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Background: There is a discrepancy in the surgical and endoscopic literature for managing duodenal perforations. Although often managed conservatively, surgical repair is the standard treatment for duodenal perforations. This contrasts with the gastroenterology literature, which now recommends endoscopic repair of duodenal perforations, which are more frequently iatrogenic from the growing field of advanced endoscopic procedures. This study aims to provide a scoping review to summarize the current literature content and quality on endoscopic repair of duodenal perforations., Methods: The protocol for performing this scoping review was outlined by the Joanna Briggs Institute. All studies that reported primary outcomes of patients who had undergone endoscopic repair of duodenal perforations before February 2022, regardless of perforation etiology or repair type were reviewed, with studies after 1999 meeting inclusion criteria. The study excluded articles that did not report clinical outcomes of endoscopic repair, articles that did not describe where in the gastrointestinal tract the endoscopic repair occurred, pediatric patients, and animal studies., Results: 7606 abstracts were screened, with 474 full articles reviewed and 152 studies met inclusion criteria. 560 patients had duodenal perforations repaired endoscopically, with a technical success rate of 90.4% and a survival rate of 86.7%. Most of these perforations (74.5%) were iatrogenic from endoscopic procedures or surgery. Only one randomized control trial (RCT) was found, and 53% of studies were case reports., Conclusion: These results suggest that endoscopic repair could emerge as a viable first-line treatment for duodenal perforation and highlight the need for more high-quality research in this topic., (© 2024. The Author(s).)

Background: Duodenal stump fistula represents an infrequent but serious complication after laparoscopic radical gastrectomy with Billroth II or Roux-en-Y reconstruction for gastric cancer. The present study was designed to evaluate the effectiveness of laparoscopic double half purse-string sutures plus "8" pattern of stitching for reinforcement of duodenal stump. Methods: The data of patients undergoing laparoscopic radical gastrectomy with Billroth II or Roux-en-Y reconstruction were retrospectively analyzed between August 2022 and June 2023. According to the different reinforcement methods of duodenal stump, included patients were subdivided into three groups as follows: Group A, duodenal stump was treated with double half purse-string sutures plus "8" pattern of stitching; Group B, duodenal stump was reinforced by continuous suture using a barbed suture; and Group C, duodenal stump without any additional processing. The incidences of duodenal stump fistula between three groups were documented and compared. Moreover, the independent risk factors associated with duodenal stump fistula were analyzed using the logistic regression analysis. Results: No postoperative duodenal stump fistula occurred in Group A, which was significantly different from Group B and Group C ( P = .007). In the multivariate analysis, age (odds ratio [OR], 1.191; 95% confidence interval [CI], 1.088-1.303), body mass index (OR, 0.824; 95% CI, 0.727-0.935), and American Society of Anesthesiologists score (OR, 4.495; 95% CI, 1.264-15.992) were the risk factors for duodenal stump fistula. Conclusion: Double half purse-string sutures plus "8" pattern of suture can be conducted in a relatively short operation period and could prevent the incidence of duodenal stump fistula to some extent.

Perforation is the rarest complication of duodenal diverticulum but also one of its most serious complications. Mortality rate was reported to up to 30%. Clinical diagnosis is usually vague and non-specific. High clinical suspicion is important as rapid deterioration is likely. Consensus regarding management is lacking and currently guided by a small series of case reviews. Surgical treatment is historically the standard therapeutic option. However, more current literature suggests improvement in patients with non-surgical management. In this paper, we discuss a case of a patient in her early 60s who had a perforated duodenal diverticulum that was treated conservatively. It highlights the importance of a good history and a CT scan to help with diagnosis. Close clinical observation is essential to detect disease progression. A step-up approach to clinical deterioration with either percutaneous drainage or surgical management should be considered if the patient does not respond to conservative treatment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

We present a case involving a 67-year-old patient with a medical history of gastric bypass who was recently diagnosed with a 6-centimeter duodenal mass causing biliary duct stenosis. Despite our best efforts, we were unable to access this tumor endoscopically, necessitating surgical intervention. During the surgical exploration, we discovered a duodenal diverticulum filled with stones, leading to the obstruction of the biliary ductâ?"a manifestation of Lemmel syndrome. This rare condition is characterized by obstructive jaundice in the absence of choledocholithiasis or tumors and is secondary to dilatation of peri-ampullary diverticula. While it is typically managed through endoscopy, our diagnostic and therapeutic approach was complicated by the patient's history of bariatric surgery (gastric bypass), making endoscopic access impossible despite our multiple attempts. This case report sheds light on the challenges posed by the concurrence of a rare pathology and surgically modified anatomy, which is increasingly encountered in daily surgical practice. In such situations, exploratory surgery continues to play a significant role., (Celsius.)

Background: Endoscopic balloon dilation (EBD) is a safe and effective treatment for Crohn's disease (CD)-associated strictures. However, serial EBDs have rarely been reported. This study aimed to evaluate the efficacy and safety of serial EBDs for treating CD-associated duodenal strictures compared with intermittent EBDs., Methods: Patients with CD-associated duodenal strictures who underwent EBD were recruited. The clinical data, stricture characteristics, number of EBDs, dilation diameter, complications, surgical interventions, and follow-up periods were recorded. Patients were divided into a serial dilation group and an intermittent dilation group to analyze the differences in safety and efficacy., Results: Forty-five patients with duodenal CD-associated strictures underwent a total of 139 dilations. A total of 23 patients in the serial dilation group underwent 72 dilations, for a median of 3 (range 3 ~ 4) dilations per patient, and 22 patients in the intermittent dilation group underwent 67 dilations, for a median of 3 (range 1 ~ 6) dilations per patient. Technical success was achieved in 97.84% (136/139) of the patients. During the follow-up period, three patients in the intermittent dilation group underwent surgery, and the total clinical efficacy was 93.33% (42/45). No difference in safety or short-term efficacy was noted between the two groups, but serial EBDs exhibited significantly greater clinical efficacy between 6 months and 2 years. No significant difference in recurrence-free survival was observed, but the median longest recurrence-free survival and recurrence-free survival after the last EBD in the serial dilation group were 693 days (range 298 ~ 1381) and 815 days (range 502 ~ 1235), respectively, which were significantly longer than the 415 days (range 35 ~ 1493) and 291 days (range 34 ~ 1493) in the intermittent dilation group (p = 0.013 and p = 0.000, respectively). At the last follow-up, the mean diameter of the duodenal lumen was 1.17 ± 0.07 cm in the serial dilation group, which was greater than the 1.11 ± 0.10 cm in the intermittent dilation group (p = 0.018). We also found that the Simple Endoscopic Score for Crohn's Disease was associated with an increased risk of surgical intervention (HR 2.377, 95% CI 1.125-5.020; p = 0.023) and recurrence at 6 months after the last EBD (HR 0.698, 95% CI 0.511-0.953; p = 0.024), as assessed by univariate analysis., Conclusions: Compared to the intermittent EBDs, serial EBDs for duodenal CD-associated strictures exhibit greater clinical efficacy within two years and could delay stricture recurrence. We suggest that serial EBDs can be a novel option for endoscopic treatment of duodenal CD-associated strictures., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Most duodenal diverticula (DD) are asymptomatic and rarely develop perforations. Perforation is the most serious complication of DD and often requires emergency surgery. A 97-year-old woman who had undergone total gastrectomy and Roux-en-Y reconstruction 30 years ago was referred to our department with chief complaints of abdominal pain and fever during her hospitalization after femoral neck fracture surgery in the orthopedic department. Contrast-enhanced computed tomography showed free air and residue in the abdominal cavity and right retroperitoneum, and an emergency laparotomy was performed. The abdominal cavity was mildly contaminated, and a 6-cm DD with a 1-cm perforation in the wall of the diverticulum on the contralateral side of the mesentery of the duodenum was found. Diverticulectomy and duodenal closure were performed and a drainage tube was placed. The patient experienced no complications and was transferred to the orthopedic department on postoperative day 10. Reports of perforation of DD after gastrectomy are very rare. Particular attention should be paid to perforation of DD after Billroth-II and Roux-en-Y reconstructions as they involve the formation of a duodenal stump that differs from the normal anatomy and may be highly invasive surgical procedures, depending on the degree of inflammation and fistula formation., (© 2024. The Author(s).)

Transduodenal Ampullectomy (TA) is a procedure for resecting low-malignancy ampullary tumors, with postoperative fistula as a notable complication. This study aims to clarify the indications for TA, outline the surgical robotic technique, and emphasize the importance of comprehensive complication management alongside the surgical approach. This multimedia article provides a detailed exposition of the robotic TA surgical technique, including the most important steps involved in exposing and reimplanting biliary and pancreatic ducts. The procedure encompasses the mobilization of the hepatic flexure of the colon, an extensive Kocher maneuver for duodenal mobilization, and ampulla exposure through a duodenal incision. Employing retraction loop sutures enhances surgical field visibility. Reconstruction involves securing pancreatic and biliary ducts to the duodenal mucosa, each tutored with a silicon catheter, and suturing for ampullectomy completion. The total operative time was 380 min. Final histopathology disclosed high-grade dysplasia with an isolated focus of adenocarcinoma (pT1), accompanied by clear resection margins. A postoperative duodenal fistula occurred, managed successfully through conservative treatment, utilizing subcutaneous drainage. Despite accurate robotic TA execution, complications may arise. This study underscores the importance of a comprehensive approach, incorporating meticulous surgical technique and effective complication management, to optimize patient outcomes., (© 2024. Italian Society of Surgery (SIC).)

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).)

Hayashi and colleagues developed a novel salvage technique using a cap-fitted ultrathin endoscope to cannulate the bile duct when a papilla concealed within a duodenal diverticulum is inaccessible with conventional methods. It can be a useful and safe option for endoscopic retrograde cholangiopancreatography in patients with papillae hidden in duodenal diverticula., (© 2024 Japanese Society of Hepato‐Biliary‐Pancreatic Surgery.)

Background/aims: There is limited knowledge regarding the management of duodenal subepithelial lesions (SELs) owing to a lack of understanding of their natural course. This study aimed to assess the natural course of asymptomatic duodenal SELs and provide management recommendations., Methods: Patients diagnosed with duodenal SELs and followed up for a minimum of 6 months were retrospectively investigated., Results: Among the 443,533 patients who underwent esophagogastroduodenoscopy between 2008 and 2020, duodenal SELs were identified in 0.39% (1,713 patients). Among them, 396 duodenal SELs were monitored for a median period of 72.5 months (interquartile range, 37.7-111.3 mo). Of them, 16 SELs (4.0%) showed substantial changes in size or morphology at a median follow-up of 35.1 months (interquartile range, 21.7-51.4 mo). Of these SELs with substantial changes, tissues of two SELs were acquired using endoscopic ultrasound-guided fine needle aspiration biopsy: one was a lipoma and the other was non-diagnostic. Three SELs were surgically or endoscopically removed; two were diagnosed as gastrointestinal stromal tumors, and one was a lipoma. An initial size of 20 mm or larger was associated with substantial changes during follow-up (p = 0.016)., Conclusion: While the majority of duodenal SELs may not exhibit substantial interval changes, regular follow-up with endoscopy may be necessary for cases with an initial size of 20 mm or larger, considering a possibility of malignancy.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: Hirofumi Kogure received the honoraria from Gedelius Medical. All remaining authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interest.

Background: Paraduodenal hernias (PDHs) are the most common congenital internal hernias. Herein, we present a successful laparoscopic repair of a left PDH and we review the minimally invasive techniques that have been used to treat PDHs., Materials and Methods: An 18-year-old female patient with multiple visits to the emergency department for abdominal pain was ultimately diagnosed with a left PDH. She underwent a four-port laparoscopic repair. In order to review the minimally invasive PDH repair techniques used, we searched the PubMed® database and found 53 original studies with a total of 66 minimally invasive PDH repairs (51 left PDH repairs, 15 right PDH repairs) over a period of 24 years (1998-2022)., Results: The patient's postoperative course was uneventful and she was discharged on the 7th postoperative day. The literature review showed that closure of the hernia orifice was performed in 88% of left PDH repairs, whereas wide opening of the hernia orifice with or without mobilization of the right colon was performed in 81% of right PDH repairs. Of the patients with available postoperative data, none experienced complications other than grade Ι according to the Clavien-Dindo classification in the early postoperative period, and only one patient presented symptomatic hernia recurrence at a median follow-up of 1 year., Conclusions: Based on limited publications and our own experience, minimally invasive repair of PDHs has so far been shown to be feasible and safe in the great majority of cases without irreversible small intestine ischemia/peritonitis.

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).)

Introduction: Paraduodenal hernias (PDH) are rare congenital internal hernias with non- specific symptoms. Left-sided paraduodenal hernia is three times more common than right-sided paraduodenal hernia with similar clinical presentation but different embryological origins., Materials and Methods: We report a series of eight cases of paraduodenal hernia who presented with varied clinical presentation ranging from vague abdominal pain to complete intestinal obstruction. Six cases had left-sided paraduodenal hernia, while two cases had right-sided paraduodenal hernia., Results: Seven cases based on their presentation underwent surgery either electively or on emergent basis. Three cases underwent laparoscopic repair. One case had a recurrence and was re-operated four months later. There was no mortality among any of the cases., Conclusion: A pre-operative diagnosis of paraduodenal hernia is essential. Laparoscopic surgery is safe in select cases and is found to be beneficial., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

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 most common site of the congenital duodenal web is the second part. Web distal to the second part of the duodenum is rare. It mimics the windsock deformity. Diagnosis may be missed if accompanying malrotation is present. We hereby report two cases of distal duodenal webs associated with malrotation and challenges in their diagnosis and management., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Considering that right paraduodenal hernia is a rare internal hernia with abnormal anatomy and is often encountered during an emergency, surgeons may lack knowledge about it and choose incorrect treatment. Thus, this case report is a helpful complement to the few previously reported cases of right paraduodenal hernia. Additionally, we reviewed all the reported right paraduodenal hernia cases and proposed appropriate surgical strategies according to different anatomical features., Case Presentation: The case involved a 33-year-old Chinese male patient who was admitted to the hospital due to abdominal pain. The patient was initially diagnosed with small bowel obstruction, and conservative treatment failed. An emergency operation was arranged, during which a diagnosis of right paraduodenal hernia was made instead. After surgery, the patient recovered well without abdominal pain for 2 years., Conclusion: Although right paraduodenal hernia accounts only for a small proportion of paraduodenal hernia, its anatomical characteristics can vary considerably. We divided right paraduodenal hernia into three types, with each type requiring a different surgical strategy., (© 2023. The Author(s).)

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Brunner's gland hyperplasia constitutes 10.6% of benign tumors of the duodenum, with an incidence of 0.008%. It is usually an incidental finding during endoscopy or imaging tests as they are small and asymptomatic. In the case of symptomatic tumors, resection of the lesion is indicated. In lesions ≤2 cm, endoscopic resection can be chosen, reserving surgery for larger lesions or endoscopically inaccessible ones. We present the case of a patient with a history of vomiting and hyporexia of months of evolution who presented peptic ulcer perforation and underwent surgery. During follow-up, she presented intestinal obstruction due to pyloric stenosis. Given the impossibility of ruling out a neoplastic process with certainty in diagnostic tests, surgical resection (antrectomy) was decided with an anatomopathological finding of Brunner's gland hyperplasia.

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.)

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).)

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.)

Paraduodenal hernias (PDHs) are rare types of internal hernias that pose a significant diagnostic and therapeutic challenge because they can present with non-specific symptoms ranging from digestive disorders and chronic abdominal pain to symptoms of intestinal obstruction which may be life-threatening. We describe here a woman in her early 30's who presented to the emergency department with a three-hour history of generalized intermittent crampy abdominal pain. She had experienced multiple similar episodes of this pain over the past 20 years. Totally laparoscopic technique was used to complete the diagnosis and treatment of a large left PHD with accompanying acute intestinal obstruction. The operation was successful and the patient was discharged from hospital 10 days later. PDH should be considered if a patient complains of recurrent abdominal pain without any other obvious explanation; a laparoscopic approach can be used to identify and repair the hernia.

Cystic dystrophy in heterotopic pancreas, or paraduodenal pancreatitis, is a rare and complicated presentation involving heterotopic pancreatic tissue in the duodenal wall. This condition is present in 5% of the general population but disease mainly affects middle-aged alcoholic-smoking men with chronic pancreatitis (CP). It may be purely duodenal or segmental (pancreatico-duodenopathy). Its pathophysiology arises from alcohol toxicity with obstruction of small ducts of heterotopic pancreatic tissue present in the duodenal wall and the pancreatic-duodenal sulcus, leading to repeated episodes of pancreatitis. The symptomatology includes episodes of acute pancreatitis, weight loss, and vomiting due to duodenal obstruction. Imaging shows thickening of the wall of the second portion of the duodenum with multiple small cysts. A stepwise therapeutic approach is preferred. Conservative medical treatment is favored in first intention (analgesics, continuous enteral feeding, somatostatin analogues), which allows complete symptomatic regression in 57% of cases associated with a 5% rate of complications (arterial thrombosis and diabetes). Endoscopic treatment may also be associated with conservative measures. Surgery achieves a complete regression of symptoms in 79% of cases but with a 20% rate of complications. Surgery is indicated in case of therapeutic failure or in case of doubt about a malignant tumor. Pancreaticoduodenectomy and duodenal resection with pancreatic preservation (PPDR) seem to be the most effective treatments. PPDR has also been proposed as a first-line treatment for purely duodenal location of paraduodenal pancreatitis, thereby preventing progression to an extended segmental form., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

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.)

Competing Interests: Competing interests: None declared.