Seventy-five percent of duodenal diverticula are parapapillary duodenal diverticula, which require surgery when clinical symptoms caused by diverticula are not treated by internal medicine or when pancreaticobiliary diseases are combined. Surgery for parapapillary duodenal diverticula should be strictly controlled for the indications. The choice of surgery depends on the clinical manifestations and the location of the diverticulum. Bile or food diversion surgery is safer and more effective than diverticulectomy.
Indications for surgery
Asymptomatic diverticula do not require treatment, but clinical symptoms caused by diverticula that are not treated by internal medicine or combined with serious complications require surgery.
Indications for surgery are.
(1) Diverticulosis caused by the digestive tract symptoms by non-surgical treatment is not effective;
(2) Biliary, duodenal and pancreatic duct obstruction caused by diverticula;
(3) X-rays or endoscopic diverticula are huge, and barium stays in the diverticula for >6 h;
(4) Recurrent pancreatitis caused by diverticula;
(5) Biliary tract infection and bile duct stones caused by diverticula;
(6) diverticula with hemorrhage, gangrene and perforation;
(7) Recurrent diverticular inflammation leading to constrictive duodenal papillitis; (8) Diverticular carcinoma.
Surgical procedures and their considerations
The surgical approach depends on the surgical indication and the location of the diverticulum, and Chandy et al. classified JPDD into three types: adjacent papillary, marginal papillary, and intra-papillary, which are useful for clinical treatment. Adjacent papillary diverticula, with a large diverticulum base and small neck opening, are prone to complications such as diverticulitis, bleeding or perforation due to food retention, and diverticulotomy or diversion surgery is more effective. Papillary marginal diverticula, diverticula are small, food retention is rare, mostly no clinical symptoms, generally do not need special treatment. Intra-papillary diverticula, often accompanied by reflux cholangitis, pancreatitis and bile duct stone formation. In this case, it is difficult to remove the diverticulum, and the surgery can easily cause stenosis at the opening of the common bile duct and pancreatic duct or lead to sphincter relaxation after the loss of Oddi sphincter function, so the focus of this type of surgery is to deal with biliopancreatic disease, rather than resection as the purpose and first choice; in contrast, diversion surgery is safer and more effective. For intrapapillary diverticula, Greene et al. classified it as type III of congenital bile duct cysts, i.e., diverticula or dilatation of the intracholedochoduodenal wall segment.
The surgical approach to JPDD consists of diverticulectomy and diversion surgery, which is subdivided into major gastrectomy and common bile duct jejunostomy Roux-en-Y anastomosis.
Diverticulectomy
For JPDD, diverticulectomy is only indicated for some diverticula that are large and easy to find. Diverticulectomy is relatively safe for diverticula lateral to the descending duodenum and is also indicated for diverticular hemorrhage and perforation. The early literature reported high mortality and complication rates for this procedure, and in recent years there has been little literature of this type. Difficulties commonly encountered during diverticulectomy include: intraoperative difficulty in finding diverticula, difficulty in detecting them and difficulty in distinguishing them from the normal intestinal wall; difficulty in resection, and the possibility of damaging the biliopancreatic duct and causing postoperative duodenal stricture if complete resection is performed. If the diverticulum is found to be deeply buried in the pancreatic parenchyma, it is easy to damage the bile duct and pancreatic duct and worry about the occurrence of postoperative intestinal fistula and pancreatic fistula.
Therefore, diverticula removal should be abandoned at this time and diversion surgery should be performed. If the diverticulum is removed blindly, it will often lead to serious complications and even death. If the bile duct cannot be confirmed intraoperatively, the common bile duct can be incised and a probe can be placed as a guide; the bile duct can also be explored by combined choledochoscopy. Intraoperatively, a “T” tube can be placed or the common bile duct can be sutured in one stage. Although diverticulotomy is a simple procedure, it is not recommended because of the uncertainty of postoperative outcome and the possibility of duodenal obstruction and bile duct obstruction after inversion.
Massive gastrectomy
Gastrectomy Billroth II anastomosis with open duodenum prevents food from entering the diverticulum and avoiding recurrent inflammation of the diverticulum, thus allowing biliopancreatic fluid to drain freely and facilitating the control of retrograde infection. For parapapillary diverticula and multiple diverticula that are difficult to resect, it is a safe and commonly used surgical procedure. This procedure was used more often in the early years and reported to have better results. The decrease in the literature in recent years may be related to the mastery of surgical indications. Because of the complications after major gastrectomy such as reflux gastritis, some scholars have proposed duodenojejunostomy with duodenal absences for duodenal diverticula, which treats duodenal diverticula while preserving the integrity of the stomach and pylorus and their functions, reduces the occurrence of postoperative complications such as anastomotic ulceration and bile reflux, and helps prevent the occurrence of residual gastric cancer.
Roux-en-Y anastomosis of common bile duct jejunum
This is indicated for gallbladder stones, common bile duct stones and Oddi sphincter stenosis with parapapapillary diverticulum. In this case, if there are no associated pancreatic and pancreatic duct stenosis problems, only the bile duct problems can be treated and there is no need to remove the diverticulum. JPDD is sometimes easily missed and the possibility of a parapapillary diverticulum of the duodenum should be considered in the following cases.
(1) symptoms persist after cholecystectomy or recurrent biliary duct infections without residual stones;
(2) Recurrent episodes of common bile duct stones and cholangitis after common bile duct exploration;
(3) Recurrent episodes of biliary tract infection of unknown origin;
(4) recurrent pancreatitis. Choosing the appropriate surgical procedure can avoid recurrent biliary and intestinal diseases.
Pancreaticoduodenectomy
In case of diverticular carcinoma or periampullary carcinoma, diverticular hemorrhage or perforation cannot be solved by simple conventional surgery; pancreaticoduodenectomy is feasible for complications such as biliopancreatic leakage or obstruction after diverticulectomy or endorectal surgery. It is worth mentioning that duodenal diverticulum perforation, although rare, is the most serious complication with a morbidity and mortality rate of up to 20%. The main reason may be that sometimes the perforation is located in the retroperitoneum, making early detection difficult. The choice of surgical approach can range from diverticulectomy to pancreaticoduodenectomy. It depends mainly on the location of the diverticulum and the degree of inflammation.
Endoscopic treatment
For duodenal diverticular bleeding, endoscopic treatment to stop the bleeding has the advantages of safety, convenience, rapidity and few side effects, and is the preferred method to diagnose and treat duodenal diverticular bleeding. However, for those who bleed profusely or fail after endoscopic treatment, they should be promptly converted to surgical treatment. ERCP is a safe and effective treatment for patients with JPDD combined with common bile duct stones whose papillae open at the lower edge of the diverticulum, with a strictly controlled incision. Effective non-surgical or endoscopic treatment of diverticular perforation has also been reported.