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Background: Abdominal aorta-duodenal fistulas are rare abnormal communications between the abdominal aorta and duodenum. Secondary abdominal aorta-duodenal fistulas often result from endovascular surgery for aneurysms and can present as severe late complications., Case Presentation: A 50-year-old male patient underwent endovascular reconstruction for an infrarenal abdominal aortic pseudoaneurysm. Prior to the operation, he was diagnosed with Acquired Immune Deficiency Syndrome and Syphilis. Two years later, he was readmitted with lower extremity pain and fever. Blood cultures grew Enterococcus faecium, Salmonella, and Streptococcus anginosus. Sepsis was successfully treated with comprehensive anti-infective therapy. He was readmitted 6 months later, with blood cultures growing Enterococcus faecium and Escherichia coli. Although computed tomography did not show contrast agent leakage, we suspected an abdominal aorta-duodenal fistula. Esophagogastroduodenoscopy confirmed this suspicion. The patient underwent in situ abdominal aortic repair and received long-term antibiotic therapy. He remained symptom-free during a year and a half of follow-up., Conclusions: This case suggests that recurrent infections with non-typhoidal Salmonella and gut bacteria may be an initial clue to secondary abdominal aorta-duodenal fistula., (© 2024. The Author(s).)

Competing Interests: Declaration of competing interest The author has no financial or other conflicts of interest to disclose.

Background: Common marmosets (Callithrix jacchus) are widely used as primate experimental models in biomedical research. Duodenal dilation with chronic vomiting in captive common marmosets is a recently described life-threatening syndrome that is problematic for health control. However, the pathogenesis and cause of death are not fully understood., Case Presentation: We report two novel necropsy cases in which captive common marmosets were histopathologically diagnosed with gastric emphysema (GE) and pneumatosis intestinalis (PI). Marmoset duodenal dilation syndrome was confirmed in each case by clinical observation of chronic vomiting and by gross necropsy findings showing a dilated, gas-filled and fluid-filled descending duodenum that adhered to the ascending colon. A diagnosis of GE and PI was made on the basis of the bubble-like morphology of the gastric and intestinal mucosa, with histological examination revealing numerous vacuoles diffused throughout the lamina propria mucosae and submucosa. Immunostaining for prospero homeobox 1 and CD31 distinguished gas cysts from blood and lymph vessels. The presence of hepatic portal venous gas in case 1 and possible secondary bacteremia-related septic shock in case 2 were suggested to be acute life-threatening abdominal processes resulting from gastric emphysema and pneumatosis intestinalis., Conclusions: In both cases, the gross and histopathological findings of gas cysts in the GI tract walls matched the features of human GE and PI. These findings contribute to clarifying the cause of death in captive marmosets that have died of gastrointestinal diseases., (© 2024. The Author(s).)

Background: Operative options for duodenal Crohn's disease include bypass, stricturoplasty, or resection. What factors are associated with operation selection and whether differences exist in outcomes is unknown., Methods: Patients with duodenal Crohn's disease requiring operative intervention across a multi-state health system were identified. Patient and operative characteristics, short-term surgical outcomes, and the need for future endoscopic or surgical management of duodenal Crohn's disease were analyzed., Results: 40 patients underwent bypass (n = 26), stricturoplasty (n = 8), or resection (n = 6). Median age of diagnosis of Crohn's disease was 23.5 years, and over half of the patients had undergone prior surgery for CD. Operation type varied by the most proximal extent of duodenal involvement. Patients with proximal duodenal CD underwent bypass operations more commonly than those with mid- or distal duodenal disease (p = 0.03). Patients who underwent duodenal stricturoplasty more often required concomitant operations for other sites of small bowel or colonic CD (63%) compared to those who underwent bypass (39%) or resection (33%). No patients required subsequent surgery for duodenal CD at a median follow-up of 2.8 years, but two patients required endoscopic dilation (n = 1 after stricturoplasty, n = 1 after resection)., Conclusion: Patients who require surgery for duodenal Crohn's disease appear to have an aggressive Crohn's disease phenotype, represented by a younger age of diagnosis and a high rate of prior resection for Crohn's disease. Choice of operation varied by proximal extent of duodenal Crohn's disease., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Cholecystoduodenal fistula (CDF) arises from persistent biliary tree disorders, causing fusion between the gallbladder and duodenum. Initially, open resection was common until laparoscopic fistula closure gained popularity. However, complexities within the gallbladder fossa yielded inconsistent outcomes. Advanced imaging and robotic surgery now enhance precision and detection., Method: A 62-year-old woman with chronic cholangitis attributed to cholecystoduodenal fistula underwent successful robotic cholecystectomy and fistula closure., Results: Postoperatively, the symptoms subsided with no complications during the robotic procedure. Existing studies report favourable outcomes for robotic cholecystectomy and fistula closure., Conclusions: Our case report showcases a rare instance of successful robotic cholecystectomy with CDF closure. This case, along with a review of previous cases, suggests the potential of robotic surgery as the preferred approach, especially for patients anticipated to face significant laparoscopic morbidity., (© 2024 The Authors. The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons Ltd.)

Primary aortoduodenal fistula is a rare condition caused mainly by a bulging infra-renal aortic aneurysm with subsequent erosion of the duodenum and formation of a fistula. We present a patient who suffered from a herald upper gastrointestinal bleeding followed by circulo-respiratory collapse only hours after, due to bleeding from the fistula. The mortality is reported to be 100 %, requiring emergency EVAR or open aortic graft repair to control any further bleeding.

Competing Interests: Disclosure All authors disclosed no financial relationships. Commentary A great many endoscopists have experience with treating benign strictures, most commonly in the esophagus but in other locations as well. That having been said, most endoscopists do not have much experience with true luminal webs. These webs are, in practice, very rare. This case illustrates a patient with a significant duodenal stricture from a web that was treated with incisional therapy, similar to what is often performed in people with fibrotic refractory benign esophageal strictures. In this case, an insulated ITknife was used to incise the web, with appropriate hemostasis applied as needed. The images show a very striking result at the end of this procedure. It is interesting that the authors chose to use a feeding tube at the end of the procedure, given how good the result looked; I suspect many endoscopists would have simply initiated oral feeding after the procedure and skipped the feeding tube entirely. This case illustrates how an aggressive endoscopist who is willing to be innovative can produce a significant benefit for a patient in need. Douglas G. Adler, MD, FASGE, GIE Editor-in-Chief Amy Tyberg, MD, FASGE, FACG, Associate Editor for Focal Points

Background: We report a one-stage surgery to the case of secondary aortoenteric fistula (sAEF) after prosthetic reconstruction of abdominal aortic aneurysm, by multifaceted approach., Case Presentation: A 63-year-old male was admitted to our unit under diagnosed of sAEF after prosthetic reconstruction of abdominal aortic aneurysm, and a pseudoaneurysm of thoracoabdominal aorta due to infection. The patient underwent emergency operation. Firstly, we placed the patient in a modified right lateral decubitus position and performed thoracoabdominal aortic replacement with retroperitoneal approach by thoracoretroperitoneal incision which combined thoracotomy and pararectal incision, and secondly, we changed to a supine position and performed closure of the duodenal fistula and omental flap transposition by midline abdominal incision. The patient was doing well without complications., Conclusions: A one-stage, multifaceted surgical approach covering both prosthetic reconstruction of thoracoabdominal aorta and closure of sAEF with omentopexy is reasonable and useful strategy., (© 2024. The Author(s).)

Diverticular disease is a major cause of hospitalizations, especially in the elderly. Although diverticulosis and its complications predominately affect the colon, the formation of diverticula in the small intestine, most commonly in the duodenum, is well characterized in the literature. Although small bowel diverticula are typically asymptomatic, and diagnosed incidentally, a complication of periampullary duodenal diverticulum is Lemmel syndrome. Lemmel syndrome is an extremely rare condition whereby periampullary duodenal diverticula, most commonly without diverticulitis, leads to obstruction of the common bile duct due to mass effect and associated complications including acute cholangitis and pancreatitis. Here, we present the first case, to our knowledge, of periampullary duodenal diverticulitis complicated by Lemmel syndrome with concomitant colonic diverticulitis with colovesical fistula. Our case and literature review emphasizes that Lemmel syndrome can present with or without suggestions of obstructive jaundice and can most often be managed conservatively if caught early, except in the setting of emergent complications., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

A 72-year-old woman was admitted to our department in March 2020 for an evaluation of nausea, vomiting, diarrhea, liver dysfunction, and hypokalemia, which had persisted intermittently since 2013. Thickening of the descending duodenal wall and a sac-like appearance the intestinal tract in the vicinity of the duodenal papilla were observed in abdominal computed tomography. No duodenojejunal curvature, with two intestinal loops identified in the descending region, was detected in contrast-enhanced upper gastrointestinal imaging. Based on these imaging findings, the patient was diagnosed with intestinal malrotation (incomplete rotation and fixation) accompanied by a right paraduodenal hernia based on the Nishijima classification. Thus, surgery was performed at our hospital. Gastrointestinal symptoms did not recur, and liver dysfunction and hypokalemia improved postoperatively.

The authors describe a case of a male neonate with split notochord syndrome presenting with cervico-thoracic deformity, thoracic neuroenteric cyst, separate abdominal duodenal duplication cyst and concurrent intestinal malrotation. This combination of abnormalities is very rare. When these lesions are suspected, patients must be investigated carefully.This case is presented not only to recount an infrequent combination of structural abnormalities but also to raise awareness of the signs that should point to clinical suspicion and prompt diagnosis.Following surgical excision of the thoracic neuroenteric cyst, the patient has made a good recovery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Duodenal web is complete or incomplete obstruction of the duodenum due to a membranous web or intraluminal diverticulum. This abnormality is one of the main causes of intestinal obstruction in children. The symptoms of this disease may rarely appear in older age and cause gastric outlet obstruction in adults. In the present paper, we report a 69-year-old male patient with heartburn, abdominal discomfort, frequent non-bilious, non-bloody vomiting for the past 6 months. Furthermore, the patient had experienced a weight loss of 12 kg during this period. He had been taking aspirin daily for years due to his ischemic heart disease. After performing contrast-enhanced CT imaging, esophagogastroduodenoscopy and barium meal examination, the patient was diagnosed to suffer from duodenal web. Since surgery is currently the mainstay of treatment in the management of this disease, the patient finally underwent a gastrojejunostomy., (© 2023 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

The duodenum is the second most common location for a diverticulum to form after the colon. These duodenal diverticula (DD) are often found incidentally and rarely require intervention. In recent years, surgical management has been restricted to patients with significant complicated sequelae, such as perforation, abscess, or fistula formation. We present the rare case of a perforated broad-based diverticulum in the third portion of the duodenum necessitating surgical correction. The patient presented with persistent symptoms following failure of conservative management and underwent surgical resection. Due to difficulty visualizing the extent of the diverticulum, a novel intraoperative technique of bowel insufflation via nasogastric tube was used allowing for elucidation of the diverticular borders and complete resection. Although DD are common, there exists no consensus on when operative intervention is indicated. Given that significant morbidity and mortality can be associated with symptomatic DD, a systematic way to guide management decisions is needed. After conducting a review of the literature, we propose that the modified Hinchey classification can be used not only to categorize duodenal diverticulitis but to guide treatment choice in cases with unclear risk benefit profiles.

Introduction: A common feature of external duodenal fistulae is the devastating effect of the duodenal content rich in bile and pancreatic juice on nearby tissues with therapy-resistant local and systemic complications. This study analyzes the results of different management options with emphasis on successful fistula closure rates., Methods: A retrospective single academic center study of adult patients treated for complex duodenal fistulas over a 17-year period with descriptive and univariate analyses was performed., Results: Fifty patients were identified. First line treatment was surgical in 38 (76%) cases and consisted of resuture or resection with anastomosis combined with duodenal decompression and periduodenal drainage in 36 cases, rectus muscle patch, and surgical decompression with T-tube in one each. Fistula closure rate was 29/38 (76%). In 12 cases, the initial management was nonoperative with or without percutaneous drainage. The fistula was closed without surgery in 5/6 patients (1 patient died with persistent fistula). Among the remaining 6 patients eventually operated, fistula closure was achieved in 4 cases. There was no difference in successful fistula closure rates among initially operatively versus nonoperatively managed patients (29/38 vs. 9/12, p = 1.000). However, when considering eventually failed nonoperative management in 7/12 patients, there was a significant difference in the fistula closure rate (29/38 vs. 5/12, p = 0.036). The overall in-hospital mortality rate was 20/50 (40%)., Conclusions: Surgical closure combined with duodenal decompression in complex duodenal leaks offers the best chance of successful outcome. In selected cases, nonoperative management can be tried, accepting that some patients may require surgery later., (© 2023. The Author(s).)

Duodenal varices are detected infrequently, and their rupture is very rare. We encountered an 87-year-old man who developed duodenal varices rupture during chemotherapy with atezolizumab and bevacizumab (ATZ/BV) for hepatocellular carcinoma. We identified massive bleeding of a ruptured varix in the horizontal portion of the duodenum with emergency esophagogastroduodenoscopy (EGD). Successful hemostasis was achieved by endoscopic injection sclerotherapy with Histoacryl. Although ATZ/BV can cause esophageal varices rupture, there have been no cases of duodenal varices rupture. We should take care to check the duodenal varices as well as esophagogastric varices before ATZ/BV treatment.

Purpose: Duodenal fistula in Crohn's disease (CDF) is a rare condition with an unclear optimal surgical management approach. We reviewed a Korean multicenter cohort of CDF surgery cases and assessed their perioperative outcomes to evaluate the effectiveness of the surgical interventions., Methods: The medical records of patients who underwent CD surgery between January 2006 and December 2021 from three tertiary medical centers were retrospectively reviewed. Only CDF cases were included in this study. The demographic and preoperative characteristics, perioperative details, and postoperative outcomes were analyzed., Results: Among the initial population of 2149 patients who underwent surgery for CD, 23 cases (1.1%) had a CDF operation. Fourteen of these patients (60.9%) had a history of previous abdominal surgery, and 7 had duodenal fistula at the previous anastomosis site. All duodenal fistulas were excised and primarily repaired via a resection of the originating adjacent bowel. Additional procedures such as gastrojejunostomy, pyloric exclusion, or T-tube insertion were performed in 8 patients (34.8%). Eleven patients (47.8%) experienced postoperative complications including for anastomosis leakages. Fistula recurrence was noted in 3 patients (13%) of which one patient required a re-operation. Biologics administration was associated with fewer adverse events by multivariable analysis (P = 0.026, odds ratio = 0.081)., Conclusion: Optimal perioperative conditioning of patients receiving a primary repair of a fistula and resection of the original diseased bowel can successfully cure CDF. Along with primary repair of the duodenum, other complementary additional procedures should be considered for better postoperative outcomes., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

We describe the case of a 76-year-old woman with a spontaneous nephroduodenal fistula. The patient was initially evaluated for gastrointestinal and urinary symptoms associated with fever and anemia, after which she was admitted with the diagnosis of right chronic pyelonephritis, hydronephrosis, and renal lithiasis. The fistula was diagnosed incidentally by percutaneous pyelography during a right nephrostomy and was later confirmed with an abdominal CT scan. A multidisciplinary decision was made to surgically treat the fistula (right nephrectomy plus duodenal repair); the surgery had a short-term positive outcome. We report a systematic review of the literature related to spontaneous pyeloduodenal fistulæ and their treatments., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Periampullary duodenal diverticula are rare and pancreaticobiliary complications infrequent, however, when they are diagnosed and associated with symptoms, they warrant urgent intervention. The aim of this article is to present a clinical case of severe cholangitis secondary to the presence of a periampullary diverticulum successfully treated endoscopically., Clinical Case: A 68-year-old man with a history of diabetes and hypertension, was admitted to the emergency room with symptoms of abdominal pain, fever, and tachycardia. With acute kidney injury and alterations in liver function tests, ultrasound with dilated common bile duct and gallstones. Magnetic resonance cholangiography is performed, showing duodenal diverticulum and choledocholithiasis. Antibiotic management is given, and endoscopic retrograde cholangiopancreatography is decided, finding a duodenal diverticulum with stones and pus inside, sphincterotomy, transpapillary dilation and multiple sweeps are performed. Cholecystectomy was performed 7 days later, and the patient was discharged without complications., Conclusions: In patients with signs of severe cholangitis, it is important not to delay endoscopic retrograde cholangiopancreatography, even when infrequent associated pathologies are evidenced, such as a periampullary duodenal diverticulum, since this represents the diagnostic and therapeutic method of choice with high rates of resolution in the case of an obstructive pathology of the bile duct., (© 2023 Revista Médica del Instituto Mexicano del Seguro Social.)

Competing Interests: The authors report no conflicts of interest.

Intramural duodenal haematoma is a rare complication of endoscopic biopsy. Though other causes such as blunt abdominal trauma are more common, it remains a rare problem in paediatric population. In this article, we report a patient who developed intramural duodenal haematoma following an endoscopic biopsy that was performed to look for evidence of gut graft versus host disease., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

We report a case of a 73-year-old woman affected by Lemmel's syndrome, a rare type of obstructive jaundice caused by a periampullary duodenal diverticulum. The patient was admitted to the Emergency Department for pneumonia associated with mild epigastric pain and vomiting. While hospitalized for antibiotic treatment, the appearance of jaundice led us to discover a periampullary duodenal diverticulum by endoscopy and CT scan. The jaundice was successfully managed endoscopically with removal of food debris from the diverticulum., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Mesenteric hematoma is an uncommon condition caused by focal bleeding in the mesenteric vessels. Hematomas are related to trauma, pancreatitis, arteriopathy, and the use of antithrombotic agents. Although hematomas cause intestinal stenosis by compressing the adjacent small bowel, duodenal stenosis due to hematoma is rare. Therefore, the treatment indications for cases of hematoma with stenosis have not been established. We herein report a case with a large mesenteric hematoma that caused duodenal stenosis by compressing the third portion of the duodenum. Stenosis was successfully ameliorated after long-term use of a double elementary diet tube.

Intramural duodenal hematoma (IDH) is a rare entity and is generally associated with trauma. Spontaneous (nontraumatic) intramural duodenal hematoma is associated with bleeding disorders, anticoagulation therapy, alcoholism, pancreatitis, tumours  and duodenal ulcers. We report two cases of spontaneous intramural duodenal hematoma in middle-aged men who subsequently developed pancreatitis. The underlying pathophysiology is still unclear. In the cases described, it is not clear whether the intramural duodenal hematoma contributed to the development of pancreatitis or pancreatitis has contributed to the development of IDH.

In pediatric age, duodenal hematoma is rare and generally occurs following a closed abdominal trauma due to the crushing of the duodenum against the rigid plane of the spine; it rarely follows anticoagulant therapy, pancreatitis, bleeding disorders, vasculitis, tumors or upper digestive endoscopy. Duodenal hematoma is a rare cause of obstruction of the upper gastrointestinal tract and acute pancreatitis, and the diagnosis is sometimes difficult and late. On the other hand, the identification of the pathology in its initial stages allows the young patients to be subjected to a conservative treatment that resolves the issue most of the time, thus avoiding surgery. In this article we describe an unusual case of duodenal hematoma, following esophagus-gastro-duodenoscopy, in a 12-year-old boy with Di George syndrome., (© 2020. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Diverticula of the small bowel can be categorised as true, with Meckel's being the only example, or false. False small bowel diverticula (SBD) are acquired through herniation of the internal layers of the bowel wall through the muscularis propria. Peri-ampullary duodenal diverticula are a well-recognised example; however, the importance of more distal SBD in the jejunum and ileum is underappreciated, and they are under-reported on cross-sectional imaging. SBD are a known cause of anaemia, malabsorption, and diarrhoea, and there are myriad complications of SBD and Meckel's diverticula, which range in severity from inflammation and perforation to haemorrhage, tumour formation, and obstruction. Before the advent of computed tomography (CT), SBD were readily diagnosed on fluoroscopic oral contrast studies; however, radiologists are less comfortable with their cross-sectional imaging appearances. This imaging review combines our experience of multiple proven cases, with illustrative diagrams and radiological images of SBD to provide distinct imaging characteristics, allowing for confident diagnosis of SBD and their numerous complications. We discuss the importance of SBD as a cause of benign, non-surgical pneumoperitoneum. We additionally provide important pitfalls to be aware of such as SBD masquerading as other abnormalities., (Copyright © 2021 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

A 67-year-old man with massive hematemesis was transferred to the emergency unit of our hospital. The patient was diagnosed with primary aortoduodenal fistula (PADF) based on the CT findings. Upon emergent exploration, multiple duodenal diverticula were found and in situ abdominal aortic aneurysm (AAA) repair using polytetrafluoroethylene (PTFE) graft was performed. The third and fourth parts of the duodenum with multiple duodenal diverticula and the origin of jejunum were excised, and end-to-side duodenojejunostomy was performed. The patient was discharged on the 38th postoperative day with another 6 month oral antibiotic treatment. The duodenal diverticula may be the cause for PADF., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Lemmel's syndrome is an uncommon entity that causes obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledolithiasis or neoplasia. To date, there are few published cases and the etiopathogenesis remains unclear.

Background: Diverticula are commonly observed in the duodenum. Duodenal Diverticulum (DD) usually does not give symptoms throughout life and is diagnosed by coincidence. However, it may present with different symptoms in patients., Objective: This study aims to evaluate the prevalence of DD and Juxtapapillary Duodenal Diverticulum (JDD) and its association with other possible pathologies and to determine its clinical impact by using Computed Tomography (CT)., Methods: This retrospective observational study, which was taken consecutively between the years of 2013-2020, was evaluated in the Radiology Department. The total number of cases was 4850 (male-2440; female-2410). CT images were evaluated by two experienced radiologists at the workstation. DD and JDD prevalence and clinical findings in the hospital registry system were examined., Results: The age of the patients included in the study ranged from 17 to 92 years (mean age 46.94±16.42). In patients with DD (female-130; male-101), mean age was 62.24 ± 12.69 (21-92). The prevalence of DD was 4.76% (n=231). The prevalence of JDD was 4.02% (n=195) and increased with age (p<0.01). The average diameter of the JDD was measured as 23.29±8.22 (9.5-55.3) mm. A significant positive correlation was found between age and DD diameter (p=0.039). DDs were found most commonly 84.42% (n=195) in the second segment of the duodenum as JDD. In patients with JDD, the mean diameter of choledochus and wirsung canal were 6.7 ± 2.4 (3-15.3) mm and 0.31 ± 0.1 (0.1-6.5) mm respectively. The choledochal diameter was correlated with the JDD size (p = 0.004). Cholelithiasis (n=56), choledocholithiasis (n=20), cholecystitis (n=52), diverticulitis (n=15), duodenitis (n=37), pancreatitis (n=5) and hiatal hernia (n=60) with JDD were observed. Periampullary carcinoma was detected in one patient., Conclusion: Our study shows that cholelithiasis, choledocholithiasis, cholecystitis, diverticulitis, duodenitis, pancreatitis may be associated with JDD. Therefore, in contrast-enhanced abdominal CT scans taken for various reasons, investigation of the presence and characteristics of JDD and detection of pathologies that may be associated with JDD are important for patients to benefit from early diagnosis and treatment opportunities and to take precautions against possible complications., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

A 30-year-old man presented with colicky abdominal pain for 2 months, associated with occasional episodes of bilious vomiting. He had a history of similar complaints at the age of 16 and 26 years. Contrast-enhanced computed tomography abdomen was consistent with a diagnosis of left paraduodenal hernia. On laparoscopy a 3 × 3 cm hernial defect was identified in the left paraduodenal fossa (fossa of Landzert). Contents were jejunal, and proximal ileal loops which were dilated and edematous. Anterior border of the sac was formed by the inferior mesenteric vein and left branch of the left colic artery. Initial reduction of contents was easy. However, complete reduction proved to be difficult due to adhesions with the sac opening, the hernial sac instead laid open by dividing the Inferior Mesentric Vein (IMV) (anterior border of defect) using a vascular stapler. The patient was discharged on postoperative day 3 in a stable condition. On follow-up the patient is doing well., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Endoscopic negative pressure therapy is a novel and successful treatment method for a variety of gastrointestinal leaks. This therapy mode has been frequently described for rectal and esophageal leakages. Duodenal diverticular perforations are rare but life-threatening events. The early diagnosis of duodenal diverticular perforation is often complicated by inconclusive symptoms. This is the first report about endoscopic negative pressure therapy in patients with perforated duodenal diverticula., Case Presentation: We present two cases of duodenal diverticula perforations treated with endoscopic negative pressure therapy as stand-alone treatment. Start of symptoms varied from one to three days before hospital admission. Early sectional imaging led to the diagnosis of duodenal diverticular perforation. Both patients were treated with endoluminal endoscopic negative pressure therapy with simultaneous feeding option. Three respective changes of the suction device were performed. Both patients were treated with antibiotics and antimycotics during their hospital stay and be discharged from hospital after 20 days., Conclusions: This is the first description of successful stand-alone treatment by endoscopic negative pressure therapy in two patients with perforated duodenal diverticulum. We thus strongly recommend to attempt interventional therapy with endoluminal endoscopic negative pressure therapy in patients with duodenal diverticular perforations upfront to surgery., (© 2021. The Author(s).)

A 75-year-old man presented with a 3-week history of melaena and right upper quadrant pain. This was on a background of significant alcohol intake and a complex medical history. He was haemodynamically unstable with investigations indicating a new iron-deficiency anaemia. After resuscitation, urgent intervention was required under general anaesthesia. This involved a triple phase abdominal CT, followed by emergency oesophagogastroduodenoscopy. This revealed deep ulceration with extension to the pancreatic head and common bile duct. There was also evidence of pneumobilia on CT, secondary to a choledochoduodenal fistula. Treatment encompassed an invasive and medical approach. Following treatment, the patient was stable, with follow-up endoscopy exhibiting good duodenal mucosal healing., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Tuberculosis (TB) is a common disease in developing countries that can virtually affect any organ in the body. The abdomen is one of the most common sites for extra-pulmonary tuberculosis. Primary Pancreatic tuberculosis (PPTB) is rare and can be clinically elusive. It is commonly encountered in immunodeficient individuals in regions endemic for TB. However, it is extremely rare in immunocompetent individuals with very few case reports in the literature. We describe a case of PPTB in an immunocompetent young man complicated with duodenal fistula. There was complete resolution of symptoms and the fistulous tract with a significant reduction of the size of the lesion on imaging after 6 months of anti-tubercular therapy (ATT)., (© 2021. Japanese Society of Gastroenterology.)