A systematic review of the perforated duodenal diverticula: lessons learned from the last decade

Abstract

Background: The perforated duodenal diverticulum remains a rare clinical entity, the optimal management of which has not been well established. Historically, primary surgery has been the preferred treatment modality. This was called into question during the last decade, with the successful application of non-operative therapy in selected patients. The aim of this systematic review is to identify cases of perforated duodenal diverticula published over the past decade and to assess any subsequent evolution in treatment.

Methods: A systematic review of English and non-English articles reporting on perforated duodenal diverticula using MEDLINE (2008-2020) was performed. Only cases of perforated duodenal diverticula in adults (> 18 years) that reported on diagnosis and treatment were included.

Results: Some 328 studies were identified, of which 31 articles met the inclusion criteria. These studies included a total of 47 patients with perforated duodenal diverticula. This series suggests a trend towards conservative management with 34% (16/47) of patients managed non-operatively. In 31% (5/16) patients initially managed conservatively, a step-up approach to surgical intervention was required.

Conclusion: Conservative treatment of perforated duodenal diverticula appears to be an acceptable and safe treatment strategy in stable patients without signs of peritonitis under careful observation. For patients who fail to respond to conservative treatment, a step-up approach to percutaneous drainage or surgery can be applied. If surgery is required, competence in techniques ranging from simple diverticulectomy to Roux-en-Y gastric diversion or even Whipple's procedure may be required depending on tissue friability and diverticular collar size.

Keywords: Duodenal diverticulum; Duodenum; Management; Perforation.

Fig. 1

Search strategy. Among 328, 285 publications did not meet the inclusion criteria. The majority of these publications were excluded because they related to causes of duodenal perforation other than diverticula. Several articles were excluded because they focused on colonic diverticula. Other common reasons for exclusion were lack of appropriate data regarding treatment and outcomes, as well as publications in languages other than English, German or French. Of the 43 articles proceeding to full text screening, 12 were excluded due to inadequate details regarding therapy and outcome

Fig. 2

Anatomical distribution of duodenal diverticula. The majority of duodenal diverticula grow from the concave, pancreatic border of the duodenum, morphologically the mesenteric duodenal border. * Junction D1/D2; Junction D2/D3; Junction D3/D4 as reported by published autopsy series.—No further specific information available

Fig. 3

Selection of patients for initial conservative management. Imaging features of two patients successfully managed conservatively. A A 59-year-old patient was admitted with 24 h of vomiting and acute epigastric pain radiating to the back. Extraluminal, retroperitoneal air was found (arrow). Conservative therapy with bowel rest, jejunal feeding tube, intravenous broad-spectrum antibiotic- and PPI-therapy was established. B A 58-year-old female presented a brief history of epigastric pain. Clinical examination revealed a tenderness in the right upper quadrant. Again, extraluminal, retroperitoneal air was found on CT scan (arrow). The patient was managed with the same conservative regimen. She was discharged after 1 week and is asymptomatic at 8 months follow-up.

Fig. 4

Patient stratification algorithm enabling a step-up approach. The algorithm differs between patients who are clinically stable without generalized peritonitis, who may be considered for conservative treatment, and potentially delayed elective surgical treatment. Absence of peritonitis, old age and presence of significant comorbidities were key reasons underpinning the decision for conservative management. The various technical options should highlight the complexity of the procedure, depending not only on the anatomical location (e.g. proximity to biliopancreatic duct) or morphology (width of diverticular collar) of the duodenal diverticula but also on the degree of tissue vulnerability at the time of exploration. * conservative treatment was defined as: intravenous antibiotic treatment, jejunal feeding tube or TPN, ± percutaneous abscess drainage. + there is no actual definition of a narrow or wide collar. However, a defect who, after surgical closure, will not narrow the lumen of the duodenum might be considered as a narrow collar