Perforated duodenal diverticulum successfully treated with a combination of surgical drainage and endoscopic nasobiliary and nasopancreatic drainage: a case report

Abstract

Background: Perforation of a duodenal diverticulum is a rare complication that may become fatal with a delay in appropriate treatment. However, the optimal treatment for perforated duodenal diverticulum remains controversial, ranging from conservative therapy to surgery including pancreatoduodenectomy. Case presentation: The patient was a 60-year-old woman with no particular medical history who visited our hospital with chief complaints of continuous fever and right dorsal pain. Upon arrival, she had tenderness in the right upper quadrant of the abdomen. Laboratory data showed the elevation of inflammatory markers. Computed tomography revealed free air with abscess formation around the duodenum, which was diagnosed as duodenal perforation with abdominal abscess. We decided on emergent surgery, and we identified the perforation site on the dorsal side of the second portion of the duodenum intraoperatively. However, the inflammation around the perforation site was severe, and it was difficult to perform primary closure or dissection of the perforated diverticulum. Therefore, we finished surgery by placing four indwelling intra-abdominal tubes. Since postoperative day (POD) 1, the elevation of inflammation markers appeared to be uncontrollable, owing to the leakage of bile and pancreatic juice. We decided to perform endoscopic retrograde cholangiopancreatography on POD 2, and inserted endoscopic nasobiliary drainage and nasopancreatic drainage tubes. The patient showed a good postoperative course and was discharged on POD 57. Conclusions: Endoscopic nasobiliary and nasopancreatic drainage in combination with surgical drainage may be an effective treatment for perforated duodenal diverticulum.

Perforated Duodenal Diverticulum With Postoperative Diverticulum Bleeding Successfully Treated Using Transcatheter Arterial Embolization

“…Based on the above, postoperative duodenal leakage may be a potential risk factor for DDB, and drainage of digestive juices (duodenal, bile, and pancreatic juice) should be considered. The effectiveness of endoscopic nasobiliary and nasopancreatic drainage for postoperative leakage of DDP has been reported [29]. However, postoperative ERCP for unstable patients, as in our case, presents several risks.…”

“…Based on our search on PubMed (2013-present), there have been 29 reports of non-traumatic, noniatrogenic DDP (Table 1) [11,[13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]. Including our case, the location of DDP was at D2 in 20 cases (67%) and D3 in six cases (20%).…”

“…As a diversion procedure, duodenojejunostomy (two cases) and pyloric exclusion (one case) have been reported [16,19,25]. Biliary drainage was performed in three cases (bilio-duodenal drain, cystic duct tube, and postoperative endoscopic nasobiliary drainage, one case each) [14,28,29]. In some cases, dissection of the duodenum and performance of PD had to be undertaken because of severe inflammation and the risk of postoperative leakage [26,28].…”

Duodenal diverticulum at the site of the major papilla may be a risk factor for biliary stent migration

“…4 ). Duodenal diverticulum is commonly an incidental diagnosis demonstrated during ERCP, and its presence in the duodenum is similarly associated with bleeding, infection, biliary obstruction and perforation [ 8 , 9 ]. The adjacent diverticulum may interfere with the normal emptying mechanism of the ductal systems, predisposing patients to biliary obstruction and stent migration.…”

Nonoperative Management of Perforated Diverticulitis of the Duodenum: Report of Three Cases and Review of Literature

“…In recent years, several publications reported on treatment of perforated diverticulitis or a subsequent abscess by endoscopic therapy. Endoscopic nasogastric drainage or endoscopic transluminal water irrigation has been described as a feasible successful treatment for specific cases [ 21 – 24 ].…”