DD are frequently located at the papilla or near the papilla (70%) (
1). In this case, the DD was in the second part of the duodenum on the lateral wall. The incidence of lateral diverticula in the second part of the duodenum is 3% ( 1). It predominantly occurs in women. DD is generally an acquired disease; it is rarely seen in patients before the 4th decade of life.
Usually, duodenal diverticula are asymptomatic or have nonspecific symptoms, including abdominal pain located in epigastrium or right upper abdomen, nausea, vomiting, and diarrhea. Accumulation of food in the diverticula or diverticular bezoar formation may be the possible causes of symptoms. This may lead to blind loop syndrome. Bezoar formation is remarkable in bigger duodenal diverticula like in this case. Moreover, adenocarcinoma is reported to develop from duodenal diverticulum (
2). The clinical presentation of the disease differs when DD is complicated (perforation, hemorrhage, bile duct or pancreatic duct obstruction).
Asymptomatic types of DD are commonly diagnosed incidentally during upper gastrointestinal endoscopy. Upper gastrointestinal barium meal reveals the diverticula that can be missed in the initial endoscopy. However MR, CT and ERCP can help diagnose diverticula. Only 1% - 5% of DD are complicated and it is difficult to diagnose a complicated diverticulitis (
1). It is not easy to make an accurate diagnosis of DD before surgery because of the complex anatomy of the duodenal region. It is difficult to make differential diagnosis of pancreatic pathologies, when there is a mass in imaging, especially in the second part of the duodenum. There are several case reports of such patients. It is quite important to make the accurate diagnosis, as the type of the surgery, especially laparoscopy, depends much more on this diagnosis.
In this case, a large DD was observed with duodenitis and nonspecific gastrointestinal symptoms. Upper gastrointestinal endoscopy incidentally showed DD. In such cases, there may be bezoar formation and bezoar related complications (obstruction, perforation, diverticulitis, blind loop syndrome, etc.). The location and type of DD affect the treatment choice. The cause of perforation is food accumulation and digestion process in 57% of DD cases (
3). Perforation of DD is an important complication, with mortality rate of 30% ( 4).
Asymptomatic, incidentally diagnosed DD cases do not require surgery, unless it is outside duodenum. Protruding DD can be surgically resected without making a duodenotomy. Although different types of surgical treatment are described, conventional or laparoscopic surgical resection of symptomatic DD seems to be the best option (
5). Surgical intervention in this area has high postoperative morbidity and mortality ( 6). The mortality rate after surgical diverticulectomy is reported at 30%. Late diagnosis or misdiagnosis causes perforation with a mortality rate of 90% ( 7).
Laparoscopy is the preferred type of surgery for abdominal operations. The advantages of laparoscopic operations (less postoperative pain, better cosmetic results, shorter hospital stay, etc.) are widely accepted. The only disadvantage of laparoscopic surgery is the need for an experienced surgeon.
There are two case reports about laparoscopic resection of DD. Both of them reported the laparoscopic procedure feasible and safe (
8, 9). After an accurate diagnosis, the choice of surgery depends on the location, type and size of the DD. It is easy to reach laterally located and protruding DD, as in this case, but it is relatively difficult to access the other parts of the duodenum with laparoscopy because of lack of laparoscopic experience. We used four trocars (as stated before). Protruding type of DD has perforation risk, because the diverticulum’s wall consists only of mucosa and the wall is exposed to irritation from bezoar formation and digestive irritation. After careful dissection of the diverticulum neck, one should be careful about not to narrow the duodenal lumen. Laparoscopic excision of duodenal diverticula is feasible and safe.