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Invited Critique
Jan 2012

Experience Be a JewelComment on “The Perforated Duodenal Diverticulum”

Author Affiliations

Author Affiliation: Department of Surgery, Veterans Affairs Sierra Nevada Health Care System, Reno.

Arch Surg. 2012;147(1):88. doi:10.1001/archsurg.2011.1012

Experience be a jewel. —William Shakespeare, The Merry Wives of Windsor1

Thorson et al2 describe 4 cases of perforated duodenal diverticula that they successfully managed nonoperatively and also present an update of the world literature on the subject. Their report is quite helpful as an encouragement to surgeons who encounter this uncommon entity to try the nonoperative approach. Although the authors were wise not to extrapolate too much from the series of case reports, one wonders what factors contribute to successful nonoperative management. Their review found no significant difference in clinical presentations of the operative compared with the nonoperative groups. This finding is not surprising because duodenal diverticular perforations are difficult to distinguish from other more common upper abdominal conditions. Once again, the multisection helical computed tomography scan makes the diagnosis. Perhaps the finding of peritonitis on examination should prompt operative intervention; however, the authors also found that the observed rate of peritonitis was not statistically different between the operative and nonoperative groups. Can we really believe statistics performed on case reports? I don't think the authors believe it either because they still advise that patients with peritoneal signs and sepsis should be taken “promptly for operative intervention.” That is good surgical common sense speaking. With their track record of successful nonoperative experience, I’m listening.

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