Excision of a juxtapapillary duodenal diverticulum causing biliary obstruction: report of three cases

Abstract

We report three cases of biliary obstruction caused by a juxtapapillary duodenal diverticulum that were treated by excision of the diverticulum. A 72-year-old man, a 77-year-old woman, and an 81-year-old woman each presented with recurrent obstructive jaundice. Diagnostic imaging revealed a juxtapapillary duodenal diverticulum compressing the common bile duct (CBD). Following cholecystectomy, the diverticulum between the intrapancreatic CBD and pancreatic parenchyma was isolated and excised successfully in each case. The patients have been followed up for 34, 31, and 22 months, respectively. In one patient, choledocholithiasis developed 33 months after the surgery, necessitating endoscopic sphincterotomy. Duodenal diverticulectomy is a useful procedure to relieve biliary obstruction caused by a juxtapapillary duodenal diverticulum. However, it remains unclear whether excision of the diverticulum is preferred to biliodigestive anastomosis from the point of view of long-term prognosis. Subsequent surveillance is necessary.

Abdominal pain in a young woman (2009: 8b)

“…Yoneyama et al [7] think that the first option should be chosen, but warn of the difficulty in cases with severe peridiverticular inflammation, as in our case. They insist on the importance of "carefully defining" the diverticular neck with respect to the papilla to avoid lesion to the latter.…”

“…It is said that only 1-2% of duodenal diverticula require surgical treatment [4,6,12] and there is controversy over when to perform a simple excision of the complicated diverticulum or a bilio-digestive anastomosis [7,12]. Yoneyama et al [7] think that the first option should be chosen, but warn of the difficulty in cases with severe peridiverticular inflammation, as in our case.…”

“…Prevalence has been observed to rise with age and may be between 10 and 27% in the over-50-year-olds [3,7,11,14].…”

“…The increase in diverticular size with the consequent compression of the bile duct can lead to an obstructive jaundice without choledocholithiasis, known as Lemmel's syndrome [7] Perforation of a duodenal diverticulum is the rarest complication though the most serious, generally being preceded by diverticulitis in as many as 57% of cases [4,6,13].…”

Treatment Options of Lemmel’s Syndrome: A Case of Benign Obstructive Jaundice in The Elderly

“…[1][2][3] Most patients with Lemmel's syndrome present with jaundice, abdominal pain or acute cholangitis, mimicking periampulary tumors. 2,12,13 Diverticula of the gastrointestinal tract are outpouchings of all or part of the intestinal wall which can occur anywhere throughout the gastrointestinal tract. The duodenum is second most common site of diverticula in the gastrointestinal tract after colon, followed by jejunum, ileum and stomach.…”