Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Desk Q3, Cleveland, OH 44195. USA,
Surg Endosc. 2013 Apr;27(4):1406. doi: 10.1007/s00464-012-2573-0. Epub 2012 Oct 18.
A 49-year-old woman presented with a 3-month history of nausea, vomiting, and weight loss. Her symptoms were severe, and she required total parenteral nutrition for nutrition support. Both CT and barium upper GI series demonstrated a large "windsock" diverticulum that obstructed the duodenal lumen. The patient was referred to undergo a surgical diverticulectomy. After a multidisciplinary discussion, a less invasive endoscopic diverticulotomy was recommended, and the patient agreed. The linked video demonstrates the endoscopic findings and therapeutic technique. Upper endoscopy showed the diverticulum arising from the proximal duodenum. The scope could not traverse the true lumen due to compression by the diverticulum. A guidewire was passed to delineate the true lumen. At that point, the diverticulum spontaneously inverted into a proximal position. The tip of the diverticulum was then clipped to the duodenal wall to increase exposure and to allow a more controlled incision. Clips were placed on the vascular pedicle of the diverticulum to prevent bleeding. An incremental incision was performed using a needle-knife to divide the diverticulum completely. Mild bleeding occurred twice and was managed with clips. A complete diverticulotomy was accomplished, allowing easy passage of the endoscope. The patient had an uneventful postprocedural recovery and was discharged the same day with instructions for dietary advancement. After 2 months, the patient reported complete symptom resolution. She was eating well, had gained weight, and had discontinued total parenteral nutrition. A repeat endoscopy confirmed a patent lumen and no recurrence of the diverticulum. This case demonstrates the feasibility and effectiveness of endoscopic diverticulotomy performed from a proximally inverted position. This "top-down" approach provided very good exposure for the incision and easy treatment of bleeding complications.
一位 49 岁女性因恶心、呕吐和体重减轻就诊，病史 3 个月。她的症状严重，需要全胃肠外营养支持。CT 和上消化道钡剂造影均显示一个大的“风箱”样憩室，导致十二指肠腔完全梗阻。患者被转至外科行憩室切除术。经过多学科讨论，建议采用创伤较小的内镜下憩室切开术，患者也表示同意。该链接视频展示了内镜下所见和治疗技术。上消化道内镜检查显示憩室起自近端十二指肠。由于憩室的压迫，内镜无法通过真正的腔道。通过导丝来描绘真正的腔道。此时，憩室自动翻转为近端位置。然后用夹子夹住憩室尖端以增加显露并允许更可控的切开。用夹子夹住憩室的血管蒂以防止出血。使用针刀进行逐渐切开以完全分隔憩室。有 2 次发生轻微出血，用夹子处理。完成完全憩室切开术，内镜可轻松通过。患者术后恢复顺利，当天出院并指导逐渐恢复饮食。2 个月后，患者报告完全缓解症状。她饮食良好，体重增加，已停止全胃肠外营养。重复内镜检查显示腔道通畅，无憩室复发。该病例证明了从近端反转位置进行内镜下憩室切开术的可行性和有效性。这种“自上而下”的方法为切口提供了很好的显露，并且便于处理出血并发症。
