente como parece? / Non-lithiasic obstructive biliary syndrome or Lemmel's syndrome. Is it as rare as it seems?

Introducción. Aproximadamente el 5 % de los divertículos duodenales pueden causar síntomas y el 1 % presentar complicaciones, siendo la colangitis la más frecuente. El síndrome de Lemmel corresponde a un tipo de ictericia obstructiva intermitente, asociado a la presencia de divertículos periampulares y disfunción del esfínter de Oddi, sin presencia de coledocolitiasis. Método. Se realizó una revisión sistemática de la literatura en Pubmed, Google Académico y ProQuest, con los términos: síndrome de Lemmel, divertículo duodenal sintomático e ictericia obstructiva intermitente. Resultados. Se encontraron 38 casos, siendo España el país con mayor número, seguido de México, Japón y Colombia. No hay diferencias de distribución con respecto al género. El tratamiento más frecuentemente empleado fue la colangio pancreatografia retrógrada endoscópica. Conclusión. El síndrome de Lemmel es poco frecuente, sin un cuadro clínico especifico, con un incremento en los casos informados en los últimos años, posiblemente debido a la mejor disponibilidad de métodos diagnósticos. Es más frecuente en pacientes en la octava década de la vida y su tratamiento generalmente es endoscópico

Introduction. Approximately 5% of duodenal diverticula can cause symptoms and 1% have complications, cholangitis being the most common. Lemmel syndrome corresponds to a type of intermittent obstructive jaundice, associated with the presence of peri-ampullary diverticula and sphincter of Oddi dysfunction, without choledocholithiasis. Method. A systematic review of the literature was carried out in Pubmed, Google Scholar, ProQuest, with the terms: Lemmel syndrome, symptomatic duodenal diverticulum, and intermittent obstructive jaundice.Results. 38 cases were found, Spain being the country with the highest number, followed by Mexico, Japan and Colombia. There are no differences in distribution with respect to gender. The most frequently used treatment was endoscopic retrograde cholangiopancreatography.Conclusion. Lemmel syndrome is a rare disease, without a specific clinical presentation, with an increase in reported cases in recent years possibly due to the better availability of diagnostic methods. It is more frequent in patients in the eighth decade of life and its treatment is generally endoscopic

Diverticulosis de intestino delgado, hallazgo intraoperatorio / Diverticulosis of the small bowell, intraoperative finding / Diverticulose do intestino delgado, achado intraoperatório

La diverticulosis puede presentarse en cualquier sector del tubo digestivo. La topografía de intestino delgado es infrecuente, se presenta sobre todo a nivel del yeyuno y en un 35% de los casos se asocia con diverticulosis colónica. Es más frecuente en mayores de 40 años. Los divertículos van disminuyendo de tamaño y número hacia el sector distal. Habitualmente el diagnóstico es incidental, sin embargo, pueden presentar complicaciones de las cuales se destacan por frecuencia el sangrado gastrointestinal y la diverticulitis. Se plantea que la deficiencia de fibra dietética generaría anomalías en el peristaltismo intestinal, lo que junto con fenómenos pseudo-obstructivos y alta presión intraluminal, actuaría en áreas de debilidad focal provocando la lesión. Presentamos el caso de una paciente de 88 años con una oclusión de colon a la cual se le realizó una cirugía de Hartmann, en el intraoperatorio se identificó divertículos de yeyuno sin elementos complicaciones.

Multiple Jejunal diverticulosis complicated by perforation: case report and a brief literature review

Background: Multiple small-bowel diverticulosis comprises a rare entity with probable underestimated incidence, and that may be the reason why it is sometimes overlooked when managing cases with peritonitis. Case report: In the present paper, we report the case of a 76-year-old male presenting abdominal pain and fever in an acute setting. Computed tomography (CT) scans revealed jejunal thickening and numerous images of saccular addition that were interpreted as jejunoileal diverticulitis. After an initial period of clinical treatment, surgical management was indicated based on a worsening clinical picture and the presence of an extraluminal focus of gas detected in a subsequent CT scan. Through a laparoscopic approach, multiple small-bowel diverticula and a tamponade perforation were found. A segmental intestinal resection was performed, and the patient was discharged after a ten days. Conclusions: Multiple jejunal diverticulosis is a rare condition that should be remembered in the setting of an acute abdomen. As it prevails among older patients, early diagnosis with radiological aid is crucial to establish the most adequate management, including intestinal resection, if necessary. (AU)

Preescolar con divertículo de Zenker y hallazgo intraoperatorio de cuerpo extraño esofágico / Preschool-age child with Zenker's diverticulum and intraoperative finding of an esophageal foreign body

Introducción. El divertículo de Zenker es una evaginación sacular ciega que puede presentarse a nivel faringoesofágico. No se conoce exactamente su incidencia en la edad pediátrica, constituyendo una patología muy infrecuente. La sintomatología es inespecífica, lo que dificulta el diagnóstico precoz y determina un mayor riesgo de complicaciones asociadas. Caso clínico. Paciente preescolar femenina con cuadro recurrente de emesis con deshidratación, posteriormente asociado a disfagia, a quien se le diagnosticó un divertículo de Zenker. Se realizó tratamiento quirúrgico con hallazgo intraoperatorio de dilatación esofágica, un área de estenosis secundaria al hallazgo incidental de un cuerpo extraño y divertículo de Zenker en la región lateral del esófago dilatado. Discusión. Esta patología es extremadamente rara, pero se debe tener en cuenta dentro de los diagnósticos diferenciales en pacientes con sintomatología faringo-esofágica. Conclusión. Se presenta una preescolar sin antecedente de procedimientos esofágicos o malformaciones congénitas asociadas con diagnóstico de un divertículo de Zenker y dilatación esofágica por un cuerpo extraño, tratada quirúrgicamente de forma exitosa.

Introduction. Zenker's diverticulum is a blind saccular evagination that can present at the pharyngoesophageal level. Its incidence in pediatric age is not exactly known, constituting a very infrequent pathology. The symptoms are nonspecific, which makes early diagnosis difficult and determines a higher risk of associated complications.Clinical case. Female preschool patient with recurrent dehydration due to emesis, later associated with dysphagia, who was diagnosed with Zenker's diverticulum. Surgical treatment was performed with intraoperative finding of esophageal dilation, an area of stenosis secondary to the incidental finding of a foreign body, and a Zenker's diverticulum in the lateral region of the dilated esophagus. Discussion. This pathology is extremely rare, but it should be taken into account within the differential diagnoses in patients with pharyngo-esophageal symptoms. Conclusion: We present a preschool female patient with no history of esophageal procedures or congenital malformations associated with a diagnosis of Zenker's diverticulum and esophageal dilation due to a foreign body, successfully treated surgically.

Divertículo duodenal intraluminal como causa de obstrucción duodenal / Intraluminal duodenal diverticulum as a cause of duodenal obstruction

Introducción. El divertículo duodenal intraluminal, también conocido como windsock diverticulum, es una causa rara de dolor abdominal intermitente y plenitud postpandrial, que puede complicarse con obstrucción, sangrado, pancreatitis o colangitis. Suele cursar de forma asintomática y ante la aparición de síntomas el tratamiento de elección es quirúrgico. Caso clínico. Presentamos el caso de una mujer de 24 años, sin antecedentes de interés, que es estudiada por dolor abdominal y plenitud postpandrial, que resulta finalmente en una obstrucción intestinal alta. Tras estudio exhaustivo y necesidad de una cirugía previa, es diagnosticada de un divertículo duodenal intraluminal. Conclusión. La paciente se trató mediante cirugía con resolución exitosa del cuadro de obstrucción intestinal.

Introduction: Intraluminal duodenal diverticulum, also known as a windsock diverticulum, is a rare cause of intermittent abdominal pain and postprandial fullness, which can be complicated by obstruction, bleeding, pancreatitis, or cholangitis. It is usually asymptomatic and when symptoms appear, the treatment of choice is surgical. Clinical case: We present the case of a 24-year-old woman with no relevant history who is studied for abdominal pain and postprandial fullness, presented with an upper intestinal obstruction. After an exhaustive study and the need for a previous surgery, she was diagnosed with an intraluminal duodenal diverticulum.Conclusion: The patient was treated by surgery with successful resolution of the intestinal obstruction

Uso de la enteroscopía intraoperatoria como método diagnóstico en pacientes con sangrado gastrointestinal de origen oscuro. Experiencia inicial / Use of intraoperative enteroscopy as a diagnostic method in patients with obscure gastrointestinal bleeding. Initial experience

Introducción: el sangrado gastrointestinal de origen oscuro es una entidad poco frecuente y se reserva a los casos en los que ya se ha realizado exploración del intestino delgado (endoscópica/radiológica) sin encontrar la causa. Actualmente el estándar de oro es la videocápsula, que se ha descrito como una técnica segura, útil y eficaz para el diagnóstico y tratamiento de las enfermedades del intestino delgado. Objetivo: describir variables demográficas, indicaciones, hallazgos, segmento explorado, tratamiento y tiempo de procedimiento quirúrgico de la enteroscopía transoperatoria en 15 pacientes con diagnóstico de sangrado de tubo digestivo de origen oscuro. Material y métodos: se incluyeron 15 pacientes adultos con el diagnóstico de sangrado de origen oscuro con panendoscopía y colonoscopía negativa a sangrado. A todos se les realizó laparotomía exploradora y enteroscopía transoperatoria con un gastroduodenoscopio. Resultados: se realizaron 15 enteroscopías transoperatorias con gastroduodenoscopio; 10 en mujeres y 5 en hombres, con promedio de edad de 67.2 años. Se exploró la tercera y cuarta porción del duodeno, yeyuno e íleon terminal. Los diagnósticos encontrados fueron enfermedad de Crohn en 1 paciente (6.66%), adenomas en 2 (13.3%), divertículo yeyunal en 6 (40%) y angiectasias en 6 casos (40%). La localización fue en yeyuno [12 casos (80%)] e íleon [3 casos (20%)]. Conclusiones: la enteroscopía intraoperatoria es una alternativa diagnóstica en el sangrado de origen oscuro cuando no se cuente con la enteroscopía doble balón o la videocápsula endoscópica.

Background: Bleeding of dark origin is a rare entity and it is reserved for cases in which exploration of the small intestine has already been performed (endoscopic / radiological) without finding the cause. Currently, the gold standard is the videocapsule which has been described as a safe, useful and effective technique for the diagnosis and treatment of diseases of the small intestine. Objective: The objective was to describe demographic variables, indications, findings, explored segment, treatment and time of the surgical procedure of the intraoperative enteroscopy in 15 patients with a diagnosis of gastrointestinal bleeding of dark origin. Material and methods: 15 adult patients with the diagnosis of bleeding of dark origin with panendoscopy and negative colonoscopy to bleeding were included. All of these underwent exploratory laparotomy and intraoperative enteroscopy with a gastroduodenoscope. Results: 15 intraoperative enteroscopies were performed with a gastroduodenoscope; 10 women and 5 men with an average age of 67.2 years. Third and fourth portions of the duodenum, jejunum, and terminal ileum were explored. The diagnoses found were Crohn's disease 1 (6.66%), Adenomas 2 (13.3%), jejunal diverticulum 6 (40%) and angiectasias in 6 cases (40%). The location was in jejunum, 12 cases (80%) and ileum, 3 cases (20%). Conclusions: Intraoperative enteroscopy is a diagnostic alternative in bleeding of dark origin when there is no double balloon enteroscopy or endoscopic video capsule.

Divertículos duodenales periampulares y el fallo técnico-terapéutico durante colangiopancreatografía retrógrada endoscópica (CPRE) / Periampullary duodenal diverticula and technical-therapeutic failure during endoscopic retrograde cholangiopancreatography (ERCP)

Resumen Introducción y objetivos: los divertículos duodenales periampulares (DDP) son infrecuentes y su hallazgo es incidental. Además, se clasifican en tres tipos según Boix por la cercanía a la ampolla mayor. El objetivo de este estudio fue realizar una descripción de nuestra experiencia con esta anomalía anatómica y demostrar la forma en que esto afecta la tasa de éxito técnica y terapéutica del procedimiento. Material y métodos: se realizó un estudio de corte transversal, con recolección de datos de forma retrospectiva en un período de 5 años de pacientes con divertículos periampulares duodenales. Se evaluó el fracaso terapéutico, complicaciones y dificultad de canulación de la vía biliar. Resultados: se evaluó un total de 214 pacientes, con una relación mujer-hombre de 2,15:1. La distribución de los sujetos por tipo de DDP fue: tipo 1 (29,9 %), tipo 2 (51,9 %) y tipo 3 (18,2 %). La indicación más frecuente de CPRE fue los cálculos del conducto biliar común en un 53,3 %. El DDP tipo 1 presentó mayor dificultad de canulación (11,6 %) y falla terapéutica (28,12 %). Conclusión: la presencia de DDP durante la CPRE se asocia con una mayor falla técnica (falla en la canulación) y falla terapéutica (persistencia de la obstrucción biliar). Además, estas fallas aumentan considerablemente cuando se trata de una papila intradiverticular tipo 1 de la clasificación según Boix. Por lo anterior, se sugiere que los procedimientos endoscópicos biliares en estas condiciones sean realizados por endoscopistas con gran experiencia con el fin de minimizar la probabilidad de falla técnica y terapéutica, y las complicaciones asociadas.

Abstract Introduction and objectives: Periampullary duodenal diverticula are infrequent, and their finding is incidental. They are classified into three types according to Boix due to their proximity to the larger blister. This study aims to describe the experience with this anatomical abnormality and to demonstrate how this affects the technical and therapeutic success rate of the procedure. Materials y Methods: A cross-sectional study was conducted, with retrospective data collection over a 5-year period of patients with periampullary duodenal diverticula. Therapeutic failure, complications, and difficulty of cannulation of the bile duct were evaluated. Results: A total of 214 patients were evaluated, with a female-male ratio of 2.15: 1. The distribution of the subjects by type of PDD was: type 1 (29.9%), type 2 (51.9%), and type 3 (18.2%). The most frequent indication for ERCP was common bile duct stones in 53.3%. Type 1 PDD presented greater difficulty in cannulation (11.6%) and therapeutic failure (28.12%). Conclusion: The presence of PDD during ERCP is associated with greater technical failure (failure in cannulation) and therapeutic failure (persistence of biliary obstruction). In addition, this failures increases considerably when it is a type 1 intradiverticular papilla of the Boix classification. Therefore, it is suggested that biliary endoscopic procedures in these conditions are performed by highly experienced endoscopists to minimize the probability of technical and therapeutic failure and associated complications.

Coristoma pancreático dentro de un divertículo duodenal: a propósito de un caso / Pancreatic Choristoma within a duodenal diverticulum, an accidental finding: apropos of a case

Resumen El coristoma pancreático, o páncreas heterotópico, es una condición rara en gastroenterología. Esta entidad consiste en el hallazgo de tejido pancreático aberrante, en alguna zona del tracto gastrointestinal, sin continuidad vascular o anatómica con el páncreas normal, es poco reportado y presenta sintomatología variable. Presentamos el caso de un individuo de 46 años con dolor abdominal a quien se le encontró mediante exámenes invasivos un divertículo duodenal, el cual al examen histopatológico e inmunohistoquímico mostró un coristoma pancreático.

Abstract Pancreatic choristoma, also called heterotopic pancreas is a rare condition in gastroenterology. This entity consists of the presence of aberrant pancreatic tissue in some other area of the gastrointestinal tract without vascular or anatomical continuity with the normal pancreas; it has been seldomly reported and it could exhibit variable symptomathology. We herein report the case of a 46-year-old male, who presented with abdominal pain and was found, through invasive examinations to have a pancreatic choristoma within a duodenal diverticulum. The diagnosis was made using histopathology and immune-histochemistry testing.

Clinical analysis of 554 patients with colorectal diverticulosis / 中华胃肠外科杂志

Objective: Most patients with asymptomatic colorectal diverticulosis are easily overlooked. However, some of diverticulosis become diverticulitis, bleeding and even perforation, which cause extensive harm to patients. The purpose of this study is to analyze the incidence, clinical features, diagnosis and treatment of colorectal diverticulosis in order to improve the clinical understanding of diverticulosis and its related complications. Methods: A descriptive cohort study was carried out. Clinical data of 554 patients with colorectal diverticulosis confirmed by CT, colonoscopy, digestive tract radiography or operation in Peking University First Hospital from January 2009 to June 2019 were retrospectively analyzed. Patients with malignant tumors, autoimmune diseases, long term use of immunosuppressive drugs, chronic liver diseases and renal diseases, and mental disorders were excluded. The analysis parameters included gender, onset age, clinical symptoms, location of diverticulitis, treatment and prognosis. According to the criteria established by the World Society of Emergency Surgery (WSES), acute diverticulitis was divided into 5 stages based on the extension of the infectious process. Stage 0 was simple diverticulitis and stage 1-4 was complicated diverticulitis. Results: Among the 554 patients with colorectal diverticulosis, 358 (64.6%) were males, the median onset age was 63 years; 191 patients (34.5%) had various digestive symptoms, of whom 113 (20.4%) had chronic constipation and abdominal distension, 78 (14.1%) had chronic diarrhea and abdominal pain; the other 363 patients had no obvious abdominal symptoms. Four hundred and six patients were found by colonoscopy and 465 patients were found by CT. Twenty-five patients were diagnosed by lower gastrointestinal tract radiography and 3 were confirmed during operation. There were 339 patients with multiple diverticula (61.2%) and 215 patients with single diverticulum (38.8%). 76.5% (424/554) of diverticula were located in colon, 37.0% (205/554) in ascending colon, 21.3% (118/554) in multiple sites, and 2.2% (12/554) in rectum. The median diameter of diverticulum was 7 mm, and 78 cases (14.1%) was ≥30 mm. Forty-nine patients (8.8%) developed acute diverticulitis, including 13 patients with simple diverticulitis and 36 patients with complicated diverticulitis. Among 36 patients with complicated diverticulitis, 29 (80.6%) were males, 27 (75.0%) had recurrent abdominal pain and fever before onset; diverticula of 25 cases were located in sigmoid colon; 11 cases in ascending colon. Nine cases developed sigmoid colon perforation and 8 cases developed vesicocolonic fistula, and these 17 patients underwent surgical treatment. The other 19 cases with complicated diverticulitis developed gastrointestinal bleeding, of whom 18 cases were male, 11 cases were located in ascending colon; 13 cases were healed after conservative treatment, 4 cases received endoscopic hemostatic intervention, and 2 cases underwent surgery. Conclusions: Colorectal diverticulosis is more common in male patients, and CT and colonoscopy are main diagnostic methods. The symptoms of complicated colonic diverticulitis are related to the location of diverticulum. In addition to symptomatic treatment, surgical procedures are the most important treatments.

Terapia endoscópica combinada en hemorragia diverticular de colon / Combined endoscopic therapy for colonic diverticular bleeding

La hemorragia diverticular es la causa más frecuente de hemorragia digestiva baja. La hemorragia es abrupta, indolora, abundante. La mayoría de los divertículos que sangran se localizan en el lado derecho, este sangrado se autolimita hasta en un 80% de los casos. Cuando no se autolimita su manejo puede llegar a ser complejo. El manejo de estos sangrados, pueden variar desde conservador, endoscópico, arteriografía más embolización y el quirúrgico. Entre las alternativas de manejo endoscópico, tenemos la terapia de inyección, la térmica, hemoclips, ligadura con banda. El presente caso es de un paciente con hemorragia diverticular en el que se realizó terapia endoscopica combinada, infiltración de adrenalina, aplicación indirecta de hemoclips y aplicación tópica de ácido tranexámico que es un antifibrinolítico.

Diverticular bleeding is the most common cause of lower GI bleeding. The bleeding is most often abrupt, painless and abundant. Most of the bleeding diverticula are located on the right side of the colon, this bleeding is self-limited in up to 80% of cases. When it is not, it could turn into a difficult situation to manage. The management of these bleeds can vary from conservative to an endoscopic, arteriography plus embolization and surgical. Among the endoscopic management alternatives, we have injection therapy, thermal therapy, hemoclips, band ligation. The present case is about a patient with diverticular bleeding who underwent combined endoscopic therapy, adrenaline infiltration, indirect application of hemoclips, and topical application of tranexamic acid, which is an antifibrinolytic.

Impresión 3D de rara patología congénita de aorta y vasos supraaórticos / 3-Dimensional impression of a rare congenital disease of aortic and supra-aortic vessels

Resumen El divertículo de Kommerell es una anomalía de muy baja incidencia y prevalencia en la edad pediátrica. Se reporta el caso de un paciente de 11 años de edad, con diagnóstico de divertículo de Kommerell con arco aórtico derecho y origen anómalo de arteria subclavia izquierda desde la rama pulmonar izquierda a través de conducto arterioso persistente. Dado que es una anomalía cardiovascular compleja se decidió realizar un modelo impreso en 3 D, el cual proporcionó una mejor comprensión de su distribución espacial, tamaño y forma real, como si fuera una pieza de anatomía patológica. Este modelo ayudó en la toma de decisiones, planificación y seguridad de la ejecución de una posible cirugía cardiaca. Este es el primer reporte de caso de este tipo de anomalía, así como el primer prototipo cardíaco impreso en modo tridimensional realizado en Perú para el tratamiento de la misma.

Abstract Kommerell's diverticulum is an anomaly of very low incidence and prevalence in paediatrics. A case is presented of an 11 year-old patient with a diagnosis of Kommerell's diverticulum with a right aortic arch and a left subclavian artery of anomalous origin from the pulmonary branch through a patent ductus arteriosus. Given that this was a complex cardiovascular anomaly, it was decided to make a print model in 3-D. This provided a better understanding of its spatial distribution, size, and real shape, as it was a histopathology piece. This model helped in taking planning and safety decisions on any possible cardiac surgery. This is the first report of a case of this type of anomaly, as well as the first prototype of a cardiac print in 3-dimensional mode, performed in Peru.

Asymptomatic Bladder Diverticulum Can Develop New Urinary Symptoms after a New Onset of Stroke: a Case Report

Bladder diverticulum can be caused by many varying factors. It is usually asymptomatic in nature and thus often found by chance. In adult males, it can develop as a result of increased intravesicular pressure in the presence of an underlying benign prostatic hyperplasia. We observed a case in which a patient with asymptomatic bladder diverticulum developed new urinary symptoms owing to an underlying neurogenic lower urinary tract disorder which occurred following a cerebral infarction.

Adult Ileocolic Intussusception Caused by Diffuse Large B Cell Lymphoma / 대한소화기학회지

Intussusception is a medical condition, in which a proximal part of the intestine folds into the distal intestine. Adult intussusceptions are rare and account for approximately 5% of all cases of intussusceptions. The anatomical leading points include tumors, diverticulums, polyps, and strictures in 80-90% of adult intussusceptions, and 65% of colon intussusceptions and 30% of small bowel intussusceptions originate from malignant tumors. Treatments for adult intussusception have not been established, but most cases require surgical treatment. The gastrointestinal tract is the most common extranodal site for non-Hodgkin lymphoma. The symptoms are mostly non-specific, but they rarely lead to complications, such as bleeding, perforation, and intussusception. Furthermore, few cases of primary gastrointestinal lymphomas causing intussusception have been reported. This paper reports a case of small bowel diffuse large B cell lymphoma that caused ileocolic intussusception in a 69-year-old woman with no medical history. She underwent a small bowel resection and received six cycles of adjuvant chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. Since then, she has been in complete remission.

Tratamiento hibrido de divertículo de Kommerell complicado / Hybrid treatment of complicated Kommerell's diverticulum

Se describe un caso clínico en el que se aplica una técnica hibrida para el tratamiento del Divertículo de Kommerell complicado por ser una estrategia segura para nuestra paciente. La decisión debe basarse en el conocimiento de la anatomía compleja, el inicio y extensión de la disección como el estado clínico del paciente.

A clinical case is described in which a hybrid technique is applied for the treatment of Kommerell's Diverticulum, complicated by being a safe strategy for our patient. The decision should be based on knowledge of the complex anatomy, the initiation and extent of the dissection as well as the clinical status of the patient.