Size Of Diverticulum Research Articles

Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases.

Several reports since the early 1990s have advocated a minimally invasive technique, endoscopic staple diverticulostomy (ESD), to treat Zenker's diverticulum. However, long-term results and comparisons with the reported experience with external or other endoscopic approaches have been lacking in the literature. We present follow-up on our experience with ESD since 1995 and compare it with the results obtained by other endoscopic or external techniques for treatment of Zenker's diverticulum. Retrospective review of 159 consecutive ESD procedures performed on 150 unique patients with Zenker's diverticulum between March 1995 and August 2002. Telephone interviews of patients were conducted to assess long-term treatment outcome. Review of the literature was performed by Ovid MEDLINE search for all reports on the surgical treatment of Zenker's diverticulum in the English language between January 1990 and August 2002. Data were retrospectively reviewed and information was tabulated for age, sex, size of diverticulum, symptoms, duration of symptoms, operative time, length of hospital stay, time before oral intake, complications, and relief of symptoms at first postoperative visit. Follow-up interviews of patients were conducted to assess current status of symptoms and, if any symptoms returned, how many months after the procedure they recurred. All case series in the literature in the English language since 1990 that were found in the Ovid MEDLINE database and referenced from identified articles were also tabulated for the same information. At the time of initial follow-up after ESD, 98% of patients reported complete or improved symptoms. Average hospital stay was 0.76 days, with a diet started on postoperative day 0.25. There was a 2.0% significant complication rate without mortality. Further follow-up (average, 32.2 mo) identified a recurrence rate of 11.8%. On review of the literature, patients who underwent ESD had shorter perioperative courses, quicker return to diet, and lower complication and mortality rates compared with external procedures. ESD had comparable operative times and mortality rates, but fewer complications and more rapid convalescent times compared with other endoscopic procedures. Recurrence rates were found to be variable. Overall, ESD is an outpatient procedure with few complications. The technique has a faster operative and convalescence period with fewer complication rates compared with other endoscopic or external transcervical approaches. The results in the present study and those reported in the English language literature advocate that ESD be the initial preferred treatment for Zenker's diverticulum.

Sequential transurethral resection of the prostate and laparoscopic bladder diverticulectomy: comparison with open surgery

Objectives To compare our experience with transurethral resection of the prostate and sequential laparoscopic bladder diverticulectomy with a previous series of combined open bladder diverticulectomy and transvesical prostatectomy. Methods We compared the data of 10 consecutive patients (group 1) who underwent sequential transurethral resection of the prostate and transperitoneal laparoscopic bladder diverticulectomy and 13 consecutive patients (group 2) who underwent traditional combined open bladder diverticulectomy and transvesical prostatectomy. The following parameters were considered: size and position of the diverticulum, transrectal ultrasound adenoma volume, operative time, postoperative hemoglobin variations, analgesic requirement, complications, postoperative hospital stay, and urinary flowmetry. Results No statistically significant differences existed between the two groups either for diverticulum size (6.8 versus 7.2 cm) or diverticula position. A significant difference was observed in the operative time (247 minutes for group 1 versus 136 minutes for group 2, P <0.0001), mean postoperative hemoglobin decrease (2.6 g/dL for group 1 and 3.9 g/dL for group 2, P = 0.001), analgesic requirement (1.3 ampoules of buprenorphine cloritrate for group 1 versus 1.8 ampoules for group 2, P = 0.45), and postoperative hospital stay (3 days for group 1 versus 9.6 days for group 2, P <0.0001). No statistically significant difference was recorded for control flowmetry. No intraoperative complications were recorded for the two groups. Conclusions In our series, sequential transurethral resection of the prostate and transperitoneal laparoscopic diverticulectomy for large diverticula proved to be a safe, effective, and minimally invasive procedure, despite the longer operative times compared with transvesical prostatectomy and open bladder diverticulectomy.

Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women

Objectives. Accurate determination of the size and extent of urethral diverticula can be important in planning operative reconstruction and repair. Voiding cystourethrography (VCUG) is currently the most commonly used study in the preoperative evaluation of urethral diverticula. We reviewed our experience with the use of endoluminal (endorectal or endovaginal) magnetic resonance imaging (eMRI) in these patients as an adjunctive study to VCUG to evaluate whether the MRI provided anatomically important information that was not apparent on VCUG. Methods. A retrospective analysis of all patients with a clinical diagnosis of urethral diverticula undergoing MRI at a single institution was performed. Patients were evaluated with history, physical examination, cystoscopy, VCUG, and eMRI. Endoluminal MRI was retrospectively compared to VCUG with respect to size, extent, and location found at operative exploration. Results. Twenty-seven consecutive patients underwent endorectal or endovaginal coil MRI in the evaluation of suspected urethral diverticula. Twenty patients subsequently had attempted transvaginal operative repair of the diverticulum. In 2 patients, eMRI demonstrated a urethral diverticulum, whereas VCUG did not. Operative exploration in these patients revealed a urethral diverticulum. In 14 of 27 patients, the VCUG underestimated the size and complexity of the urethral diverticulum as compared to eMRI and operative exploration. In 13 of 27 patients, the size, location, and extent of the urethral diverticulum on VCUG correlated well with the eMRI and/or operative findings. Conclusions. We have found endorectal and endovaginal coil MRI to be extremely accurate in determining the size and extent of urethral diverticula as compared to VCUG. This information can be critical when planning the approach, dissection, and reconstruction of these sometimes complex cases.

Endoscopic staple-assisted esophagodiverticulostomy: an excellent treatment of choice for Zenker's diverticulum.

The objectives of the present study are to review the technique of endoscopic staple-assisted esophagodiverticulostomy (ESED) for the treatment of Zenker's diverticulum and to describe our experience and modifications with ESED and the advantages of ESED over previous treatments of Zenker's diverticulum. Retrospective review of 74 cases of ESED performed for the treatment of Zenker's diverticulum. Patient's records were retrospectively reviewed and tabulated for age, sex, size of diverticulum, symptoms, duration of symptoms, operative time, length of postoperative hospital stay, oral intake, complications, and relief of symptoms. The senior author (R.L.S) previously reported results in 36 cases of ESED performed in 34 patients with Zenker's diverticulum. We have performed an additional 38 cases of ESED in 37 patients between March 1997 and August 1999. The rate of success of ESED was similar between the two series The average perioperative time, time until oral intake, and length of postoperative hospital stay decreased in the second series. Overall, there were no mortalities and few complications with ESED. Compared with other forms of treatment of Zenker's diverticulum, such as Dohlman's procedure, diverticulectomy, and diverticulopexy, ESED has a similar rate of success, decreased perioperative time, decreased convalescence, and decreased mortality and complications. Cost-effectiveness, safety, and efficacy of ESED offer new advantages over previously used treatments for Zenker's diverticulum. These results continue to support the use of ESED as the initial treatment of choice for patients with Zenker's diverticulum.

3556 Endoscopic treatment of zenker's diverticulum.

Background - The treatment of Zenker's diverticulum had been done surgically using several techniques as diverticulotomy with or without cricopharyngeal myotomy, only cricopharyngeal myotomy and diverticulopexy with myotomy. Recently, three studies showed the possibility of endoscopic diverticulotomy with cricopharyngeal myotomy as an alternative therapy to surgical treatment. Patients and methods - Since September 1997, 12 patients (10 men and 2 women; 51 to 85 years of age) underwent an endoscopic diverticulotmy. All patients had severe dysphagia (average of 6,25 in a 0 to 10 score), 11 had regurgitation, 7 had respiratory symptoms with chronic cough and 2 had recurrent aspiration pneumonia. The diverticulum size were small (less than 2 cm) in 2, medium (2 to 4 cm) in 4 and large (over 4 cm) in 6 patients. The procedure consisted on endoscopic incision of the septum untill the diverticulum base with a needle knife, using cutting/coagulation current. It was performed with sedation as a routine endoscopic examination. All patients were clinically and endoscopically evaluated 30 days after the procedure. When there were symptoms and a septum, a new procedure was performed. Oral intake of liquid food was begun in the first day after the operation. All patients received antibiotics for 24 hours. Results - Treatment using a mean of 1,41 (1 to 3) sessions per patient was successful. Three complications (1 cervical emphysema and 2 hemorrhage) were managed clinically. Dysphagia disappeared in 11 patients (6 with one session and 5 with two sessions) and the respiratory symptoms disappeared in all them, with no recurrence. Conclusion - The endoscopic diverticulotomy is an alternative and safe procedure to open surgery, with equivalent results, and should be considered as a therapy for Zenker's diverticulum, especially for patients with high surgical risk.

Evaluation of colonic diverticular disease in autosomal dominant polycystic kidney disease without end-stage renal disease.

A previous study had shown an increased prevalence (83%) of diverticula among patients with autosomal dominant polycystic kidney disease (ADPKD) with end-stage renal disease (ESRD) compared with other ESRD patients without ADPKD (32%). Others have also suggested an increased risk for diverticular complications in renal transplant recipients with ADPKD. To determine whether there was an increased occurrence of diverticula among non-ESRD patients with ADPKD, we studied 55 patients with ADPKD who were not receiving renal replacement therapy compared with 12 unaffected family members (non-ADPKD) and 59 random patients who had undergone barium enemas (control [C]). No study patient had a history of diverticular disease. All patients underwent a double-contrast barium enema after administration of glucagon. The occurrence, number, location, and size of diverticula were noted. There was no significant difference among the three groups in regard to sex (men: ADPKD, 42% versus non-ADPKD, 42% versus C, 37%) or age (ADPKD, 49.3 +/- 0.7 versus non-ADPKD, 51.2 +/- 2.1 versus C, 49 +/- 1 years). There was no significant difference in the percentage of patients with diverticula (ADPKD, 47% versus non-ADPKD, 58% versus C, 59%), the percentage with only right-colon diverticula (ADPKD, 5% versus non-ADPKD, 17% versus C, 5%), the mean number of diverticula in patients with diverticulosis (ADPKD, 13.8 versus non-ADPKD, 7.9 versus C, 9.9 diverticula), or the size of the largest diverticula (ADPKD, 9.5 versus non-ADPKD, 10.4 versus C, 10.5 mm). There was no significant difference in these variables between the patients with ADPKD with a creatinine clearance greater than 70 mL/min/1.73 m(2) (n = 25) or less than 70 mL/min/1.73 m(2). This study does not show the greater prevalence of diverticular disease in non-ESRD patients with ADPKD compared with the general population. Thus, patients with ADPKD need not be considered at greater risk for diverticular disease than the general population.

Zenker's diverticulum: analysis of surgical complications from diverticulectomy and cricopharyngeal myotomy.

To identify risk factors for postoperative complications in patients undergoing diverticulectomy and cricopharyngeal (CP) myotomy for Zenker's diverticulum. Retrospective. A chart review was conducted of all patients with a Zenker's diverticulum who were treated with diverticulectomy and cricopharyngeal myotomy at three tertiary care centers in central Indiana between 1988 and 1998. Of the 24 patients identified, 9 developed postoperative complications (2 medical and 7 surgical). Statistical analysis of multiple potential risk factors revealed that only diverticulum size greater than 10 cm2 at surgery placed the patient at increased risk for postoperative surgical complications. To our knowledge, this is the first report that has specifically addressed diverticulum size as an independent risk factor for postoperative surgical complications following diverticulectomy and CP myotomy. Given our findings, we recommend considering diverticulopexy rather than diverticulectomy in a patient with a Zenker's diverticulum greater than 10 cm2 in size if a cervical approach is the selected treatment.

Diverticular Disease of the Colon: A Risk Factor for Peritonitis in Continuous Peritoneal Dialysis

To study the possible influence of colonic diverticula on the risk of peritonitis of enteral (intestinal) origin in patients undergoing continuous peritoneal dialysis, a barium enema was carried out as a pretreatment investigation in 129 consecutive patients starting CAPD over a 9-year period. In this prospective study comprising 3103 patient months, a total of 44 (15% of all) episodes of peritonitis with micro-organisms of enteral origin occurred in 30 of the 129 patients. The estimated probability of developing such an episode was 16% and 24%, respectively, within 1 or 2 years of treatment. Diverticula (greater than or equal to 1) were found in 54 (42%) of all patients. In all cases the following factors: greater than or equal to 10 diverticula, diverticular size of greater than or equal to 10 mm and diverticula in the ascending, transverse, or descending colon, significantly increased the risk of developing peritonitis of enteral origin (P less than 0.05). Neither diverticula in the sigmoid colon nor diverticulitis, as assessed by radiological findings, were identified as risk factors. Enteral episodes (as defined in this study) appear to represent mainly microperformations of existing diverticula; such episodes should probably be regarded as and handled differently from episodes due to major perforations of the colon secondary to diverticulitis. We conclude that diverticular disease of the non-sigmoid colon is a risk factor for peritonitis in CAPD.

Clinical study of urethral pressure profile (author's transl)

Pre-and post-operative urethral pressure profile in various lower uropathies, obtained by Brown's method was analyzed for urethral length and pressure in the external sphincteric area.1) The posterior urethral length in normal male was 3.6cm (2.0-4.5cm) on the average, and pressure in the external sphincteric area was 30mmHg (20-42mmHg).2) The average posterior urethra was lengthened to 4.3cm (3.0-7.0cm) and the average pressure at the external sphincteric area increased to 39mmHg (20-50mmHg) in 16 cases of benign prostatic hypertrophy and 3 cases of prostatic carcinoma. There was a marked reduction in both length and pressure in postoperative profile.3) In vesical neck contracture, preoperative urethral length was 4.0cm (3.0-4.5cm) and pressure was 35mmHg (28-50mmHg). The postoperative reduction in length and pressure was less marked comparing to the prostatic hypertrophy group.4) In chronic paraplegic patients the length was 1.8cm (1.3-2.5cm) and the pressure was 23.9 (10-36mmHg). The profile was independent of the level of cord lesion and the duration after injury. No difference in profile was observed between the groups with or without subarachnoidal phenol block. The wave and the spike in anterior urethral profile, which were scarecely found in nonparaplegics, were frequently observed.5) The urethral pressure profile offered valuable clues to the identification of the position and the size of anterior urethral diverticulum and urethral stricture, which helped the diagnosis, selection of operative approach and evaluation of postoperative result.6) Pressure at the external sphincteric area of patients with post-prostatectomy incontinence is lower than 10mmHg. No patient with pressure above 14mmHg at this area was incontinent.This is on easily performable method even in the outpatient clinic, and yet the careful analysis of the curvature gives valuable informations as to the management of various lower uropathies.

Dynamic or Disappearing Diverticula of the Colon

Diverticula can appear and disappear while under fluoroscopic observation at barium enema examination. These changing diverticula may exhibit all the various shapes that are seen with the ordinary, nondisappearing type of diverticulum. Within the past two years, roentgenograms obtained during examination of three patients, besides the case reported here, showed spontaneously appearing and disappearing diverticula (Fig. 14). Only a few references are made in the literature to spontaneously appearing or disappearing diverticula (3, 10), and no reference has been made to fluoroscopic observation of this phenomenon. Since 1925, colon diverticula coated by muscle have been described as intramural diverticula, early or “pre-” diverticula (2, 5–8), or spastic colon diverticulosis (1, 3). Recently, diverticular disease without diverticula has been documented (1, 9). It has been suggested that “early” stages of diverticula may develop into large, saccular diverticula in months or years (3, 6). That this development can take place in a matter of seconds and be reversible is apparently not generally known. The appearance of diverticula in a normal-appearing colon is often attributed to the opening of occluded ostia. Failure of redemonstration of barium-filled diverticula on subsequent examinations has been attributed to either (a) occlusion with or without diverticulitis (4) or (b) reduction of mucosal hernias through the colon wall in the manner of a hiatus hernia(3–10). A case of appearing and disappearing diverticula was studied in vivo and in vitro at the Saint Francis Memorial Hospital and at the University of California San Francisco Medical Center. Appearance and disappearance of the diverticula proved to be related to changes in intestinal muscle tone and unrelated to the volume of the colon. The diverticula did not resemble diverticulosis in a spastic colon, as described by Fleischner et al. (3). A 60-year-old female patient had a six-month history of intermittent lower abdominal pain without fever and with no known bleeding. On barium enema examination a 1.5 cm midsigmoid polyp, surrounded by diverticula in the sigmoid and descending colon, was seen. The diverticula appeared upon filling (Fig. 1) and disappeared completely upon evacuation (Fig. 2). On the second barium enema examination, performed six weeks after the first, the increase in number and size of diverticula was recorded in rapid spot-film sequence. These appeared and grew with increasing filling and volume of the colon (Fig. 3). After evacuation, fewer diverticula remained, and most of these were smaller in size (Fig. 4). Not all diverticula disappeared on the second examination as they did on the first. Upon a third filling, fewer diverticula were present at the completion of filling than at the start (Figs. 5 and 6).

The barium swallow in thyroid enlargment.

The barium swallow examination was urtdertaken as a routine pre-operative investigation in patients undergoing thyroidectomy, and the findings in 150 of these cases have been reviewed. It is noted that there may be marked oesophageal compression by the thyroid with no increase in the incidence of dysphagia. Most cases with severe compression of the upper oesophagus by the thyroid had had thyrotoxicosis and had been treated medically. This compression is not related to the size of the goitre or to pre-tracheal or posttracheal soft tissue enlargement. Marked oesophageal compression can also be caused by lymphadenoid goitre. Marked oesophageal displacement is associated with nodular goitres. It is the only reliable method of assessing posterior intrathoracic extension of a cervical goitre. Zenker's diverticulum and crico-pharyngeal webs are not infrequently found on routine examination and are usually symptomless. The size of the Zenker's diverticulum, in the early stages, appears to be related to the patien...

Diverticulum of the Duodenum

Diverticula of the gastro-intestinal tract are not rare: cases have been reported of diverticula in the esophagus, stomach, duodenum, jejunum, ileum, and the large intestine. They may be single or multiple, and are less frequent in the upper tract than in the lower. The following case is reported not only because of the unusual size of the duodenal diverticulum, but also because of the difficulty of differential diagnosis. Report of Case J. I. B., a married, white woman, aged 40, was referred to me on July 26, 1930, by Dr. W. A. Haggard, for roentgen examination of the gall bladder and gastro-intestinal tract. Her past history revealed nothing significant, except for influenza and pneumonia, and an appendectomy fifteen years previously. There had been no loss of weight. The marital history was irrevelant; no pregnancies. The present history dates back two to three years, at which time the patient began having distress after taking acid fruits and such foods as pickles and tomatoes. Pain would commence as soon as food was swallowed, gradually diminishing in severity and finally disappearing in two or three hours. However, immediately on taking more food, pain would return. Milk had no influence on the pain, but soda and milk of magnesia at times would relieve it completely for a short period. There was no pain at night. Rarely the patient vomited. At one time there had been bile in the vomitus, but never blood or coffee-ground material. Two months previously, the patient had eaten turnip greens for supper, and the next morning vomited the whole in an undigested state. At times there was a burning sensation in the epigastrium to the right of the midline, but chiefly after taking acid foods. Occasionally, pain would strike in the region of the right scapula. There was no history of gallstone colic. The patient's appetite was poor; she was never constipated; her habits were regular. There was no history of blood or mucus in the stools. On physical examination the patient was found to be well nourished and well developed. On fluoroscopic examination both lungs were seen to be well aërated; the heart, thoracic vessels, the diaphragm, and the posterior mediastinum showed nothing remarkable. The esophagus was smooth and showed no delay. The stomach was of the modified fish-hook type, hypertonic, showing active peristalsis and hypermotility. It was completely empty in about two hours. The pylorus and duodenal bulb were smooth and regular. There was no tenderness on deep palpation, either in the stomach or the duodenum, but in the space just above the pylorus and lateral to the duodenal bulb, there was exquisite tenderness. The patient was next examined in the supine position and the area under suspicion explored fluoroscopically, with negative findings. She was then placed prone in the right oblique position, with the head of the table lowered. Immediately a large pouch was seen just above the pylorus.