Management of difficult or failed biliary access in initial ERCP: A review of current literature.

Selective bile duct cannulation is the prerequisite for all endoscopic biliary therapeutic interventions, but this cannot always be achieved easily. Despite advances and new developments in endoscopic accessories, selective biliary access fails in 5%-15% of cases, even in expert high volume centers. Various techniques - such as double-guidewire induced cannulation, pre-cut papillotomy or transpancreatic sphincterotomy with or without placement of a pancreatic stent - have been used to improve cannulation success rates. Repeated and prolonged attempts at cannulation increase the risk of pancreatitis. Repeating the ERCP within a few days after initial failed pre-cut is a successful strategy and should be tried before contemplating more invasive, alternative interventions such as percutaneous-endoscopic or endoscopic ultrasound guided rendezvous procedure, percutaneous transhepatic or surgical intervention. However, standard guidelines or sequential protocol has not been existed up to now. In certain circumstances, there are unique clinical indications for which invasive, alternative interventions should be preferred. We present and discuss the methods that can be used in difficult or failed initial ERCP, therefore to provide practical advice for endoscopists, especially those who are inexperienced.

Prognostic Role of the Endoscopic Classification "DICA".

Diverticular inflammation and complication assessment (DICA) endoscopic classification has been recently developed for patients suffering from diverticulosis and diverticular disease. Its predictive value in those patients was recently retrospectively assessed. For each patient, the following parameters were recorded: age, severity of DICA, presence of abdominal pain, C-reactive protein, fecal calprotectin test (if available) at the time of diagnosis, months of follow-up, therapy taken during the follow-up to maintain remission (if any), occurrence/recurrence of diverticulitis, and need of surgery. A total of 1651 patients (793 male, 858 female, mean age 66.6±11.1 y) were enrolled: 939 (56.9%) classified as DICA 1, 501 (30.3%) as DICA 2, and 211 (12.8%) as DICA 3. The median follow-up was 24 (9 to 138) months. Acute diverticulitis (AD) occurred/recurred in 263 (15.9%) patients, and surgery was necessary in 57 (21.7%) cases. DICA was the only factor significantly associated with the occurrence/recurrence of diverticulitis and surgery either at univariate (χ=405.029; P<0.0001) or multivariate analysis (hazard ratio=4.319; 95% CI, 3.639-5.126; P<0.0001). Only in DICA 2 patients scheduled therapy was effective for prevention of AD occurrence/recurrence with a hazard ratio (95% CI) of 0.598 (0.391-0.914) (P=0.006, log-rank test). Mesalazine-based therapies reduced the risk of AD occurrence/recurrence and need of surgery with a hazard ratio (95% CI) of 0.2103 (0.122-0.364) and 0.459 (0.258-0.818), respectively. DICA classification seems to be a valid parameter to predict the risk of diverticulitis occurrence/recurrence in patients suffering from diverticular disease of the colon.

[Diverticular disease - timing of surgery in demand]. / Divertikelkrankheit - Wann ist der Chirurg gefragt?

In preparation for operations of patients with diverticular disease an adequate medical indication has to be performed. The new classification of sigmoid diverticulitis corresponding to the German guidelines for diverticular disease classification (GGDDC) enables an appropriate strategy for evaluating the indications and selection of the time for surgery. New is, that the uncomplicated form of diverticulitis indicates an operation in exceptional case only. Furthermore the frequency of diverticulitis-exacerbation does not influence the indication for surgery any more.

Development and validation of an endoscopic classification of diverticular disease of the colon: the DICA classification.

BACKGROUND: A validated endoscopic classification of diverticular disease (DD) of the colon is lacking at present. Our aim was to develop a simple endoscopic score of DD: the Diverticular Inflammation and Complication Assessment (DICA) score. METHODS: The DICA score for DD resulted in the sum of the scores for the extension of diverticulosis, the number of diverticula per region, the presence and type of inflammation, and the presence and type of complications: DICA 1 (≤ 3), DICA 2 (4-7) and DICA 3 (>7). A comparison with abdominal pain and inflammatory marker expression was also performed. A total of 50 videos of DD patients were reassessed in order to investigate the predictive role of DICA on the outcome of the disease. RESULTS: Overall agreement in using DICA was 0.847 (95% confidence interval, CI, 0.812-0.893): 0.878 (95% CI 0.832-0.895) for DICA 1, 0.765 (95% CI 0.735-0.786) for DICA 2 and 0.891 (95% CI 0.845-0.7923) for DICA 3. Intra-observer agreement (kappa) was 0.91 (95% CI 0.886-0.947). A significant correlation was found between the DICA score and C-reactive protein values (p = 0.0001), as well as between the median pain score and the DICA score (p = 0.0001). With respect to the 50 patients retrospectively reassessed, occurrence/recurrence of disease complications was recorded in 29 patients (58%): 10 (34.5%) were classified as DICA 1 and 19 (65.5%) as DICA 2 (p = 0.036). CONCLUSIONS: The DICA score is a simple, reproducible, validated and easy-to-use endoscopic scoring system for DD of the colon.

Congenital left ventricular outpouchings: a systematic review of 839 cases and introduction of a novel classification after two centuries.

BACKGROUND: Congenital left ventricular outpouchings (LVOs) are reported under five overlapping and poorly defined terms including left ventricular accessory chamber, left ventricular aneurysm (LVA), left ventricular diverticulum (LVD), double-chambered LV, and accessory left ventricle. Diagnostic criteria are frequently mixed and not mutually exclusive. They convey no information regarding treatment strategy and prognosis. OBJECTIVES: The aim of this systematic review is to provide a clear and inclusive classification, with therapeutic and prognostic implications, for congenital LVOs. DATA SOURCES: We performed three separate sets of search on three subjects including "congenital left ventricular outpouchings," "important and simply measurable markers of left ventricular function," and "relationship of mechanics of intraventricular blood flow and optimal vortex formation in left ventricle and elliptical geometry of LV." STUDY ELIGIBILITY CRITERIA: We enrolled case series, review articles, and case reports with literature review. All types of acquired LVO's were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS: We studied the abstracts of all searched articles. We focused on diagnostic criteria and patients' outcome. To examine the validity and reliability of the novel classification, fifteen previous studies were revisited using the novel classification. RESULTS: A total of 20 papers from 11 countries fulfilled our inclusion criteria. The age of patients ranged from prenatal age to geriatric age range. Diagnostic criteria were clearly stated only for two of the above five terms (i.e., congenital LVA and congenital LVD). Cases with mixed diagnostic criteria were frequent.Elliptical geometry of left ventricle was found to have significant impact on effective blood flow mechanics in LV. A simple inclusive classification for congenital LVOs, with therapeutic and prognostic implications, was introduced. CONCLUSION: The cornerstone of this classification is elliptical LV geometry. Large-type IIc LVO have dismal prognosis, if left untreated. LVO type I and small LVO type IIa have the best prognosis.

Size and type of periampullary duodenal diverticula are associated with bile duct diameter and recurrence of bile duct stones.

BACKGROUND AND AIM: Periampullary diverticula (PAD) are not uncommon findings during endoscopic retrograde cholangiopancreatography, but its clinical significance had not been established. To investigate the clinical characteristics associated with PAD and their relationships with the type and size of PAD in patients with common bile duct (CBD) stones was aimed. METHODS: Three hundred seventy patients undergoing endoscopic retrograde cholangiopancreatography between March 2010 and July 2012 were consecutively enrolled, and their demographics, laboratory data, and CBD stone-related characteristics according to PAD type and PAD size were analyzed. RESULTS: Mean age, mean size of CBD stones, prevalence of systemic inflammatory response syndrome, and serum C-reactive protein level differed in patients with CBD stones according to the presence or absence of PAD. The presence of PAD and positive blood culture were correlated with systemic inflammatory response syndrome (P = 0.033 and P < 0.001, respectively). The recurrence of CBD stones was more frequent, and the diameter of CBD was larger in patients with PAD type I than in those with PAD type III. Mean age and CBD diameter were lower in patients with PAD size < 15 mm than those with PAD size ≥ 15 mm. Multivariate analyses indicated that CBD diameter was related to PAD size (P = 0.002) and the recurrence of CBD stones was related to PAD type (P = 0.001). CONCLUSIONS: PAD are associated with larger CBD stones and severe cholangitis with CBD stones. CBD diameter is related to PAD size, and the recurrence of CBD stones is related to PAD type.

Needle-knife fistulotomy in patients with periampullary diverticula and difficult bile duct cannulation.

BACKGROUND AND AIM: Needle-knife fistulotomy has commonly been used for overcoming difficult bile duct cannulation. Periampullary diverticula (PAD) can be an impediment to endoscopic retrograde cholangiopancreatography (ERCP) procedures. There are little data on needle-knife fistulotomy in patients with PAD. We evaluated the efficacy and safety of needle-knife fistulotomy between patients with and without PAD. METHODS: Data from December 2005 to October 2010 were reviewed. Patients who underwent needle-knife fistulotomy were divided into the group with PAD and the group without PAD (control group). The technical success and complications were compared. RESULTS: A total of 3012 ERCP cases were analyzed. Needle-knife fistulotomy was performed in 154 out of 3012 cases (5.1%) with 138 of these patients (89.6%) experiencing successful bile duct cannulation. The overall cannulation success rate was not significantly different between PAD group (n=33) and control group (n =121) (93.9% vs 88.4%; P=0.523). There was no significant difference in pancreatitis, bleeding and perforation between the two groups. CONCLUSIONS: Needle-knife fistulotomy can be performed effectively and safely in patients with periampullary diverticula and difficult bile duct cannulation.

[Diverticula in the digestive tract and their complications].

This review concerns diverticula in different parts of the digestive tract (oesophagus, stomach, duoudenum, jejunum, ileum (including Meckel" diverticulum), and large intestine). Their origin, pathogenesis, and frequency are discussed, different forms of diverticula and diverticulosis are described with reference to major complications (diverticulitis, peridiverticulitis, ulceration, bleeding, perforation, obstruction, abscess, peritonitis, fistulas, etc.). Methods of clinical, instrumental and laboratory diagnostics and their informative value are considered along with indications and contraindications for surgical treatment. A new classification of diverticula and their complications is proposed. Debatable terminological problems are discussed.

Juxtapapillary duodenal diverticula: MDCT findings in 1010 patients and proposal for a new classification.

The aim of this study is to analyze the MDCT findings of juxtapapillary duodenal diverticula (JPDD) and to propose a new radiological classification. CT-examinations of 1010 consecutive patients, all examined by 16-row MDCT of the abdomen over a time period of 20 months were retrospectively analyzed. All study patients were examined by triple phase CT (native, arterial and portal venous CT scan) of the abdomen and all recieved positive oral contrast prior to the examination. Thirty-three patients showed a juxtapapillary duodenal diverticulum, which could be seen on all CT scans, but jusually was depicted most clearly on the thin collimated arterial phase CT images. Size of diverticula range from 4 mm to 4.5 cm (mean 1.7 cm). In 17 cases the diverticulum was located ventrally to the vaterian sphincter complex, extending less or more into the pancreas at the site where the dorsal and the ventral anlage of the pancreas have fused (type I). 12 diverticula were located dorsally to the sphincter complex (type II). Three patients presented with a bilobated juxtapapillary diverticulum extending to both sides, ventrally and dorsally (type III) and one patient showed a little diverticulum ventrally to the minor papilla (type IV).Three patients presented with food impaction in the diverticulum but only one of these patients with a large IPDD showed a Lemmel-syndrome, whereas the other three patients with non-calculous extrahepatic cholostasis showed larger diverticula without food impaction. MDCT allows to identify four different types of juxtapapillary duodenal diverticula and using the proposed classification may be helpful for a more exact, anatomy based radiological description of this CT finding.

Left ventricular pseudodiverticulum.

The differential diagnosis between left ventricular aneurysm and diverticulum remains a matter of debate. Cardiac magnetic resonance is dramatically helpful in the anatomical and functional characterization of the walls of any angiographical left ventricular outpouching.

Current evaluation and management of female urethral diverticula.

The identification of female urethral diverticula remains a challenging problem for many clinicians. Many of these patients are often undiagnosed or misdiagnosed due to a clinical presentation that frequently mimics other pathologic processes. There can be significant variation in the urethral diverticular anatomy in terms of size, location, and configuration. This update provides a succinct and comprehensive review of the clinical presentation, evaluation, and treatment options for female urethral diverticula.

Outcomes of surgery of female urethral diverticula classified using magnetic resonance imaging.

OBJECTIVES: We evaluated the surgical outcomes of transvaginal diverticulectomies classified using magnetic resonance imaging (MRI). METHODS: We evaluated 30 women (mean age: 46.4 yr; range: 31-73 yr) who were followed up for at least 12 mo after urethral diverticulectomies (mean follow-up: 29 mo; range: 12-93 mo). Characteristics of urethral diverticula were confirmed before surgery by MRI. Diverticula were classified as simple, U-shaped, or circumferential according to MRI features. Transvaginal excisions of urethral diverticula were performed using vaginal flaps and three-layer closures. Cure was defined as the absence of a diverticulum and symptoms. RESULTS: Seventeen cases (57%) had simple diverticula, three (10%) had U-shaped diverticula, and 10 (33%) had circumferential diverticula. After the first operation, 23 cases (77%) were cured. None of the simple diverticula recurred, but 33% of the U-shaped and 60% of the circumferential diverticula did recur. Of the seven recurrent cases, three did not require a second operation because their symptoms resolved. Of the four cases that underwent a second operation, three were cured and one was cured after two additional operations. The success rate for circumferential diverticula after initial diverticulectomies was less than that of simple or U-shaped diverticula (p<0.05). Location, size, and multiplicity of urethral diverticula did not affect the surgical outcome (p>0.05). CONCLUSIONS: Transvaginal diverticulectomy is effective for treatment of female urethral diverticula. For circumferential urethral diverticula, however, surgical procedures should be adapted to achieve complete resections of the diverticulum.

Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula.

BACKGROUND/AIMS: To propose a classification schema to describe periampullary duodenal diverticula (PDD) found at endoscopic retrograde cholangiopancreatography (ERCP), and to study the characteristics of these diverticula. MATERIALS AND METHODS: Among 400 consecutive patients in whom an ERCP was performed, PDD were present in 131 (32.8%), being these patients significantly older than the remaining, served as controls. RESULTS: PDD were classified in 3 different types according to the position of the major duodenal papilla: type I (16.3%), inside the diverticulum; type II (10.2%), in the margin of the diverticulum; and type III (6.5%), near the diverticulum. PDD were not associated with a more difficult cannulation of the biliary tract. CONCLUSIONS: PDD are common, especially in older patients, and do not significantly increase the difficulty of deep cannulation.

Diverticulitis cecal aguda: nuestra conducta terapéutica / Cecal acute diverticulitis: our experience

Antecedentes: La diverticulitis cecal aguda es una enfermedad poco frecuente que simula el cuadro de una apendicitis aguda, y que presenta problemas en el diagnóstico. Objetivo: Evaluación de la conducta terapéutica de acuerdo a las formas clínicas de presentación y los hallazgos intraoperatorios. Lugar de aplicación: Servicio de Guardia del Hospital Nacional de Clínicas U.N.C. y grupo ABC. Diseño: Retrospectivo observacional. Método: Han sido tratados quirúrgicamente veinte pacientes con diverticulitis cecal aguda. Catorce eran del sexo masculino con una edad promedio de 48,2 años. El síntoma principal fue el dolor abdominal especialmente localizado en f.i.d., pero en 2 oportunidades se presentó un cuadro de abdomen agudo perforativo. Los pacientes fueron intervenidos quirúrgicamente con el diagnóstico de apendicitis aguda en nueve, neoplasia de ciego en tres, perforación de víscera hueca en dos, diverticulitis cecal en tres y los restantes sin sospecha diagnóstica. Resultados: Se practicaron catorce hemicolectomías derechas. En los seis restantes se efectuó una cecostomía. De éstos últimos, uno falleció en el postoperatorio por un T.E.P.A. Cinco pacientes presentaron un absceso de pared, tres de ellos tenían una hemicolectomía derecha y dos una cecostomía. En el postoperatorio alejado, tres pacientes presentaron una eventración mediana. Conclusiones: Consideramos que en aquellos pacientes con serias dificultades para decidir la malignidad o benignidad del proceso, aún siendo jóvenes, o cuando estamos frente a la probabilidad de un divertículo cecal perforado con compromiso inflamatorio o infeccioso del ciego, creemos que el mejor tratamiento es la hemicolectomía derecha

Diverticulitis cecal aguda: nuestra conducta terapéutica / Cecal acute diverticulitis: our experience

Antecedentes: La diverticulitis cecal aguda es una enfermedad poco frecuente que simula el cuadro de una apendicitis aguda, y que presenta problemas en el diagnóstico. Objetivo: Evaluación de la conducta terapéutica de acuerdo a las formas clínicas de presentación y los hallazgos intraoperatorios. Lugar de aplicación: Servicio de Guardia del Hospital Nacional de Clínicas U.N.C. y grupo ABC. Diseño: Retrospectivo observacional. Método: Han sido tratados quirúrgicamente veinte pacientes con diverticulitis cecal aguda. Catorce eran del sexo masculino con una edad promedio de 48,2 años. El síntoma principal fue el dolor abdominal especialmente localizado en f.i.d., pero en 2 oportunidades se presentó un cuadro de abdomen agudo perforativo. Los pacientes fueron intervenidos quirúrgicamente con el diagnóstico de apendicitis aguda en nueve, neoplasia de ciego en tres, perforación de víscera hueca en dos, diverticulitis cecal en tres y los restantes sin sospecha diagnóstica. Resultados: Se practicaron catorce hemicolectomías derechas. En los seis restantes se efectuó una cecostomía. De éstos últimos, uno falleció en el postoperatorio por un T.E.P.A. Cinco pacientes presentaron un absceso de pared, tres de ellos tenían una hemicolectomía derecha y dos una cecostomía. En el postoperatorio alejado, tres pacientes presentaron una eventración mediana. Conclusiones: Consideramos que en aquellos pacientes con serias dificultades para decidir la malignidad o benignidad del proceso, aún siendo jóvenes, o cuando estamos frente a la probabilidad de un divertículo cecal perforado con compromiso inflamatorio o infeccioso del ciego, creemos que el mejor tratamiento es la hemicolectomía derecha (AU)

[Female urethral diverticuli]. / Divertículos uretrales femeninos.

OBJECTIVES: To review the etiopathogenic, diagnostic and therapeutic criteria for female urethra diverticula. METHODS: Urethral diverticulum was diagnosed in four patients, all of them with recurring urinary tract infections and irritative voiding symptoms. The final diagnosis was established by VCUG (Voiding cystourethrography). Other procedures, more recent and more in use, are also referred. RESULTS: All patients required surgical treatment, three of them with good results and one without success. The therapeutic procedures most frequently used in the literature during the last decade are also mentioned. CONCLUSIONS: The milestone in the management of female urethral diverticula is to think on it in patients with lower urinary tract symptoms. Surgical excision when amenable obtains optimal results.

Divertículo de duodeno, presentación de un caso y actualización bibliográfica / Duodenal diverticuli, presentation of a case and bibliographic update

Se presenta una paciente de 82 años que ingresa con un cuadro de colecistitis aguda que remite con tratamiento médico y se opera por vía convencional lesionándose durante la maniobra de Vautrin-Kocher un divertículo duodenal. Se decide realizar una actualización por ser esta patología poco frecuente. Se clasifican los divertículos de duodeno comentándose la forma de presentación, diagnóstico y la conducta quirúrgica ante cada uno de ellos. Es una patología rara vez detectada por ser en general asintomática. Suele lesionarse durante procedimientos endoscópicos o quirúrgicos por el escaso interés en su búsqueda y por la falta de experiencia del cirujano. No tiene indicación de resección salvo que se encuentre una complicada. Por último destacamos su aparición en pacientes con episodios de pancreatitis aguda recurrente por lo que consideramos que debería incluírselo dentro de las causas de pancreatitis

Divertículo de duodeno, presentación de un caso y actualización bibliográfica / Duodenal diverticuli, presentation of a case and bibliographic update

Se presenta una paciente de 82 años que ingresa con un cuadro de colecistitis aguda que remite con tratamiento médico y se opera por vía convencional lesionándose durante la maniobra de Vautrin-Kocher un divertículo duodenal. Se decide realizar una actualización por ser esta patología poco frecuente. Se clasifican los divertículos de duodeno comentándose la forma de presentación, diagnóstico y la conducta quirúrgica ante cada uno de ellos. Es una patología rara vez detectada por ser en general asintomática. Suele lesionarse durante procedimientos endoscópicos o quirúrgicos por el escaso interés en su búsqueda y por la falta de experiencia del cirujano. No tiene indicación de resección salvo que se encuentre una complicada. Por último destacamos su aparición en pacientes con episodios de pancreatitis aguda recurrente por lo que consideramos que debería incluírselo dentro de las causas de pancreatitis

[Congenital left ventricular aneurysms and diverticula. Two case reports]. / Anévrysmes et diverticules congénitaux du ventricule gauche. A propos de deux observations.

The authors report the cases of two young adults (25 and 27 years) presenting with congenital left ventricular aneurysm or diverticulum with healthy coronary arteries. This saccular evagination of the ventricular wall is rare. The authors describe a classification distinguishing muscular (contractile) diverticula, composed of the three cardiac tunics, fibrous diverticula and finally aneurysms with a dyskinetic wall. Although the limits of this classification are sometimes poorly defined, it presents a prognostic value, because it appears logical to propose nonsurgical management in the context of muscular diverticula and it seems legitimate to operate on fibrous diverticula and aneurysms due to the risks of rupture, extension, thrombosis or arrhythmia.