Right-sided Aortic Arch with Aberrant Left Subclavian Artery arising from Kommerell's Diverticulum: A case report.

Right-sided aortic arch, first documented by Fioratti and Aglietti in 1763, is a rare variant of the thoracic vascular anatomy present in about 0.1% of the adult population. In half of these cases the left subclavian artery is also aberrant. The aberrant left subclavian artery usually originates from a conical dilatation near its origin from the aorta also known as "Kommerell's diverticulum." Fewer than 80 of these cases have been reported in the literature as far as our web search is concerned. It is usually asymptomatic and diagnosed incidentally during adulthood. We are presenting a 56 years old male patient presented with right side chest and shoulder pain of 1 week duration. The pain exacerbated with motion of the right upper extremity and radiates to his lower back. However, he had no history of cough, shortness of breath, syncope, and dysphagia. The vital signs were in normal range. Pulmonary and cardiovascular exam were unremarkable. The complete blood count (CBC), electrocardiogram (EKG), and echocardiography showed no abnormality. In the adult population a right-sided aortic arch with an aberrant left subclavian artery arising from Kommerell's diverticulum is a rare occurrence often asymptomatic unless aneurysmal disease or compression of mediastinal structures ensues. Even though it is rare and at times an incidental finding, the condition is clinically relevant because of the morbidity caused by the complications. We report a case of Kommerell's Diverticulum of an aberrant left subclavian artery in an adult patient with a right-sided aortic arch. Right-sided aortic arch with aberrant left subclavian artery arising from Kommerell's Diverticulum is quite rare and may remain asymptomatic. On times it may cause symptoms in adulthood often as a result of early atherosclerotic changes of the anomalous vessels, dissection, or aneurysmal dilatation with compression of adjacent structures causing dysphagia, dyspnea, cough, or chest pain. Even though there are no general guidelines for the management of this condition patients need to be informed about the nature and possible outcomes of their condition. Close follow up of asymptomatic patients is one option of management until there are situations which require consideration of surgical intervention.

Comparison of flexible endoscopic needle knife septotomy and peroral endoscopic myotomy for treatment of Zenker's diverticulum.

BACKGROUND AND AIMS: Treatment of Zenker's diverticulum (ZD) has evolved from flexible endoscopic septotomy (FES) to peroral endoscopic myotomy (Z-POEM). In this study, we compare efficacy and safety of FES with a needle knife septotomy (FENKS) and Z-POEM for symptomatic ZD. METHODS: Consecutive patients at a single institution who underwent endoscopic ZD treatment by FENKS or Z-POEM were identified. Demographics, clinical characteristics, procedure technique, technical and clinical success, and adverse events (AEs) within 30 days were reviewed and compared between the two groups. AEs were classified by the AGREE classification. Baseline and post-procedure Dakkak and Bennett's (DB) scores were reported at 6, 12 and 24 months. Clinical success (DB score ≤1) was assessed by per-protocol (PP) and intention-to-treat analyses (ITT). RESULTS: 60 patients (55% M, mean 72±12 yrs.) underwent FENKS (n=21) or Z-POEM (n=39) between 2016 and 2023. Baseline clinical characteristics were similar and overall technical success was 98.3%. Clinical success by PP and ITT analyses at 6, 12 and 24 months after intervention were similar between both groups. The FENKS group had a higher prevalence (29% vs. 5%, p=0.018) and severity (p=0.032) of AEs and were more likely to be hospitalized after treatment (71% vs. 33%, p=0.007). During a median follow up of 18 months, reintervention was required for 5 (10%) in the FENKS (n=2, 9%) and Z-POEM (n=3, 7.6%) groups (p=1.0) a mean 7.6 ± 4.4 months after initial therapy. CONCLUSION: Treatment of ZD with Z-POEM appears to be safer than FENKS with similar short- and mid-term clinical success.

The correlation between chronic endometritis and Caesarean scar diverticulum.

PURPOSE: To investigate the risk factors for Caesarean Scar Diverticulum (CSD) with Chronic Endometritis (CE) and the correlation between CE and clinical symptoms of CSD. METHODS: The frequency of CE in 44 patients with CSD who underwent surgical treatment and 20 control women who underwent total hysterectomy was assessed and the clinical symptoms in the presence and absence of CE were compared. In accordance with the presence of one or more CD138-positive plasma cells per high-power field, CE was classified as mild or severe group. RESULTS: According to multivariate analysis, the presence of mild CE (OR 8.963, 95 % CI 2.177-36.907, p = 0.002) or severe CE (OR 21.773, 95 % CI 2.285-207.419, p = 0.007) was significantly associated with CSD. Mild CE (OR 12.390, 95 % CI 1.158-132.511, p = 0.037) or severe CE (OR 22.463, 95 % CI 1.657-304.541, P = 0.019) or depth of diverticulum (OR 1.294, 95 % CI 1.003-1.668, p = 0.047) was associated with prolonged menstruation in patients with CSD. The degree of CE in patients with CSD was positively correlated with the days of prolonged menstruation (r = 0.552, p < 0.001) and negatively correlated with haemoglobin level (r = -0.408, p = 0.038). CONCLUSIONS: CE was associated with CSD and its clinical symptoms, including prolonged menstruation and decreased haemoglobin. The severity of clinical symptoms of CSD is associated with endometrial inflammation.

Comparative analysis of CO2 laser and ultracision harmonic scalpel for endoscopic treatment of Zenker's diverticulum using a propensity score: A retrospective observational study.

OBJECTIVES: Zenker's diverticulum (ZD) is a progressive condition that can cause dysphagia and aspiration. Endoscopic cricopharyngeal myotomy (ECPM) is the gold standard treatment for ZD, but there are various techniques available. We aimed to compare the efficacy and safety of the ultrasonic harmonic scalpel (UHS) versus the CO2 laser (CO2L) for ECPM in ZD. DESIGN: We led an observational study. The main composite outcome consisted in persistence of postoperative dysphagia OR recurrence/reoperation of symptomatic ZD within two years postoperatively. Surgery was considered effective when no dysphagia within two years postoperatively. The secondary outcome was the occurrence of acute mediastinitis within 72 h postoperatively. A propensity score was built to adjust for differences observed between non-randomized groups. Additional sensitivity analyses were performed. SETTING: All patients with ECPM surgery for ZD were included from 2011 to 2018 in a single tertiary center. Patients with failure of endoscopic exposition were excluded. PARTICIPANTS: The study included 86 patients who underwent ECPM with either the CO2L (n = 53) or UHS (n = 33) technique. ZD size and other demographic variables were comparable between the groups. MAIN OUTCOME MEASURES: UHS had superior efficacy compared to CO2L (relative risk of failure = 0.29; 95 % confidence interval: 0.05-1.0; p = 0.05), but there was a higher incidence of mediastinitis in the UHS group (12 % vs. 4 %), although this was not statistically significant. RESULTS AND CONCLUSION: The UHS technique appears to be an effective technique for ECPM in ZD patients but its safety remains to explore by further larger studies.

Meckel's "Wallet": A Unique Case of Intestinal Obstruction.

While bowel obstruction is the most common surgical disorder of the small intestine, small bowel obstruction due to Meckel's diverticulum is a relatively rare occurrence. We encountered a compelling case of small bowel obstruction that turned out to be more complex than anticipated, involving a Meckel's diverticulum with some unforeseen findings. We followed standard guidelines for history-taking, examination, investigations, and management of the intestinal obstruction. After exhausting conservative treatment options, we opted for surgical intervention, and the unexpected cause of the obstruction took us by surprise. This case report highlights an exceedingly rare entity: Meckel's diverticulum precipitating uncommon complications.

Postoperative Surprises: A Carcinoid Tumor Within a Perforated Meckel's Diverticulum.

Meckel's diverticulum, a true diverticulum originating from the incomplete closure of the vitelline duct during embryologic development, rarely presents with carcinoid tumors. The coexistence of a Meckel's diverticulum and carcinoid tumor following laparoscopic sigmoid colectomy for diverticulitis is an uncommon phenomenon, with limited documented cases in the literature. We present a case of a 74-year-old male with a past medical history of hypertension and diverticulitis who underwent a laparoscopic sigmoid colectomy for dysplastic and cancerous changes of a polyp revealed during a screening colonoscopy. Initially, the patient's postoperative journey was uneventful with the resumption of regular bowel movements and favorable diet progression. However, he later presented to the emergency department for worsening abdominal pain and distension. Imaging prompted surgical intervention due to perforation and obstruction, resulting in the identification of a carcinoid tumor within a perforated Meckel's diverticulum. This case highlights the intricate challenges of postoperative complications, particularly the unexpected emergence of Meckel's diverticulum pathology following a colectomy. The atypical presentation, featuring a carcinoid tumor within a perforated Meckel's diverticulum, underscores the importance of evaluating abdominal symptoms postoperatively.

Meckel's diverticulum complicated by acute intestinal obstruction: a case report.

Introduction and importance: Meckel's diverticulum is a rare congenital intestinal anomaly that can sometimes cause serious complications. The authors' aim is to review the literature on this condition by reporting the clinical case of a young adult with Meckel's diverticulum complicated by acute intestinal obstruction. Case presentation: This was a 24-year-old young man, operated on for open bladder stones received for occlusive syndrome. Abdominal computed tomography (CT) suggested a flange occlusion. Surgical exploration found a Meckel's diverticulum creating a flange around the last one. An intestinal resection was performed with direct anastomosis with simple consequences. Clinical discussion: Meckel's diverticulum is a rare congenital intestinal anomaly. It is discovered incidentally or in the face of serious complications such as intestinal obstruction. Intestinal resection with one-stage anastomosis emerges as a standard and safe management approach. Conclusion: A Meckel's diverticulum can be complicated by acute intestinal obstruction mimicking a postoperative flange that can err the diagnosis.

Naldemedine-induced perforation of a diverticulum in the sigmoid colon of a patient with opioid-related constipation: a case report.

BACKGROUND: Naldemedine is an orally available peripherally acting µ-opioid receptor antagonist approved to treat opioid-induced constipation (OIC). It is contraindicated for patients with known or suspected gastrointestinal obstruction to protect against naldemedine-induced perforation. Here, we report a clinical case of suspected perforation of a diverticulum in the sigmoid colon associated with naldemedine. CASE PRESENTATION: The patient was a 65-year-old man with a history of oral cancer who had been prescribed oxycodone (20 mg/day) for cancer pain. On day 0, the patient started naldemedine 0.2 mg once daily before bedtime for OIC. The dose of oxycodone was increased for pain control up to 60 mg/day. On day 35 of naldemedine treatment, the patient developed fever and abdominal pain, and his frequency of defecation had decreased. Initial laboratory results showed a C-reactive protein (CRP) level of 28.5 mg/dL and white blood cell (WBC) count of 13,500/µL. On day 37, the patient still had tenderness in his lower abdomen. Abdominal computed tomography revealed free air in the abdominal cavity suggesting an intestinal perforation. A Hartmann procedure was performed. Histopathological findings showed numerous diverticula in the sigmoid colon, some of which were perforated. CONCLUSIONS: These results suggest that the effects of OIC may have compressed the intestinal tract, which was followed by naldemedine-activation of peristalsis, which led to the onset of intestinal perforation. In patients with pre-existing diverticular disease, we should monitor for increased WBC counts and CRP levels after the initiation of treatment with naldemedine, and consider performing appropriate tests early in the event of abdominal complaints.

British Association of Urological Surgeons (BAUS) consensus document for the management of benign female urethral lesions.

OBJECTIVE: To provide a consensus document for the management of benign female urethral lesions. METHODS: The British Association of Urological Surgeons (BAUS) Female, Neurological and Urodynamic Urology (FNUU) Section created a consensus document to guide the management of the commonest of urethral swellings using expert consensus with a modified Delphi technique. RESULTS: Benign urethral lesions in females can include urethral mucosal prolapse, urethral caruncle, Skene's gland cysts and urethral diverticulum. They can present in a variety of ways including haematuria, lower urinary tract symptoms and voiding dysfunction, and can initially be overlooked or not recognised, resulting in delayed management. CONCLUSION: This consensus statement led by the FNUU Section of the BAUS, in consultation with BAUS members and consultants working in units throughout the UK, aimed to create a comprehensive and pragmatic management pathway for the assessment, investigation and treatment of benign urethral lesions in females.

SPECT/CT in the Diagnosis of Ectopic Gastric Mucosa-Meckel's Diverticulum.

Aim The imaging of Meckel's diverticulum (MD) is based of accumulation of Tc-99m pertechnetate in the ectopic gastric mucosa (EGM) content. Although the diagnostic accuracy of this imaging modality is high, there are some overlap patients with coexisting gastrointestinal bleeding and false positive causes hampering diagnostic power. The aim of this study was to evaluate the possible contribution of single-photon emission computed tomography/computed tomography (SPECT/CT) in EGM-MD diagnosis and to determine the indication of this additional imaging modality. Materials and Methods Fifty-two pediatric patients (24 girls, 28 boys; mean age: 8.06 ± 5.22 years old) who have suspicion of MD and referred for scintigraphy were evaluated retrospectively. Additional SPECT/CT were performed to selected five cases among the group. The results of the scintigraphy as well as SPECT/CT were compared with endoscopy, pathology, and/or follow-up results. Results There were 9 patients with equivocal study results, 12 positive results, and the others were considered negative MD scintigraphy. One patient was out of follow-up and 10 patients underwent surgery. Only one single patient was negative during surgery but scintigraphy was also negative. The diagnostic sensitivity, specificity, and accuracy were 100, 95, and 96%, respectively. Among five patients with SPECT/CT results one patient was diagnosed by only SPECT/CT who had EGM in duplication cyst, one equivocal patient was diagnosed as descending colon bleeding, and one patient's lesion was clearly delineated by SPECT/CT. Conclusion SPECT/CT has clear advantage over standard planar scintigraphy imaging in EGM-MD determination. This modality might decrease equivocal and false positive results but this issue has to be addressed with further studies.

Retroperitoneal Duodenal Diverticulum Microperforation: The Role of Computed Tomography.

Duodenal diverticula are relatively common, but perforations are rare and therapy has not yet been standardized. The most common location of diverticula is the descending duodenum, usually on the lateral side next to the pancreas, so perforations present with an atypical clinical course. We present a case of a 73-year-old female patient with epigastric pain and nausea. Abdominal CT revealed an air-fluid collection near the laterocaudal border of the descending duodenum, suggestive of duodenal microperforation and incipient abscess formation. During the operation, a diverticulectomy was performed with primary duodenal closure and abdominal drainage. A diverticulum microperforation contains some extraduodenal air bubbles, no evidence of abscess, and free air in the subdiaphragmatic region. It is an imaging entity with distinct clinical and biochemical features, and radiological findings often determine the final decision on treatment.

Recognizing perforated Meckel's diverticulum: A crucial differential in acute appendicitis imitation.

Key Clinical Message: Meckel's diverticulitis (MD) mimics acute appendicitis with right lower abdominal pain. Clinicians must consider MD in acute abdomen cases to avoid diagnostic delays. Perforated MD can lead to serious complications. Timely use of advanced imaging and surgical assessment is essential for accurate diagnosis and management. Abstract: Meckel's diverticulum (MD) is a gastrointestinal congenital anomaly that signifies a persistent remnant of the omphalomesenteric duct. While frequently asymptomatic, its complications vary widely, ranging from mild and painless to potentially life-threatening conditions. This is a case of a 4-year-old female patient with sudden abdominal pain and tenderness, with an elusive cause before surgery. The definitive diagnosis of a perforated MD was established during diagnostic laparoscopy due to worsening symptoms. Detecting MD and its potential complications requires a high degree of suspicion. Once recognized, prompt management is essential to prevent further complications. Although perforation is uncommon in MD, its symptoms can mimic acute appendicitis, confusing emergency settings. This article underscores the significance of diagnosing MD, despite its rarity, and emphasizes the necessity for swift treatment upon identification.

Recent updates on classification and unsolved issues of diverticular disease: a narrative review.

Recently, a paradigm shift has occurred in the classification of diverticular disease and the understanding of its pathogenesis. Diverticular disease is now defined as a variety of clinically significant conditions such as diverticulitis, diverticular bleeding, symptomatic uncomplicated diverticular disease, and segmental colitis associated with diverticulosis. Low-grade inflammation, visceral hypersensitivity, abnormal intestinal motility, and genetic factors have emerged as the key contributors to the pathogenesis of diverticular disease. Routine antibiotic use is no longer recommended for all cases of diverticulitis, and simple recurrence is not an indication for surgical treatment. Early colonoscopy with proper preparation is recommended for the treatment of diverticular bleeding, although recent studies have not shown significant efficacy in preventing recurrence. The roles of dietary fiber, nonabsorbable antibiotics, 5-aminosalicylates, and probiotics in the prevention of diverticular disease are controversial and require further investigation.

Traditional septotomy or Z-POEM for Zenker's diverticulum.

Zenker's diverticulum (ZD), also known as a cricopharyngeal pouch, is a pulsion pseudodiverticulum located dorsally at the pharyngoesophageal junction. The pathophysiology of ZD involves cricopharyngeal spasm, incoordination, impaired upper esophageal sphincter opening, and structural changes in the cricopharyngeal muscle, leading to symptoms such as dysphagia, regurgitation of undigested food, foreign body sensation, halitosis, unintentional weight loss, and respiratory issues. Treatment for symptomatic ZD typically involves myotomy of the cricopharyngeal muscle. Endoscopic techniques, particularly flexible endoscopy septotomy (FES) and Zenker peroral endoscopic myotomy (Z-POEM), have become preferred options due to their minimally invasive nature. This review discusses the techniques and clinical outcomes of FES and Z-POEM, focusing on specific clinical scenarios to guide the choice between these methods. Additionally, the variability in FES techniques, the effectiveness of Z-POEM, and the impact of different diverticulum sizes on treatment outcomes are analyzed, providing a comprehensive overview of current therapeutic approaches for ZD.

Vascular Ring Surgical Repair: Re-Implantation of the Left Subclavian Artery into the Left Carotid Artery in a Pediatric Patient.

Vascular rings are a rare congenital anomaly of the aortic arch, in which a ring-shaped structure forms, surrounding the trachea and/or esophagus, potentially causing compression. We describe the case of a 14-month-old female patient with failure to thrive secondary to dysphagia, and a vascular ring formed by a right aortic arch, an aberrant left subclavian artery, and a left ligamentum arteriosum. Surgical repair involved ligamentum arteriosum division, Kommerell's diverticulum obliteration, and left subclavian artery re-implantation into the left carotid artery. Endoscopy and EndoFLIPTM evaluated the intraoperative improvement in esophageal narrowing and impedance, respectively. The postoperative period was uneventful, and follow-up visits demonstrated dysphagia resolution and a patent re-implanted left subclavian artery.

The safety and efficacy of endoscopic approaches for the management of Zenker's diverticulum: a multicentre retrospective study.

INTRODUCTION: Minimally invasive endoscopic options are safe and effective alternatives to surgery for the treatment of symptomatic Zenker's diverticulum (ZD). However, there is no consensus on the gold-standard approach. We compared the safety and efficacy of Zenker's peroral endoscopic myotomy (Z-POEM), flexible diverticulotomy (FD), and rigid diverticulotomy (RD) for the management of ZD. METHODS: Patients undergoing treatment for ZD at three UK tertiary referral centres were identified and analysed between 2013 and 2023. Patient demographics, procedural details, clinical success, and 30-day adverse events (AE) were recorded. The primary outcomes were technical and clinical success defined as a fall in Dakkak and Bennett dysphagia score to ≤ 1 without re-intervention. RESULTS: There was no difference in baseline characteristics amongst 126 patients undergoing intervention (50 RD, 31 FD, 45 Z-POEM). Technical success for RD, FD, and Z-POEM was 80%, 100%, and 100%, respectively (p < 0.001). Over a mean follow-up of 11.0 months (95% CI 8.2-13.9), clinical success amongst those treated was 85.3% (RD), 74.1% (FD), and 83.7% (Z-POEM; p = 0.48) with recurrence in 17.2% (RD), 20.0% (FD), and 8.3% (Z-POEM; p = 0.50). AEs were equivalent between groups (p = 0.98). During this time, 11 patients underwent surgical myotomy with low clinical success (36.4%) and high morbidity. CONCLUSION: Endoscopic options for the treatment of ZD show equivalent rates of success, but failed RD often led to open myotomy with worse outcomes. Flexible endoscopic modalities are both safe and highly effective treatments that may be considered first-line in experienced centres and should be offered before surgery.

A rare case of chicken wishbone in Meckel's diverticulum causing partial perforation and diverticulitis.

Meckel's diverticulum (MD), a rare congenital abnormality, can lead to issues like diverticulitis and bleeding. Foreign bodies in MD are even rarer, causing vague symptoms and perforation, requiring urgent surgery. This case report highlights a patient with a foreign body in MD, focusing on clinical presentation and management. A 55-year-old male presented with abdominal pain, nausea, and vomiting. Computed tomography scan revealed a foreign body perforating the small bowel. Exploratory laparotomy found a partially perforated MD with a foreign body. Diverticulectomy was performed, and the patient recovered, discharged the next day. Foreign bodies in MD are exceedingly rare and can cause inflammation, infection, and perforation, mimicking appendicitis. Diagnosis is challenging due to nonspecific symptoms, with imaging and clinical evaluation crucial. Surgical intervention, like diverticulectomy, is primary. Early diagnosis and prompt surgery are critical in managing MD complicated by foreign bodies, ensuring favorable outcomes. This report underscores symptom recognition and effective management strategies.