Treatment of uterine scar cystoid diverticulum by hysteroscopy combined with laparoscopy.

OBJECTIVE: To report a patient with prolonged intermenstrual bleeding and a cystic mass at a cesarean scar treated with laparoscopic folding sutures and hysteroscopic canalization. DESIGN: A 4.0 cm-cystic mass formed at the uterine scar caused continuous menstrual blood outflow in the diverticulum and was treated with hysteroscopy combined with laparoscopy. SETTING: University hospital. PATIENTS: A 38-year-old woman of childbearing age who had undergone two cesarean sections and two abortions reported vaginal bleeding for 10 years, which began shortly after the second cesarean section. Curettage was performed, but no abnormality was found. The patient unsuccessfully tried to manage her symptoms with traditional Chinese medicine and hormone drugs. The muscular layer of the lower end of the anterior wall of the uterus was weak, and there were cystic masses on the right side. INTERVENTION: The bladder was stripped from the lower uterine segment under laparoscopy, and the surrounding tissue of the mass at the uterine scar was separated. The position of the cesarean scar defect was identified by hysteroscopy combined with laparoscopy, and the relationship between the uterine mass and surrounding tissues was analyzed. An electric cutting ring resection on both sides of the obstruction was performed to eliminate the valve effect. The active intima of the scar diverticulum was destroyed by electrocoagulation, followed by laparoscopic treatment of the uterine scar diverticulum mass. An intraoperative tumor incision revealed visible bloody fluid mixed with intimal material. The uterine scar diverticulum defect was repaired using 1-0 absorbable barbed continuous full-thickness mattress fold sutures. Finally, the bilateral round ligament length was adjusted so that the uterus tilted forward. MAIN OUTCOME MEASURES: Recovery of menstruation and anatomy of the uterine isthmus. RESULTS: The operation was successful, and the postoperative recovery was fast. There was no interphase bleeding at the 1-month follow-up, and the uterine scar diverticulum was repaired, with the thickness of the uterine scar muscle layer increasing to 0.91 cm. CONCLUSION: The simple, straightforward procedure to resolve the abnormal cystic, solid mass formed because of the continuous deposition of blood in the uterine scar diverticulum involved laparoscopic folding and docking sutures combined with hysteroscopic canal opening.

An elderly male with lower urinary tract symptoms during COVID-19 pandemic: Extraperitoneal perforation of bladder diverticulum.

CASE: We present a case of spontaneous extra-peritoneal rupture of an acquired diverticulum an elderly male with symptoms of bladder outlet obstruction who presented in emergency with acute abdomen. OUTCOME: The acute phase was managed conservatively with bladder drainage and intravenous antibiotics. He recently underwent Transurethral Resection of Prostate. He is asymptomatic on follow-up. CONCLUSIONS: Acquired bladder diverticulum are rare in adults and are mostly seen in patients with high pressure bladder due to bladder outlet obstruction. Atraumatic extraperitoneal ruptures of diverticulum are uncommonly reported.

Characteristics and outcome of congenital left ventricular aneurysm and diverticulum: Analysis of 809 cases published since 1816.

BACKGROUND: Congenital left ventricular aneurysm (LVA) or diverticulum (LVD) is rare cardiac anomalies. We aimed to analyse the clinical characteristics and outcome in all ever published patients. METHODS: MEDLINE, Web of science, Google and EMBASE, and reference lists of relevant articles were searched for publications reporting on LVA or LVD patients. RESULTS: We identified 809 patients published since 1816 [354 (49.1%) LVA, 453 (50.6%) LVD, 2 (0.3%) both]. Mean age at diagnosis was 34.1±27 (LVA) and 29.7±27.6years (LVD; p=0.05). 48.9% were male. LVA was larger (38.7±22.5mm versus 31.4±21.2mm; p=0.002) and frequently found in submitral location (33% versus 4.9%; p<0.001), LVD was frequently located at the LV-apex (61.2% versus 28.7%; p<0.001). LVD was often associated with cardiac (34.2% versus 11%; p<0.001) or extracardiac anomalies (32.7% versus 3%; p<0.001). LVA patients presented more frequently with ventricular tachycardia/fibrillation (18.1% versus 13.1%; p=0.01), the incidences of rupture (4% versus 4.5%; p=0.9), syncope (8.3% versus 5.1%; p=0.1), and embolic events (4.9% versus 3.6%; p=0.4) at presentation were not different between LVA and LVD. Mean follow-up was 56.3±43months. Cardiac death occurred more frequently in the LVA group (11.5% versus 5.0%; p=0.05) at a median age of 0.8 [LVA] and 2.5 [LVD] years. The leading cause of cardiac death was congestive heart failure in the LVA-group (50.0% versus 0.0%; p=0.01), and rupture in the LVD-group (75.0% versus 27.3%; p=0.04). CONCLUSIONS: LVA and LVD are distinct congenital anomalies with different clinical and morphological characteristics. The prognosis of LVA is significantly worse during long-term follow-up.

Diverticulum of the third ventricle and absence of the interthalamic adhesion in a dog.

A 10-month-old male Pomeranian dog was examined for neurological abnormalities consistent with diffuse forebrain and cerebellar disease. Based on ultrasound and magnetic resonance imaging (MRI) a diagnosis of diverticulum of the third ventricle, partial agenesis of the corpus callosum, and absence of the interthalamic adhesion was made. As conservative treatment was unsuccessful, a ventriculoperitoneal shunt was placed.

Successful radiofrequency catheter ablation of common atrial flutter at the bottom of a coronary sinus diverticulum.

We describe a patient who underwent radiofrequency (RF) catheter ablation of cavo-tricuspid isthmus-dependent atrial flutter (AFL). Extensive ablation at the isthmus failed to terminate the AFL. A coronary sinus (CS) diverticulum arising from the proximal portion of the middle cardiac vein was found near the isthmus. An RF energy application at the bottom of the CS diverticulum resulted in completion of a bidirectional block line at the isthmus, as well as AFL termination.

Analysis of the efficacy of screening tests in colorectal cancer by faecal occult blood test--own experience.

UNLABELLED: Screening of the colon cancer seems to be important to improve the results of the surgical treatment. There are different screening programs, the most common use the fecal occult blood (FOB) tests or colonoscopy. THE AIM OF THE STUDY: was to evaluate the results of the colon cancer screening based on the FOB test and perform the algorhytm improving the effectiveness of the screening. MATERIAL AND METHODS: 941 patients with the positive results of the FOB (immunochromatographic method) test were investigated. In all cases the rectosigmoidoscopy for the detection of the lower GI tract pathology was done. 312 patients were qualified to colonoscopy. RESULTS: Adenomatous polyps and adenocarcinomas were detected in 116 patients. There was no correlation between clinical symptoms and the colorectal cancer. The colorectal cancer was recognized statistically more common at the patients with previous detected neoplasia, in the colon and other organs, with hereditary nonpolyposis colorectal cancer and with inflammatory bowel diseases. CONCLUSIONS: The colorectal cancer screening based on the FOB can be effective in the early recognition of the bowel malignancy. The previous questionnaire can eliminate from the FOB screening the patients without indications (previously done colonoscopy or barium enema) or with directly indications for colonoscopy.

Manometria anorretal no divertículo de reto / Anorectal manometry in rectal diverticulum

Divertículo localizado no reto é um achado excepcional, estimando-se que existam pouco mais de 50 casos publicados. A doença apresenta aspectos controversos, quanto a ser de origem congênita ou adquirida. Recentemente, distúrbios defecação vêm sendo relacionado à maior possibilidade do desenvolvimento da doença. Contudo, até a presente data, as alterações manométricas em portadores de divertículo do reto ainda não foram estudadas. OBJETIVO: O objetivo do presente estudo é demonstrar os resultados de estudo eletromanométrico anorretal, realizado em dois doentes portadores divertículo do reto. CASUÍSTICA E MÉTODO: Um homem e uma mulher, com 56 e 58 anos, respectivamente, foram submetidos à colonoscopia, enema opaco, ultrassonografia endorretal e ressonância magnética da pelve, para confirmação e documentação diagnóstica de divertículo localizado no reto. Os enfermos foram submetidos à eletromanometria anorretal com cateter de oito canais sob perfusão de água a 0,3 ml/min/canal, através de sistema de infusão capilar pneumático e hidráulico. RESULTADOS: O resultado dos exames em ambos os doentes mostrou perfil pressórico esfincteriano normal, tanto em repouso, como em contração voluntária máxima, não se encontrando assimetrias esfincterianas. O reflexo reto-anal inibitório encontrava-se presente e dentro de valores normais, assim como a sensibilidade e complacência retal. A análise pelo vetor volume não mostrou alterações significativas concluindo-se por estudo manométrico ano-retal normal. CONCLUSÃO: O estudo manométrico anorretal não demonstrou existência de distúrbios pressóricos nos esfíncteres anorretais reforçando a possibilidade de que o divertículo de reto possa ter origem congênita, desenvolvendo-se em pontos onde exista maior fraqueza da parede retal.

Diverticulum located in the rectum is an exceptional find with fewer than 50 cases published. The etiology of the diverticulum of the rectum still has controversial aspects regarding its origin is congenital or acquired. Recently, alterations of the evacuative dynamic had been associated with the development of the disease. Nevertheless, until the present date, the manometric alterations in patients with diverticulum of the rectum were not studied. OBJECTIVE: The aim of the present study is to demonstrate the results of electromanometric study carried out in a patient with isolated diverticulum of the rectum. CASE REPORT: A man and a woman, 56 and 58 years-old, respectively, were submitted to colonoscopy, barium enema, endorectal ultrasound and magnetic resonance of the pelvis to diagnose and document the presence of diverticulum located in the rectum. The patients were submitted to manometry using catheter with eight-channel perfusion under water at 0.3 ml/min/channel, through pneumatic and hydraulic capillary infusion system. The anorectal manometry showed normally sphincter pressure profile both in rest and squeezes pressure state, and did not find sphincter asymmetries. The anorectal inhibition reflex was present with normal values and the sensibility and rectal complaisance were between the normal limits. The vector volume analysis did not show any significant alterations and it was concluded by normal manometric anorectal study. CONCLUSION: The anorectal manometry study did not demonstrate the existence of pressure disturbances in anorectal sphincter, enhancing the possibility that the rectal diverticulum can be congenital, developing at points where there is major weakness of the rectal wall.

Rectal diverticulum: a new complication of STARR procedure for obstructed defecation.

We report a case of rectal diverticulum developed after stapled transanal rectal resection (STARR) procedure for obstructed defecation. A 21-year-old woman with chronic constipation was diagnosed with a rectocele at defecography. The patient underwent STARR procedure. Six months later, she presented with severe constipation requiring enemas and a worse condition than that preoperatively. Defecography and rectoscopy revealed a rectal wall diverticulum cavity with incomplete elimination of barium enema. The patient underwent transanal diverticulectomy and direct rectal wall repair. STARR procedure can produce new and difficult-to-treat complications and should be reserved for expert colorectal surgeons with proved familiarity in transanal surgery.

Bladder diverticulum arising adjacent to an ectopic ureter presenting as a cystic mass.

Acquired bladder diverticula due to bladder outlet obstruction are not uncommon in the adult male population. Congenital diverticula originate adjacent to the trigone and are rarely diagnosed in adults. We report an unusual case of a diverticulum arising adjacent to an ectopic ureter located on the left lateral wall near the dome of the bladder. Although the diverticulum appeared to be congenital, its large size was likely a result of high pressure voiding. The patient underwent a transurethral resection of the prostate to reduce his bladder outlet obstruction, and subsequently underwent an open diverticulectomy.

Giant sigmoid diverticulum: case report and review of the literature.

Giant colonic diverticulum is a rare entity first described in 1946 by Bonvin and Bonte. It may be congenital or acquired and the average age of presentation is 65. There are less than 150 reported cases in the literature. A large abdominal mass was detected during a routine physical examination in an 82-year-old man. CT scan showed a large air-filled mass, barium enema showed multiple sigmoid diverticula, but no communication with the mass was found. A diagnosis of giant sigmoid diverticulum was made, elective sigmoidectomy and resection of the diverticulum was performed with no complications. The clinical picture may be different, varying from asymptomatic to acute abdomen, intestinal perforation or fistula. It can be diagnosed with abdominal X-ray, CT scan, barium enema or MRI, but colonoscopy is not effective. There are two accepted theories of the pathophysiology of this entity: first, a congenital origin and second, that inflammatory diverticula are caused by a perforation with a ball-valve that allows gas to enter, but not to leave the cyst, thus, enlarging the false diverticulum, and progressively destroying the bowel layers, causing secondary fibrosis. Elective treatment is a segmental resection of the affected colon with the diverticulum and in cases of acute abdomen two-stage bowel resection is preferred.

Robotic assisted laparoscopic bladder diverticulectomy.

PURPOSE: Surgical management for bladder diverticuli includes open, endoscopic and standard laparoscopic techniques. To our knowledge we report the first series of robotic assisted laparoscopic bladder diverticulectomies. MATERIALS AND METHODS: Five patients underwent robotic assisted laparoscopic bladder diverticulectomy between December 2004 and December 2006, as performed by a single surgeon using the da Vinci robotic system for symptomatic diverticuli. The records were reviewed, the surgical technique is described and a review of the literature was performed. RESULTS: All patients underwent cystoscopy, ureteral stent placement and placement of an angiographic catheter to distend the diverticulum. The diverticulum was approached transperitoneally, mobilized and transected at its neck, and the bladder was closed in 2 layers. One patient underwent ureteral reimplantation for a Hutch diverticulum. Median total operative time was 178 minutes (range 163 to 235) and robotic operative time was 83 minutes (range 63 to 143). Length of stay was 3 days (range 1 to 6). Two patients who underwent transurethral prostate resection before diverticulum resection did well. Two patients in whom medical management failed ultimately underwent transurethral prostate resection and 1 patient continued on medical therapy with regular followup. CONCLUSIONS: Robotic assisted laparoscopic bladder diverticulectomy is safe and effective for patients with a large bladder diverticulum and small prostate. Perioperative surgical outcomes rival those of previously reported open, endoscopic and laparoscopic diverticulectomies.

Adenocarcinoma of the female urethral diverticulum treated by multimodality therapy.

A 75-year-old female presented with a 7-month history of intermittent macrohematuria and urinary retention. Physical examination revealed a firm, round mass on the anterior vaginal wall. The diagnosis by urethroscopy and radiological evaluation was localized urethral diverticular tumor. Pathological examination of the biopsy specimen revealed adenocarcinoma. The patient received two courses of intra-arterial and systemic chemotherapy using cisplatin, 5-fluorouracil and leucovorin, followed by radiation to the urethra. The tumor shrunk markedly after chemotherapy. The patient underwent total urethrectomy and vesicostomy. Two years after the operation, she had no evidence of recurrence. Adenocarcinoma of the female urethral diverticulum is rare and has been treated by surgery and/or radiation. The present case is the first case of it being treated by multimodality therapy including chemotherapy.

Diverticulitis aguda de sigma: valor de la ecografía como test diagnóstico inicial / Acute diverticulitis of the sigmoid colon: value of ultrasound as an initial diagnostic test

Objetivo: Comprobar el valor de la ecografía como método diagnóstico inicial en la diverticulitis aguda.Material y métodos: Se realizó ecografía en 76 pacientes con el diagnóstico clínico de diverticulitis aguda de sigma. El diagnóstico final se basó en el curso clínico en todos los casos, la TC (n = 46), el examen histopatológico de la pieza quirúrgica (n = 10), la colonoscopia (n = 4) y el enema opaco (n = 2). El criterio diagnóstico ecográfico fue el engrosamiento mural del sigma > de 4 mm y la presencia de al menos uno de los siguientes hallazgos: divertículos, flemón o absceso.El diagnóstico por TC se basó en dos hallazgos necesarios: engrosamiento de sigma > de 4 mm y la inflamación de la grasa pericólica.Resultados: El diagnóstico final fue diverticulitis aguda (n = 52), otro diagnóstico (n = 18) o desconocido (n = 6). La sensibilidad de la ecografía y la TC fue 81 por ciento y 94 por ciento respectivamente, y la especificidad 79 por ciento y 83 por ciento respectivamente. De los 10 falsos negativos de la ecografía siete correspondieron a diverticulitis simples y tres a diverticulitis complicadas (dos con absceso y una con neumoperitoneo). La TC diagnosticó correctamente ocho de estos casos, presentando dos falsos negativos ante diverticulitis leves.Conclusión: La ecografía resulta un buen test en el diagnóstico inicial de la diverticulitis aguda de sigma. Se debe realizar TC ante una ecografía no diagnóstica o negativa con una alta sospecha clínica de diverticulitis, y tambien ante la posibilidad de una diverticulitis complicada (AU)

[Endoscopic treatment of bladder diverticula]. / Endoskopicheskoe lechenie divertikulov mochevogo puzyria.

Transurethral endoscopic incision of the urinary bladder's diverticular neck has been performed in 29 patients aged 44 to 90 years (mean age 65 years). 25(86.2%) patients had verified concomitant diseases and high anesthesia risk prohibiting radical surgery. According to preoperative diagnosis, the volume of the diverticula ranged from 20 to 700 ml, the diameter of the neck--from 0.3 to 2.0 cm. 10 patients had multiple diverticula. Uroflowmetry registered the maximal urinary flow rate (Qmax) within 2.1-5.3 ml/s. In all the patients surgery was performed under epidural anesthesia, simaltaneously with transurethral resection (TUR) of benign prostatic hyperplasia in 18 patients, with TUR of the urinary bladder neck or incision of the prostate because of its sclerosis in 11 patients. In 2 cases there was also TUR of the bladder for papillary cancer involving the bladder wall and the diverticulum, in 6 cases one-stage pneumatic or mechanical cystolithotripsy was performed. No intraoperative complications occurred. After the operation all the patients resumed normal micturition. Control examination after 6-48-month follow-up Qmax rose to 14.1-23.0 ml/s. Neither ultrasound investigation nor cystography detected diverticulum in 13 patients. The size of the diverticulum diminished in size in 16 patients. Residual urine in large diverticula (14 patients) was 50 ml maximum. 12 months after the operation 1 patient developed recurrent sclerosis of the prostate with reappearance of residual urine. He was reoperated (TUR of the prostate) without incision of the neck of the diverticulum. Postoperative complications were the following: mild electric burn of the thigh (1 case), acute epididimitis treated conservatively (1 case) and early postoperative bleeding which required endoscopic revision of the bladder and coagulation of the bleeding vessel from the cut neck of the diverticulum (1 case). Thus, transurethral incision of the bladder's diverticular neck is effective and low-traumatic intervention which in patients with severe somatic pathology is an alternative to the open surgery, while in patients without such pathology it does not complicate open operation (diverticulectomy) if it becomes necessary.

Divertículo gigante de sigma: presentación de un caso y consideraciones sobre el manejo de esta rara complicación de la enfermedad diverticular / Giant sigmoid diverticulum

Presentamos un nuevo caso de esta entidad clínica, diagnosticado en el contexto de un cuadro séptico, con descompensación hidrópica de una cirrosis latente, fistulizado a íleon y tratado con drenajes percutáneos. El divertículo gigante de colon es una rara complicación de la enfermedad diverticular. La presentación clínica es variable, soliendo cursar con dolor y/o con masa abdominal. Aunque su etiología permanece especulativa, parece en relación con un mecanismo de pulsión en el divertículo. La radiografía simple de abdomen, el enema opaco y la tomografía axial computarizada ayudan al diagnóstico. La resección quirúrgica es el tratamiento de elección. Nuestro caso es el primero publicado tratado conservadoramente mediante drenajes percutáneos, dada la muy precaria situación clínica de la paciente (AU)

Divertículo de reto associado a adenocarcinoma / Rectal diverticulum associated to adenocarcinoma

Um caso de divertículo de reto associado a adenocarcinoma é relatado. O diagnóstico inicial foi feito por meio do exame proctológico e, durante o estadiamento, pelo enema opaco, no qual foram identificados dois divertículos localizados em parede lateral do reto inferior. O tratamento indicado foi amputação abdominoperineal do reto, em virtude da associação com adenocarcinoma.

[Surgical treatment of internal duodenal diverticulum. Report of 2 clinical cases]. / Terapia chirurgica del diverticolo duodenale interno. Presentazione di due casi clinici.

Internal duodenal diverticulum is a rare disease. Nowadays, less than 100 cases are reported in Western literature. Even if it is a pathology of malformative origin, the first clinical manifestations occur quite always during the III decade. Main symptom is a violent, suddenly arisen, abdominal colic, often associated with meals and with spontaneous remission. Frequency of accesses is variable in time; in most serious cases, colics are so close to cause a considerable reduction of nutrition. Among diagnostical means, very useful are Rx enema (that offers pathognomonical images) and endoscopy, by which the formation can be visualized directly and its connection with papilla can be delineated. In some rare cases, differential diagnosis has to be made with cystic dilatations of bile duct, and particularly with type III according to Alonso-Lej classification or choledochocele. When such a distinction is not possible, differential diagnosis will be made on the basis of histological examination of the type of mucosa present in the internal aspect of the diverticulum. Therapy of symptomatic forms is surgery. The technique of choice is transduodenal diverticulectomy. Cannulation of bile duct is a useful means to found the papilla during intervention, to protect duodenal suture in the postoperative period and to control it radiologically. Two cases of internal duodenal diverticulum operated on in the last 2 years are described and diagnostical and therapeutical items are discussed.

A 7-month-old with bilious vomiting.

We present the case of a 7-month-old boy who presented with a history of bilious vomiting, abdominal distention with a mass, anorexia, and no urinary or stool output for 2 days. Air enema demonstrated a mass effect on the rectosigmoid area, with urinary contrast revealing a large Hutch diverticulum with a narrow neck of the urinary bladder. This patient illustrates a rare case of an infant with bilious vomiting.