The perforated duodenal diverticulum

Objective: To perform a literature review of perforated duodenal diverticulum with attention to changes in management. Data Sources: We searched PubMed for relevant studies published from January 1, 1989, through August 1, 2011. In addition, we identified and reviewed 4 cases at our institution. Study Selection: Search phrases were perforated duodenal diverticulum and duodenal diverticulitis. Data Extraction: Patient demographics, clinical characteristics, radiologic findings, treatment, and outcomes were obtained. Results: We reviewed 39 studies producing 57 cases, which were combined with the 4 at our institution for a total of 61 patients. The addition of 2 previous series revealed a total of 162 patients in the world literature. Perforations were most commonly located in the second or third portion of the duodenum (60 of 61 cases [98%]), and the most frequent cause was diverticulitis (42 of 61 [69%]). There has been a dramatic improvement in the preoperative diagnosis of perforated diverticula. Only 13 of 101 reported cases (13%) were correctly diagnosed before 1989, and 29 of 61 (48%) in the present series were identified with radiologic examinations. Most patients in the current series (47 of 61) underwent operative treatment for their perforation, although 14 underwent successful nonoperative management. Complications were reported in 17 of 47 patients in the surgical group (36%), whereas only 1 complication was seen in patients undergoing nonoperative management. Mortality in the surgical group was 6% (3 of 47), and no deaths were reported in the nonoperative group. Conclusions: Perforation of a duodenal diverticulum is rare, with only 162 cases reported in the world literature. Nonoperative management has emerged as a safe, practical alternative to surgery in selected patents.