Laparoscopic Transhiatal Resection of an Esophageal Diverticulum in a Patient With Systemic Lupus Erythematosus: A Case Report.

Esophageal diverticula are relatively uncommon, especially supradiaphragmatic diverticula. Esophageal diverticula are normally managed by observation; however, surgical treatment is sometimes indicated for large diverticula or diverticula in highly symptomatic patients. Surgical approaches for esophageal diverticula include thoracoscopic or laparoscopic resection; however, consensus has not yet been reached on the optimal approach. Here, we report a case of safe laparoscopic transhiatal esophageal diverticulectomy in a patient with a giant esophageal diverticulum with severe coexisting disease. The patient was a 63-year-old woman with a 17-year history of systemic lupus erythematosus (SLE) who was managed by outpatient therapy with steroids and immunosuppressive drugs. She had a history of SLE-associated renal dysfunction and SLE-associated pulmonary artery thromboembolism, and she was receiving anticoagulation therapy. During an outpatient visit, the patient experienced pericardial discomfort, and upper gastrointestinal endoscopy and computed tomography revealed the presence of a diaphragmatic diverticulum with a diameter of 3 cm. She subsequently developed aspiration pneumonia, which was thought to be caused in part by food stagnation in the diverticulum. However, due to the risks associated with systemic complications, she was initially managed by observation. One year later, the diverticulum had expanded to 6 cm in diameter, and it was determined that the risk of esophageal perforation and aspiration pneumonia was high. Surgery was performed under a laparoscope, and the diverticulum was resected with surgical staplers under an extremely good visual field by dissecting the area around the esophageal hiatus. Postoperative pathology confirmed that the diverticulum was a pseudodiverticulum. The patient's postoperative course was initially good, and she was discharged 10 days after surgery. However, the day after discharge, a hematoma infection occurred near the suture site, requiring re-hospitalization and drainage surgery. After reoperation, she recovered without complications and was discharged 14 days later. Subsequent follow-up showed no diverticulum or pneumonia recurrence. The laparoscopic approach is a minimally invasive approach for patients with diverticula who are at high surgical risk. With an adequate view from the abdominal cavity, even a patient with a fairly large diverticulum can be safely resected.

Novel technique utilizing polymethylmethacrylate cement for the treatment of pulsatile tinnitus caused by different sigmoid sinus pathologies.

PURPOSE: Sigmoid sinus anomalies such as dehiscence or diverticula may present with pulsatile tinnitus (PT) and low-frequency hearing loss. Occasionally, these symptoms are severe, necessitating resurfacing of the affected area to restore a normal-appearing sinus wall. This study describes three cases wherein we managed PT attributed to sigmoid sinus anomalies using polymethylmethacrylate (PMMA) bone cement, a novel material. METHODS: Three patients with PT without any history of illnesses initially underwent cortical mastoidectomy to expose the affected area and resurface the sinus wall. Subsequently, PMMA bone cement was used to reconstruct any bony defects causing PT symptoms. Viscosity of the bone cement was altered based on specific characteristics and causes of the affected area. Additionally, we performed the water occlusion test (WOT), audiological assessment, the Tinnitus Handicap Inventory score (THI), and temporal computed tomography, both pre- and postoperatively, to assess the extent of PT. RESULTS: Preoperatively, all three patients had tinnitus that dissipated with pressure on the neck and the water occlusion test (WOT), with no reported vertigo, trauma, or ear infections. Moreover, all three cases had a severe handicap according to the THI. In contrast, all cases had reduced PT and a significantly decreased THI score postoperatively, as well as no recurrence or complications and no instances of increased intracranial hypertension at the 12-month follow-up. CONCLUSION: All cases showed promising results, emphasizing the sustained benefits of this novel intervention for the management of PT.

A Case of Uncomplicated Duodenal Diverticulosis Presenting With Right Upper Abdominal Pain.

Small bowel diverticulosis is not a common disease entity; however, it is increasingly diagnosed and linked to various gastrointestinal complaints. Although rare, complications can occur and may sometimes require surgical or endoscopic intervention. Furthermore, suspecting and diagnosing duodenal diverticulosis (DD) can be challenging due to the variety of presenting signs and symptoms. Much of our current knowledge comes from case reports and series. This report aims to document a case of DD presenting with severe right upper quadrant pain mimicking the signs and symptoms of acute cholecystitis. It also reviews and summarizes the available literature on the clinical manifestations of DD, its diagnostic approach, treatment modalities, and possible complications encountered in the ED.

Lemmel Syndrome: A Surgical Enigma.

A periampullary diverticulum (PAD) is the most common type of duodenal diverticula found in patients undergoing upper gastrointestinal tract assessments. Even while PAD typically does not manifest any symptoms, it can nevertheless be a source of obstructive jaundice in the absence of a tumor or choledocholithiasis, a condition known as Lemmel's syndrome. We report a case of a 60-year-old woman who presented with abdominal discomfort and multiple episodes of vomiting. After comprehensive clinical examination and investigations, a provisional diagnosis of Lemmel's syndrome was made, leading to initial conservative management for diverticulitis, followed by an exploratory procedure. This case underscores the importance of recognizing Lemmel's syndrome as a differential diagnosis for obstructive jaundice when duodenal diverticula are present, to prevent misdiagnosis and ensure timely, appropriate treatment.

Emerging indications for third space endoscopy.

This chapter will explore the recent advancements and innovations in the field of third space endoscopy. The traditional principles of per-oral endoscopic myotomy and endoscopic submucosal dissection have been applied to offer solutions to traditionally difficult to manage problems including esophageal diverticula, post-fundoplication dysphagia, post-sleeve gastrectomy stricture, bariatric procedure and Hirschsprung disease. Typically, these problems were managed surgically with potentially high rates of morbidity and mortality; however, the principles of third space endoscopy offer a safer and less invasive option for management. All of these applications of third space endoscopy are less than a decade old with some emerging in the last 1-2 years. In this chapter, we will explore the pathophysiology of these diseases and how third space endoscopy can offer a solution. We will also review the relevant literature along with the safety and effectiveness of the proposed innovations.

Diagnosis of bilateral pharyngoesophageal diverticula with using swallow contrast-enhanced ultrasound: a case report.

Pharyngoesophageal diverticulum (PED) is a rare disease of the esophagus that is usually asymptomatic and often found incidentally during a thyroid ultrasound examination. Due to its anatomical location close to the thyroid, it is easily misdiagnosed as a thyroid nodule, which leads to unnecessary thyroid biopsies and surgical treatment. The occurrence of a single esophageal diverticula is common, while the existence of multiple diverticula is rare. Left side diverticula are more common than right sided ones, while bilateral occurrences are rarely reported. We report an extremely rare case of bilateral pharyngeal esophageal diverticula. The patient was a 55-year-old asymptomatic man who came to our hospital after thyroid nodules were identified in another hospital. Due to the extensive clinical experience of the ultrasound physician at our facility, the patient was suspected to have bilateral esophageal diverticula, which was confirmed by using swallow contrast-enhanced ultrasound (CEUS). Consequently, unnecessary thyroid treatments were avoided in this patient. This study shows that although bilateral pharyngeal diverticula are unusual, the possibility of their existence should be considered if nodules are located posterior to the bilateral thyroid glands and have suspicious imaging characteristics. Particular attention should be given to nodules located on the right side of the thyroid, which are sometimes overlooked easily due to their very low incidence. If real-time ultrasound cannot be used in making the diagnosis, PED can be further identified using swallowing CEUS to avoid unnecessary thyroid fine needle aspiration (FNA) and surgical treatment.

Management of multiple giant bladder diverticula: a comprehensive approach - a case report.

Introduction and importance: Bladder diverticula are commonly due to obstruction of the bladder outlet and are typically treated conservatively. However, the rarity and complexity of multiple giant diverticula require a tailor-made surgical approach. Case presentation: We report on a 72-year-old male who presented with severe urinary symptoms and lumbar pain, diagnosed with multiple giant bladder diverticula, including one compressing the ureter. The complex presentation of the patient, including his age and comorbidities, added layers of complexity to the clinical decision-making process. Interventions and outcomes: The patient underwent a two-stage surgery consisting of transurethral prostate resection followed by resection of three diverticula. Postoperatively, the patient showed a remarkable improvement in urinary symptoms, resolution of hydronephrosis, and, more importantly, no complications, demonstrating the efficacy and safety of the surgical strategy chosen. Relevance and impact: This case underscores the challenges in managing complex bladder diverticula, highlighting the importance of personalized treatment strategies and further research in atypical urological conditions. Furthermore, this case highlights the need to increase awareness and research on rare urological conditions. By sharing detailed insights from this case, we aim to enrich the clinical knowledge base, ultimately improving patient outcomes in similar challenging scenarios.

Lower urinary tract involvement in Ehlers-Danlos and Joint Hypermobility syndromes: Review of the literature.

INTRODUCTION: Ehlers-Danlos syndrome (EDS) and Joint Hypermobility syndrome (JHS) are still poorly understood, with a prevalence of 1/5000 for EDS and 1/500 for JHS. They are characterized by multisystem involvement. Urological involvement has been little studied. The aim was to carry out a review of the literature on the urological involvement of EDS and JHS. METHOD: A review of the literature was carried out using the following databases: Pubmed, Canadian Hospitals and EMBASE. Search terms were "Ehlers-Danlos" or "Joint Hypermobility" associated with "Urology", "Bladder", "Pelvic Organ Prolapse", "Urinary Retention", "Leak", "Leakage", "Urinary Incontinence", "Urinary Tract Infection" and "Urdodynamic", no filters were added. RESULTS: Seventy-three articles were included for a total of 259 found. The prevalence of urinary incontinence in EDS is estimated at 50-60%, and that of pelvic organ prolapse (POP) at 29-75%. Bladder diverticula are also frequently reported. For JHS, the prevalence of urinary incontinence is estimated between 40 and 73%, that of POP increased with 73% of stage greater than 2, g-JHS patients are almost 3 times more affected by prolapses (OR=2.37) which seem more severe. Patients with vesicoureteral reflux, most often severe, are more affected by joint hypermobility (OR=2.79). Few studies have been carried out on urological assessment and treatment modalities. CONCLUSION: EDS patients often have urinary incontinence, pelvic organ prolapse or bladder diverticula. JHS patients frequently have urinary incontinence, pelvic organ prolapse and vesicoureteral reflux.

Edoxaban Improved End-QRS Notches and Early Repolarizations.

Cardiac computed tomography (CT) images sometimes show a donut-like oval structure on the antero-superior wall of the left atrium (LA). What is a donut? Left atrium diverticula (LADs) are common, but there are many unknown features of LADs. The direct effects of pulmonary vein thrombi (PVTs) on the heart are poorly understood. Herein, we report a case report in which we describe the different effects of edoxaban on LA thrombi, the LAD, coronary artery collaterals, early repolarizations, and end-QRS notches using cardiac CT and transesophageal echocardiography (TEE). First, we showed that there was a LAD on the anterior wall of the LA where the LA thrombi from the right lower pulmonary vein (RLPV) thrombi were connected. To our knowledge, this is the first report to reveal LAD's annular transformation and the beneficial effect of edoxaban on the end-QRS notch.

Robotic-Assisted Bladder Diverticulectomy: Indications, Technique, and Outcomes-A Case Series.

Purpose: This case series describes the experiences and outcomes of multiple Australian surgeons performing robotic-assisted bladder diverticulectomy (RABD), highlighting the procedural effectiveness and safety, for both benign and malignant indications for diverticulectomy. Methods: Outcomes were analyzed from 13 experienced Australian urologists who performed RABD between 2016 and 2023. Retrospective analysis was performed on prospectively collected data, which included patient demographics, diverticulum characteristics, surgical approaches, and post-operative outcomes. Surgical techniques included the extravesical and intravesical approaches, with the focus on maintaining oncological principles in cases of malignancy. Results: A total of 28 patients underwent RABD, with the majority being male and a mean age of 63.9 years. All surgeons utilized a four-port transperitoneal approach and opted for the extravesical dissection of the diverticular neck; one case utilized both an extravesical and a trans-diverticular approach. Functional outcomes demonstrated symptomatic resolution in patients with nonmalignant diverticula, whereas oncological outcomes indicated clear margins in 90% of malignant cases. The average length of the procedure was 106 minutes, with minimal blood loss and a mean hospital stay of 2.67 days. Early complications occurred in 14% with the majority Clavien-Dindo grade II. Conclusion: Robotic bladder diverticulectomy, predominantly via the transperitoneal extravesical approach, has emerged as a safe, effective, and reliable surgical intervention for both malignant and nonmalignant bladder diverticula. The consistent surgical approach and excellent outcomes demonstrated in this case series reinforce the procedure's potential as a safe option, even in the setting of malignancy within a diverticulum.

Acute Chyloperitoneum with Small Bowel Volvulus: Case Series and Systematic Review of the Literature.

Introduction: Chyloperitoneum arises from lymph leakage into the abdominal cavity, leading to an accumulation of milky fluid rich in triglycerides. Diagnosis can be challenging, and mortality rates vary depending on the underlying cause, with intestinal volvulus being just one potential acute cause. Despite its rarity, our case series highlights chyloperitoneum associated with non-ischemic small bowel volvulus. The aims of our study include assessing the incidence of this association and evaluating diagnostic and therapeutic approaches. Material and Methods: We present two cases of acute abdominal peritonitis with suspected small bowel volvulus identified via contrast-enhanced computed tomography (CT). Emergency laparotomy revealed milky-free fluid and bowel volvulus. Additionally, we conducted a systematic review up to 31 October 2023, identifying 15 previously reported cases of small bowel volvulus and chyloperitoneum in adults (via the PRISMA scheme). Conclusions: Clarifying the etiopathogenetic mechanism of chyloperitoneum requires specific diagnostic tools. Magnetic resonance imaging (MRI) may be useful in non-emergency situations, while contrast-enhanced CT is employed in emergencies. Although small bowel volvulus infrequently causes chyloperitoneum, prompt treatment is necessary. The volvulus determines lymphatic flow obstruction at the base of the mesentery, with exudation and chyle accumulation in the abdominal cavity. Derotation of the volvulus alone may resolve chyloperitoneum without intestinal ischemia.

Lemmel's Syndrome: Lesson Based on a Case Report.

Lemmel's syndrome is a bile duct disease caused by periampullary duodenal diverticula that develop within 2-3 cm of the Vater papilla. This disease manifests itself as nonobstructive jaundice. In most cases, duodenal diverticula do not cause disease, and only in a small percentage of patients, diverticula cause biliary tract obstruction by extrinsic compression. If the compression is severe, in the long term, it can become complicated with lithiasis and cholangitis. Diagnosis is very difficult, and recurrent biliary symptoms must be directly related to the compression of the duodenal diverticula. Imaging is essential for differential diagnosis and includes conventional contrast radiographs, endoscopic retrograde cholangiopancreatography, computed tomography, and magnetic resonance imaging. The investigations show the dilation of the intra- and extra-hepatic bile ducts in the absence of lithiasis or main pancreatic duct dilatation, compressed by the diverticula, which most frequently originate from the medial wall of the second duodenal tract. The treatment of choice is surgical with removal of the diverticula. Failure to diagnose can cause serious health complications for the patient.

Perforated jejunal diverticulitis in the setting of biologic therapy presenting as transverse Colon diverticulitis: A case report.

INTRODUCTION: Small bowel diverticula are a rare entity and are mostly found in the duodenum on diagnosis. Some common complications of this pathology include bleeding, obstruction, diverticulitis, and perforation. Furthermore, there is growing evidence supporting an association between biologic therapies and spontaneous intestinal perforation. PRESENTATION OF CASE: We present a case of a 79-year-old female on prednisone, hydroxychloroquine, and tofacitinib for rheumatoid arthritis who was misdiagnosed with transverse colonic diverticulitis and eventually found to have perforated jejunal diverticulitis on laparotomy. DISCUSSION: While tofacitinib has been associated with spontaneous intestinal perforation, it has not been documented as an aggravating factor in small bowel diverticular disease. CONCLUSION: It is imperative to maintain a high index of suspicion for this pathology in immunosuppressed patients with an atypical presentation of diverticular disease.

Gastric diverticulum mimicking a left renal mass: A case report.

Gastric diverticula are a rare condition; they are divided into true diverticula, which are congenital, and pseudodiverticula, which are acquired. True diverticula are usually located in the posterior fundus wall, below the esophagogastric junction, and appear on abdominal computed tomography as a cystic mass that is commonly taken for an extra digestive mass, especially adrenal mass. We report the case of an asymptomatic 24-year-old female patient with gastric diverticulum who was mistakenly diagnosed in ultrasound with a renal mass.

Clinical outcomes of diverticular disease in young adults: results from a tertiary referral center.

Introduction: Diverticular disease (DD), commonly associated with the elderly, is becoming more prevalent among younger individuals. This retrospective study aimed to evaluate the differences in the natural history and outcomes between young and old patients with DD. Methods: Adult patients with DD diagnosed between 2010 and 2022 at an Italian tertiary referral center were enrolled, and their demographic and clinical data were retrieved. The patients were categorized as young or old based on the 25th percentile of the population's age at diagnosis. Univariate and multivariate analyses were performed to assess the association between the collected variables and the age of disease presentation. Additionally, survival analyses were conducted to evaluate the association between the age of diagnosis and clinical outcomes at follow-up, including disease recurrence, hospital access, surgery, and death. Results: A total of 220 DD patients (with a median age of 66 years, IQR 55-74, and a female-to-male ratio of 1.4:1) were included in the study, comprising 54 patients receiving a diagnosis before the age of 49 years (young DD patients) and 166 patients diagnosed after the age of 49 years (old DD patients). Male sex (57 vs. 36%, p < 0.01), smoking (38 vs. 14%, p < 0.01), and alcohol consumption (54 vs. 38%) were highly prevalent in young patients. The complications at the time of diagnosis, particularly abscesses and free perforations, occurred more frequently in younger patients (p = 0.04). Moreover, young DD patients experienced a higher rate of hospitalization and surgical intervention (p = 0.01 and p = 0.04, respectively) over a median follow-up period of 5 years. Conclusion: Preventive strategies and prompt diagnosis are crucial in young patients with DD for achieving better disease outcomes and preventing complications.

Right Upper Quadrant Pain: A Rare Presentation of Diverticulitis.

Acute diverticulitis is a prevalent medical condition with increasing incidence rates. While the sigmoid colon is the most commonly affected part of the large intestine, there have been occurrences of right-sided diverticulitis although uncommon. We present a case report highlighting the atypical presentation of diverticulitis in a 27-year-old female patient. The patient experienced right upper and epigastric pain and was ultimately diagnosed with right-sided diverticulitis, supported by her CT imaging findings. This uncommon presentation underscores the importance of considering diverse clinical manifestations when diagnosing and managing diverticulitis.

Surgical Management of Pulsatile Tinnitus due to Sigmoid Sinus Diverticulum and Dehiscence - A Technical Note.

Pulsatile tinnitus (PT) is the perception of an auditory sensation without an external source and in synchrony with the heartbeat. One of the most common cases of PT is bony anomalies of the sigmoid sinus, including dehiscence or diverticula. This case report describes a 26-year-old female patient who presented with pulsatile tinnitus caused by sigmoid sinus diverticula and dehiscence, which was successfully treated with cortical mastoidectomy with diverticula closure using pedicled temporalis fascia and resurfacing of the dehiscence with autogenous bone pate along with bone cement. We recommend thorough clinical and radiological workup to rule out other possible causes of PT before surgical intervention. In addition, we would like to highlight the surgical technique using pedicled temporalis fascia that we have used in our patient, which is easily reproducible and offers successful outcomes.

Clinical and urodynamics outcomes in pediatric primary bladder diverticula: a comparative study.

OBJECTIVE: This study aimed to compare the effects of bladder diverticula smaller than 30 (SD) mm and larger than 30 mm (LD) on bladder functions and urodynamics. MATERIALS AND METHODS: Our retrospective analysis involved a cohort of 40 pediatric patients diagnosed with primary bladder diverticula. RESULTS: The predicted mean bladder capacity (MBC) was 197.7 ± 95.8 mL, whereas the observed MBC was lower at an average of 170.1 ± 79.6 mL. This indicates that the observed MBC was 88.2 ± 12.9% of the predicted value (percentage). The mean diverticula diameter recorded was 33 ± 19.5 mm, and the diverticula to MBC ratio were calculated to be 0.25 ± 0.18. The distribution of urinary tract infections (UTIs) differed significantly between the groups (p < 0.001). Upper UT dilatation was significantly more common in the LD group (60%, n = 12) than in the SD group (15%, n = 3) (p = 0.003). The mean detrusor pressure (P[detrusor]) was significantly higher in the LD group (137.2 ± 24.1 cm H2O) than in the SD group (63.9 ± 5.8 cm H2O) (p = 0.001). In addition, the mean peak flow rate (Qmax) was significantly higher in the SD group (20.7 ± 7.9 mL/s) compared to the LD group (12.7 ± 3.8 mL/s) (p < 0.001). CONCLUSION: Bladder diverticula size is a significant factor in the clinical presentation and management of primary bladder diverticula in pediatric patients.

OBJETIVO: Este estudio tuvo como objetivo comparar los efectos de los divertículos vesicales menores 30 mm (SD), mayores 30 mm (LD) en las funciones y urodinámica de vejiga. MATERIALES Y MÉTODOS: Nuestro análisis retrospectivo involucró una cohorte de 40 pacientes pediátricos diagnosticados con divertículos vesicales primarios. RESULTADOS: Capacidad vesical media predicha (MBC) fue de 197.7 ± 95.8 mL, mientras que MBC observada fue menor con promedio de 170.1 ± 79.6 mL. Esto indica que MBC observada fue del 88.2 ± 12.9% del valor predicho (porcentaje). Diámetro medio de divertículos registrados fue de 33 ± 19.5 mm, y se calculó que relación entre los divertículos y la MBC era de 0.25 ± 0.18. Distribución de infecciones del tracto urinario (ITU) difirió significativamente entre grupos (p < 0.001). Dilatación del tracto urinario superior (UT) fue significativamente más común en grupo LD (60%, n = 12) que en grupo SD (15%, n = 3) (p = 0.003). Presión media del detrusor (P[detrusor]) fue significativamente mayor en grupo LD (137.2 ± 24.1 cm H2O) que en grupo SD (63.9 ± 5.8 cm H2O) (p = 0.001). Además, tasa de flujo máximo promedio (Qmax) fue significativamente mayor en grupo SD (20.7 ± 7.9 mL/seg) en comparación con grupo LD (12.7±3.8 mL/seg) (p < 0.001). CONCLUSIONES: Tamaño de divertículos vesicales es factor significativo en presentación clínica, manejo de divertículos vesicales primarios en pacientes pediátricos.