Perforated duodenal diverticulum: protecting the ampulla through the imbrication technique of repair

Duodenal diverticula are the most common type of small bowel diverticula. The pathogenesis remains unclear but it is hypothesised that raised intraluminal pressure, inflammation and/or intestinal dysmotility increases the risk of mucosa and submucosa herniation through the muscularis layer resulting in a pseudodiverticula. The majority of duodenal diverticula are incidentally detected on imaging or endoscopy performed for other indications. Duodenal diverticula are usually identified in older individuals, with no gender preponderance. Complications include haemorrhage, diverticulitis and biliary obstruction can occur. Perforation is a rare complication that is associated with an enormous mortality risk of up to 30%. Herein, we describe an unusual case of perforated duodenal diverticulitis in a 27-year-old male. We also outlined important operative considerations for managing this rare entity. The patient presented to hospital with a 12-h history of an acute surgical abdomen with constitutional symptoms. Past medical history was unremarkable, with no preceding non-steroidal anti-inflammatory, alcohol or steroid usage. On assessment, the patient was unwell with associated tachycardia and fever. There was generalized peritonism. A computed tomography scan demonstrated perforated diverticulitis at the junction of the second and third parts of the duodenum (D2/D3), with free fluid extending inferiorly to the right paracolic gutter (Fig. 1). The patient underwent an emergency laparotomy which identified a pinhole perforation at the apex of the D2/D3 diverticulum (Fig. 2) with significant induration and free fluid tracking along the right retroperitoneum. The duodenum was kocherised. An attempt was made at cannulation of the cystic duct with a five French feeding tube to identify the location of the ampulla and facilitate the resection of the diverticulum, however, this was unsuccessful owing to a narrow calibre cystic duct. As such, the diverticulum was invaginated and imbricated, incorporating the mucosal perforation which was not primarily closed. More specifically, imbrication was performed using 3–0 polydioxanone suture in a single layer continuous seromuscular manner, oriented transversely. The tails of the suture were left long on each end of the segment of imbrication to facilitate reinforcement with an omental patch, which was tied down in a snug but not overly tight manner. A large bore drain was placed adjacent to the duodenum. The patient made an uneventful recovery and was discharged on day 6 of their admission. Given the rarity of perforated duodenal diverticula, management approaches are largely limited to those described in case series. In stable patients without peritonism, conservative treatment with gut rest, intravenous antibiotics and close clinical monitoring has been reported with success. Operative management is mandated in patients with sepsis or peritonism, or patients who fail initial conservative treatment. If the degree of inflammation permits, definitive management can be achieved by a diverticulectomy. Minimally-invasive approaches have been reported. In performing a diverticulectomy, it is pertinent to ensure the major duodenal papilla and common bile duct are identified and protected in any surgical approach, particularly for cases of diverticula originating from D2. The location of the ampulla may be determined by cannulation of the common bile duct via the cystic duct, as was attempted in our case. In cases where this is not possible, performing a diverticulectomy may inadvertently result in an ampullary or ductal injury. If this anatomical relationship cannot be confidently defined, the surgeon should

Duodenal diverticula are the most common type of small bowel diverticula.2][3] The majority of duodenal diverticula are incidentally detected on imaging or endoscopy performed for other indications.Duodenal diverticula are usually identified in older individuals, with no gender preponderance. 4 Complications include haemorrhage, diverticulitis and biliary obstruction can occur.Perforation is a rare complication that is associated with an enormous mortality risk of up to 30%. 5 Herein, we describe an unusual case of perforated duodenal diverticulitis in a 27-year-old male.We also outlined important operative considerations for managing this rare entity.The patient presented to hospital with a 12-h history of an acute surgical abdomen with constitutional symptoms.Past medical history was unremarkable, with no preceding non-steroidal anti-inflammatory, alcohol or steroid usage.On assessment, the patient was unwell with associated tachycardia and fever.There was generalized peritonism.
A computed tomography scan demonstrated perforated diverticulitis at the junction of the second and third parts of the duodenum (D2/D3), with free fluid extending inferiorly to the right paracolic gutter (Fig. 1).The patient underwent an emergency laparotomy which identified a pinhole perforation at the apex of the D2/D3 diverticulum (Fig. 2) with significant induration and free fluid tracking along the right retroperitoneum.The duodenum was kocherised.An attempt was made at cannulation of the cystic duct with a five French feeding tube to identify the location of the ampulla and facilitate the resection of the diverticulum, however, this was unsuccessful owing to a narrow calibre cystic duct.As such, the diverticulum was invaginated and imbricated, incorporating the mucosal perforation which was not primarily closed.More specifically, imbrication was performed using 3-0 polydioxanone suture in a single layer continuous seromuscular manner, oriented transversely.The tails of the suture were left long on each end of the segment of imbrication to facilitate reinforcement with an omental patch, which was tied down in a snug but not overly tight manner.A large bore drain was placed adjacent to the duodenum.The patient made an uneventful recovery and was discharged on day 6 of their admission.
Given the rarity of perforated duodenal diverticula, management approaches are largely limited to those described in case series.In stable patients without peritonism, conservative treatment with gut rest, intravenous antibiotics and close clinical monitoring has been reported with success. 6,7erative management is mandated in patients with sepsis or peritonism, or patients who fail initial conservative treatment.If the degree of inflammation permits, definitive management can be achieved by a diverticulectomy.Minimally-invasive approaches have been reported. 6In performing a diverticulectomy, it is pertinent to ensure the major duodenal papilla and common bile duct are identified and protected in any surgical approach, 6,8 particularly for cases of diverticula originating from D2.The location of the ampulla may be determined by cannulation of the common bile duct via the cystic duct, 9,10 as was attempted in our case.In cases where this is not possible, performing a diverticulectomy may inadvertently result in an ampullary or ductal injury.If this anatomical relationship cannot be confidently defined, the surgeon should consider alternatives such as invagination and imbrication of the diverticulum, as was successfully implemented in our case, but poorly described in the literature thus far.In cases where inflammation precludes definitive repair, principles of managing a difficult duodenum should be instituted, including consideration of diversion by subtotal gastrectomy followed by restoration of gastrointestinal continuity. 7his case highlights key management considerations in patients presenting with perforated duodenal diverticulitis.We successfully managed a 27-year-old male with perforated D2/D3 duodenal diverticulitis operatively by invaginating and imbricating the diverticulum, with omental reinforcement.Such a technique has received little attention in the literature and is an example of a safe technique allowing preservation of key biliary structures.Diverticulectomy is a preferable option if the location of the ampulla can be delineated.The over-arching principles of managing intra-abdominal sepsis apply including broad-spectrum antibiotic coverage, gastric decompression and leaving large bore surgical drains.
Informed consent has been obtained from the patient.

Fig. 1 .
Fig. 1.Coronal slice of CT imaging demonstrating perforated duodenal diverticulum at junction of D2/D3, with extraluminal locules of gas and free fluid extending along right paracolic gutter.