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Latest Research on Diverticulitis
     
World J Emerg Surg. 2008 Jan 24;3(1):5 [Epub ahead of print]
Complicated diverticular disease of the colon, do we need to change the classical approach, a retrospective study of 110 patients in southeast England.
Hussain A, Mahmood H, Subhas G, El-Hasani S.

ABSTRACT: BACKGROUND: Complicated diverticular disease of the colon imposes a serious risk to patient's life, challenge to surgeons and has cost implications for health authority. The aim of this study is to evaluate the management outcome of complicated colonic diverticular disease in a district hospital and to explore the current strategies of treatment. METHODS: This is a retrospective study of all patients who were admitted to the surgical ward between May 2002 and November 2006 with a diagnosis of complicated diverticular disease .A proforma of patientsa details, admission date, ITU admission ,management outcomes and the follow up were recorded from the patients case notes and analyzed. The mean follow-up was 34 months (range 6-60 months). RESULTS: The mean age of patients was 72.7 years (range 39-87 years).Thirty-one men (28.18 %) and Seventy-nine women (71.81%) were included in this study. Male: female ratio was 1:2.5. Sixty-eight percent of patients had one or more co-
morbidities. Forty-one patients (37.27%) had two or more episodes of diverticulitis while 41.8% of them had no history of diverticular disease. Eighty-six percent of patients presented with acute abdominal pain while bleeding per rectum was the main presentation in 14%.Constipation and erratic bowel habit were the commonest chronic symptoms in patients with history of diverticular disease. Generalized tenderness was reported in 64.28% while 35.71% have left iliac fossa tenderness. Leukocytosis was reported in 58 patients (52.72%). The mean time from the admission until the start of operative intervention was 20.57 hours (range 4-96 hours). Perforation was confirmed in 59.52% .Mortality was 10.90%. Another 4 (3.63%) died during follow up for other reasons. CONCLUSIONS: Complicated diverticular disease carries significant morbidity and mortality. These influenced by patient-related factors. Because of high mortality and morbidities, we suggest the need to target a specific group of patients for prophylactic resection.

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ANZ J Surg. 2008 Jan;78(1-2):96-8; discussion 98.
Critical evaluation: surgery for uncomplicated diverticulitis.
Platell C.
School of Surgery and Pathology, St John of God Hospital, Subiaco, University of Western Australia, Subiaco, Western Australia, Australia.

AIM: To examine the influence of previous episodes of uncomplicated diverticulitis on the prognosis of patients who subsequently develop complicated diverticulitis. PATIENTS: One hundred and fifty patients with previous episodes of diverticulitis who were admitted to the Mayo Clinic (Rochester, MN, USA) with complicated diverticulitis (perforation, abscess, obstruction, phlegmon, fistula, or bleeding). DESIGN: The retrospective analysis was based on two groups of patients: group A had one or two prior episodes of diverticulitis (n = 118) and group B had more than two prior episodes of diverticulitis (n = 32). MEASUREMENT OF OUTCOME: The following criteria were used: phlegmon was a symptomatic inflammatory mass separate from and not associated with a purulent fluid collection; pericolic abscess was a collection of purulent material localized near the colon or in the pelvis; obstruction was characterized by obstructive symptoms and a stricture or stenosis diagnosed by radiographic studies or pathological evaluation; fistulas included colovaginal and colovesicular connections; perforation was either a collection of contained air outside the bowel wall or a large amount of free intra-abdominal air; and patients who required a transfusion for a lower gastrointestinal haemorrhage associated with symptoms and signs of diverticulitis were placed in the bleeding category. RESULTS: Perforated diverticulitis occurred more often in patients from group A; because of this, patients in group A underwent more surgical diversions. There were no appreciable differences in operative complications, morbidity or mortality rates. CONCLUSION: Patients with more than two episodes of uncomplicated diverticulitis are not at increased risk for poor outcomes if they develop complicated diverticulitis.

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J Gastrointest Surg. 2008 Jan 3 [Epub ahead of print]
Does a 48-Hour Rule Predict Outcomes in Patients with Acute Sigmoid Diverticulitis?
Evans J.
Surgery University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, 06030, USA, jessicahartford2003@yahoo.com.

INTRODUCTION: Sigmoid diverticulitis is an infection that resolves with conservative management in 70-85% of patients. Some patients require prolonged hospitalization or surgery during their admission. It has been taught that one should expect clinical improvement within 48 h. In this study, we examined whether basic clinical parameters (the maximum temperature and leukocyte count) of patients would predict improvement and discharge as expected, or prolonged hospitalization. MATERIALS AND METHODS: Data was acquired from 198 patients admitted with acute sigmoid diverticulitis as confirmed by computed tomography (CT) scanning and physical exam. One hundred sixty-five patients recovered without surgery with an average hospital stay of 4 days: 120 were discharged within 4 days, whereas 45 patients required longer stays. Nineteen patients underwent surgery early during their admission (within 48 h). Fourteen patients did not improve over time and required surgery later during their hospital stay. The daily maximum temperature and leukocyte count of patients with prolonged stays was compared to the patients who were discharged within 4 days using analysis of variance analysis. RESULTS: The average maximum temperature and leukocyte count on admission were not statistically different between the groups; therefore, maximum temperature and leukocyte count on admission alone are not predictive. After the first 24 h, however, one could see a statistically significant difference in maximum temperature (p = 0.004). The leukocyte count responded significantly by hospital day 2 (p = 0.003). Both trends were significant through hospital day 4. DISCUSSION: Patients with a noticeable drop in leukocyte count and maximum temperature over the first 48 h of medical management were predictably discharged early on oral antibiotics. Patients failing to improve at 48 h required prolonged stays or surgery. CONCLUSION: By observing early trends in leukocyte count and maximum temperature of patients with diverticulitis, one can predict whether they will recover quickly as expected or if they will likely require prolonged IV antibiotics and/or surgery.

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Aliment Pharmacol Ther. 2007 Dec;26 Suppl 2:67-76.
Review article: Management of diverticulitis.
Szojda MM, Cuesta MA, Mulder CM, Felt-Bersma RJ.
Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, The Netherlands.

BACKGROUND AND AIM: The incidence and therefore complications of (sigmoid) diverticular disease are increasing. METHODS: Review of current literature. RESULTS: From all patients, 15% will develop diverticulitis, 5% complications and 5% diverticular bleeding. Diagnosis is established with computerised tomography. Colonoscopy is needed to rule out malignancy. NSAIDs increase the risk of perforation; steroids, diabetes, collagen vascular disease and immune compromised are associated with complicated disease and death. In mild diverticulitis, antibiotics are recommended. In complicated disease with abscesses, <5 cm antibiotics are sufficient. Larger abscesses are drained under computerised tomography-guidance. Peritonitis forms an indication for surgery. Diverticulitis recurrence rate is around 30%, most are uncomplicated. Recurrence after surgery is around 10%. Elective surgery is reserved for fistula closure and obstruction. The need for elective surgery to prevent recurrence has diminished because of new insights. Important is to identify risk groups. New issues are the possible relationship between diverticulitis and cancer, segmental colitis associated with diverticulitis, and treatment of diverticulitis with mesalazine and probiotics. CONCLUSIONS: Uncomplicated diverticulitis is treated medically. Complicated diverticulitis with small abscesses is treated with antibiotics while larger abscesses are drained with computerised tomography-guided puncture. Emergency surgery is reserved for peritonitis, elective surgery for fistula/stenosis. Surgery to prevent recurrence is indicated only in selected cases (e.g. immune compromised).

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Dig Surg. 2007;24(6):471-6. Epub 2007 Nov 29.
Presentation, management and outcome of acute sigmoid diverticulitis requiring hospitalization.
Alvarez JA, Baldonedo RF, Bear IG, Otero J, Pire G, Alvarez P, Jorge JI.
Service of General Surgery, Hospital San Agustín, Avilés, Spain.

AIM: This study was conducted to assess the presentation, management, and outcomes of patients with acute sigmoid diverticulitis requiring hospitalization. METHODS: From 1986 to 2005, the medical records of 265 patients treated for acute sigmoid diverticulitis requiring hospitalization were retrospectively analyzed. Data were collected with regard to patient's demographics, clinical characteristics, presentations of acute diverticulitis, treatment, morbidity, and mortality. RESULTS: Only 47 patients (17.7%) had a previous diverticulitis episode. Of the 265 patients, 166 (62.6%) were managed without operation, and 99 (37.4%) underwent surgery. Overall and major morbidity in the whole series were 30.2 (80/265) and 15.5% (40/265), respectively; whereas among the patients with surgical management, were 72.7 (72/99), and 35.3% (35/99), respectively. Overall and postoperative mortality rates were 2.6 (7/265) and 6.1% (6/99), respectively. Older age, steroid use, perforation, and co-morbidities were significantly associated with unfavorable outcomes. CONCLUSIONS: It was concluded that surgery for acute sigmoid diverticulitis requiring hospitalization carries important morbidity and mortality. To achieve improvements in outcome, a selective therapeutic approach should be considered, choosing the best surgical procedure for each complication of diverticular disease. Copyright (c) 2007 S. Karger AG, Basel

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J Emerg Med. 2007 Nov;33(4):363-6. Epub 2007 May 30.
Case series: diverticulitis in the young.
Cole CD, Wolfson AB.
University of Pittsburgh Affiliated Residency in Emergency Medicine, Pittsburgh, Pennsylvania 15213, USA.

Diverticulitis has long been regarded as a disease of the elderly, but its incidence has been increasing in those under age 40. Younger patients with diverticulitis are more likely to be male and obese. They often have atypical presentations, and 25% may have right lower quadrant pain. Not surprisingly, the condition is often misdiagnosed, resulting in unnecessary surgery. An abdominal CT scan is the modality of choice for diagnosis, but the most important diagnostic step is simply to include diverticulitis on the differential diagnosis of a young person with lower abdominal pain.

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Dis Colon Rectum. 2007 Nov;50(11):1911-7.
Early vs. Delayed Elective Laparoscopic-Assisted Colectomy in Sigmoid Diverticulitis: Timing of Surgery in Relation to the Acute Attack.
Zingg U, Pasternak I, Guertler L, Dietrich M, Wohlwend KA, Metzger U.
Department of Surgery, Triemli Hospital, Zurich, Switzerland, uzingg@uhbs.ch.

PURPOSE: The timing of elective surgery in acute sigmoid diverticulitis in relation to the acute attack is not clear. Early elective surgery during the same hospitalization as the acute attack or delayed surgery after an interval of several weeks are the options. This study was designed to evaluate the influence of timing on morbidity, conversion rate, histologic findings, and costs. METHODS: A total of 178 patients with elective laparoscopic-assisted sigmoid resections for diverticulitis between 1997 and 2005 were retrospectively assessed; 77 patients underwent early and 101 delayed surgery. Outcomes were surgical morbidity, conversion rate, histologic findings, and financial impact of timing. RESULTS: The two groups showed no significant difference apart from a higher body mass index in the delayed group (25.5 vs. 26.6 kg/m(2), P = 0.035). Surgical morbidity was not significantly different. Conversion rate was significantly higher in the early group (P < 0.001). Converted patients had an increased surgical morbidity of 23.8 vs. 19.1 percent (P = 0.323) and hospitalization was significantly longer (13.5 vs. 10.5 days; P < 0.001). Histology revealed inflammation in 75.3 percent in the early group compared with 23.8 percent in the delayed group. Total treatment costs were not different between groups, whereas total earnings were higher in the delayed group resulting in a lower hospital deficit. CONCLUSIONS: Early elective surgery in patients with acute sigmoid diverticulitis results in a higher conversion rate. If patients respond to initial antibiotic therapy, delayed colectomy after an interval of six weeks or more is recommended.

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J Gastroenterol Hepatol. 2007 Sep;22(9):1360-8.
Outcomes after medical and surgical treatment of diverticulitis: a systematic review of the available evidence.
Peppas G, Bliziotis IA, Oikonomaki D, Falagas ME.
Alfa Institute of Biomedical Sciences (AIBS), and Department of Surgery, Henry Dunant Hospital, Athens, Greece.

There is still controversy regarding the appropriate management of diverticulitis of the colon in cases when both surgical and conservative treatment may be an option. We performed a systematic review of the available evidence regarding the outcomes after medical and surgical treatment of diverticulitis from studies published after 1980 and indexed in the PubMed database. We included original studies that reported comparative data for at least one outcome in medically- and surgically-treated patients with transverse or left colon diverticulitis. The main outcomes of interest were mortality, morbidity, and recurrence of diverticulitis after medical or surgical treatment. There were 21 studies fulfilling our inclusion criteria out of 1360 initially identified as possibly relevant. More patients were treated conservatively in the included studies compared to emergency surgery (24 862 vs 6504). Emergency surgery was the main option for patients with severe complications of diverticular disease, including peritonitis. In most studies, in-hospital mortality for patients treated surgically was generally higher than that of patients treated medically, whereas there were insufficient comparative data regarding mortality during follow up. However, readmission to the hospital due to diverticular disease during follow up was more common in the group of patients treated conservatively compared to those treated surgically (4358/23 446 [18.6%]vs 22/359 [6.1%]). Conservatively-treated patients, with a first or second episode of diverticulitis, required surgery for recurrent disease during follow up in a maximum of 45% of cases, with larger studies reporting percentages lower than 11%. It should be emphasized that medical and surgical treatments have not ever been compared in a randomized controlled trial in patients with diverticulitis (without generalized peritonitis that is a surgical emergency). Although medical treatment results in more readmissions due to recurrence, it may be reasonable to avoid surgical therapy in the vast majority of patients with acute diverticulitis. It is unclear what the best treatment option is for younger patients (<50 years), namely whether elective surgery should be considered with the first episode of diverticulitis.

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Dig Surg. 2007;24(5):361-6. Epub 2007 Aug 30.
Outcome after emergency surgery for acute perforated diverticulitis in 200 cases.
Vermeulen J, Akkersdijk GP, Gosselink MP, Hop WC, Mannaerts GH, van der Harst E, Coene PP, Weidema WF, Lange JF.
Department of Surgery, MCRZ St. Clara Hospital and Zuider Hospital, Rotterdam, The Netherlands. VermeulenJ@MCRZ.nl

BACKGROUND: Mortality and morbidity rates of acute perforated diverticulitis remain high. The ideal treatment is still controversial. The object of this study was to compare patients with perforated diverticulitis treated either by resection with primary anastomosis (PA) or Hartmann's procedure (HP). METHODS: A multicenter study was carried out on 200 consecutive patients with acute perforated diverticulitis who were presented in the surgical units of four affiliated teaching hospitals in Rotterdam, The Netherlands, between 1995 and 2005. Mortality and morbidity were compared in relation to type of surgery, ASA classification, age, gender, Mannheim Peritonitis Index (MPI), Hinchey score, surgeon's experience, and the time of operation. RESULTS: There was a tendency for more severely affected patients (Hinchey, MPI, ASA and age) to undergo HP. Multivariate logistic regression analysis showed no significant difference in mortality between HP and PA. After HP, more patients needed one or more reinterventions to treat postoperative complications compared to PA. Besides, HP resulted in a longer total hospital and intensive care unit stay. Specialist colorectal surgeons performed significantly more frequently a PA instead of a HP and had fewer postoperative complications than general surgeons. The time of operation did not influence the choice of surgical procedure. CONCLUSION: Selected patients with perforated diverticulitis can be managed well by PA, as it does not seem to be inferior to HP in terms of severe postoperative complications that need surgical or radiological reintervention and mortality. This decision should be made while taking into account the patient's concomitant diseases, response on preoperative resuscitation and the availability of a surgeon experienced in colorectal surgery.

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BMC Surg. 2007 Aug 3;7:16.
The Sigma-trial protocol: a prospective double-blind multi-centre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis.
Klarenbeek BR, Veenhof AA, de Lange ES, Bemelman WA, Bergamaschi R, Heres P, Lacy AM, van den Broek WT, van der Peet DL, Cuesta MA.
Department of Surgery, VU medical centre, Amsterdam, The Netherlands. br.klarenbeek@vumc.nl

BACKGROUND: Diverticulosis is a common disease in the western society with an incidence of 33-66%. 10-25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis. METHOD: Indication for elective resection is one episode of diverticulitis in patients < 50 years and two episodes in patient > 50 years or in case of progressive abdominal complaints due to strictures caused by a previous episode of diverticulits. The diagnosis is confirmed by CT-scan, barium enema and/or coloscopy.It is required that the participating surgeons have performed at least 15 laparoscopic and open sigmoid resections. Open resection is performed by median laparotomy, laparoscopic resection is approached by 4 or 5 cannula. Sigmoid and colon which contain serosal changes or induration are removed and a tension free anastomosis is created. After completion of either surgical procedure an opaque dressing will be used, covering from 10 cm above the umbilicus to the pubic bone. Surgery details will be kept separate from the patient's notes.Primary endpoints are the postoperative morbidity and mortality. We divided morbidity in minor (e.g. wound infection), major (e.g. anastomotic leakage) and late (e.g. incisional hernias) complications, data will be collected during hospital stay and after six weeks and six months postoperative. Secondary endpoints are the operative and the postoperative recovery data. Operative data include duration of the operation, blood loss and conversion to laparotomy. Post operative recovery consists of return to normal diet, pain, analgesics, general health (SF-36 questionnaire) and duration of hospital stay. DISCUSSION: The Sigma-trial is a prospective, multi-center, double-blind, randomized study to define the role of laparoscopic sigmoid resection in patients with symptomatic diverticulitis.

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Hepatogastroenterology. 2007 Jul-Aug;54(77):1412-6.
Elective surgery for recurrent diverticulitis.
Mäkelä JT, Kiviniemi HO, Laitinen ST.
Department of Surgery, Division of Gastroenterology, Oulu University Hospital, Finland. jyrki.makela@oulu.fi

BACKGROUND/AIMS: After two documented episodes of uncomplicated diverticulitis, elective colon resection is recommended to prevent complications of the disease but the nature of symptoms in non-operated patients requires specification. METHODOLOGY: A detailed questionnaire concerning clinical variables was mailed to two hundred and sixty patients admitted into our hospital for symptoms of acute sigmoid diverticulitis between 1981 and 2002. One hundred and seventy-one patients (70 percent) answered the questions adequately. Based on the clinical symptoms reported by the patients on the questionnaires, three patient groups set up, i.e. patients treated non-operatively or operatively for recurrent diverticulitis and patients operated on for diverticular perforation. The results of the patients treated non-operatively were analyzed with special reference to readmissions and age. RESULTS: The need for treatment by a physician, the need for hospital treatment, the presence of abdominal cramps, the presence of febrile left lower abdominal pain, the need for antibiotics and the need for NSAIDs were more common in the patients treated non-operatively for recurrent diverticulitis. When the patients treated non-operatively for recurrent diverticulitis were compared in a logistic regression model in relation to the number of admissions, the need for treatment by a physician and the presence of left lower abdominal pain were significantly more common in the patients admitted twice or more often. The same variables remained significantly different when the patients admitted once or twice were compared. Age did not correlate with any of the variables tested. CONCLUSIONS: On the basis of our results, we recommend that patients with recurrent uncomplicated diverticulitis should be operated on after two documented episodes to reduce the symptoms of the patients.

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Colorectal Dis. 2007 Jul;9(6):496-501; discussion 501-2.
Acute diverticulitis—clinical presentation and differential diagnostics.
Laurell H, Hansson LE, Gunnarsson U.
Department of Surgery at Mora Hospital, Mora, Sweden. helena.laurell@kirurgi.uu.se

OBJECTIVE: To describe the clinical presentation of acute diverticulitis in an emergency department and to characterize the natural history of diverticulitis in the short perspective. Comparisons are made with an important differential diagnosis, nonspecific abdominal pain (NSAP). METHOD: Patients admitted to our hospital with abdominal pain of up to 7 days' duration were registered prospectively using a detailed schedule for history, symptoms and signs, from 1 February 1997 to 1 June 2000. Of 3349 patients initially included, 3073 (92%) were eligible for follow up after 1-3 years. RESULTS: Acute diverticulitis was the final diagnosis in 145 patients and NSAP in 1142 patients. The incidence of hospitalized patients with diverticulitis was 47 per year and 100 000 population, with a mean hospital stay of 3.3 days. Patients with diverticulitis, more frequently than NSAP, had a longer history and laboratory signs of inflammatory activity. Isolated left abdominal tenderness was more common in diverticulitis, whereas isolated right abdominal tenderness was more common in NSAP. Duration of symptoms on arrival was independent of age and was not correlated to C-reactive protein, leucocytes or body temperature. Sensitivity of diverticulitis as primary diagnosis was 64% and specificity 97%. Corresponding figures for NSAP were 43% and 90% respectively. Age and gender did not influence diagnostic accuracy or risk of surgery. CONCLUSION: Diverticulitis differs significantly from NSAP in clinical presentation and laboratory parameters. Sensitivity of primary diagnosis for diverticulitis and NSAP was low.

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Curr Treat Options Gastroenterol. 2007 Jun;10(3):248-56.
Diverticular disease: update.
Ibele A, Heise CP.
Charles P. Heise, MD G4/701A Clinical Sciences Center, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792-7375, USA. heise@surgery.wisc.edu.

Diverticular disease is an extremely common disease entity in our society. The major complication of diverticular disease, diverticulitis, can have quite variable presentations. In the acute setting, treatment is divided into nonsurgical (conservative) or surgical therapy. Cases of mild or "uncomplicated" disease benefit from a conservative approach involving antibiotic therapy. With more severe or "complicated" presentations (abscess, phlegmon, obstruction, fistula, or peritonitis), a more aggressive approach may involve percutaneous abscess drainage or urgent surgical therapy. This also may be required after a failed initial attempt at medical management. The decision regarding elective surgery after successful medical management of diverticulitis is more complicated. The primary goal is to minimize disease recurrence with as little morbidity as possible while maintaining a high quality of life. Recent evidence challenges indications for elective surgery. However, data on the natural history of recurrent diverticulitis are not clear enough to support altering current surgical guidelines. In addition, the increasing use of minimally invasive techniques with favorable outcomes for sigmoid colectomy must be considered. Prior to offering elective colectomy for diverticulitis, it remains important to individualize each case, giving special consideration to age, symptomatology, and recurrence. Ultimately, the decision for elective surgery is made by both the surgeon and a well-informed patient.

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J Gastrointest Surg. 2007 Jun;11(6):767-72.
Functional Results Following Elective Laparoscopic Sigmoidectomy After CT-Proven Diagnosis of Acute Diverticulitis Evaluation of 43 Patients and Review of the Literature.
Ambrosetti P, Francis K, Weintraub D, Weintraub J.
Clinique Générale Beaulieu, Geneva, Switzerland.

We performed a prospective study to analyze the functional results following elective laparoscopic sigmoidectomy for computed tomography (CT)-proven diagnosis of acute diverticulitis and review the literature. Forty-three of 45 available patients (96%) who had laparoscopic sigmoidectomy for CT-proven acute diverticulitis answered, after a mean time of 40 months, a questionnaire exploring new abdominal symptoms, bowel function, and the patient's own judgement of the surgical outcome. Surgical technique aimed at removing all the sigmoid by taking down the splenic flexure and do a colorectal anastomosis. Four patients (9%) complained of new abdominal pain. Bowel function was reported as better for 24 patients (56%), unchanged for 16 patients (37%), and worse for 3 (7%). Twenty patients (47%) considered their final result as excellent to good, 17 patients (40%) as satisfying, and 6 patients (13%) as mediocre. Male gender, absence of preoperative history compatible with an irritable bowel syndrome, length of resected sigmoid and residual acute inflammation on histology are statistically predictive of a better postoperative degree of satisfaction. After elective laparoscopic sigmoidectomy for CT-proven diverticulitis, a great majority of patients are very satisfied with their postoperative general comfort.

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Dig Dis. 2007;25(2):151-9.
Diverticular disease in the elderly.
Comparato G, Pilotto A, Franzè A, Franceschi M, Di Mario F.
University of Parma, Parma, Italy.

There are few diseases whose incidence varies as greatly worldwide as that of diverticulosis. Its prevalence is largely age-dependent: the disease is uncommon in those under the age of 40, the prevalence of which is estimated at approximately 5%; this increases to 65% in those > or =65 years of age. Of patients with diverticula, 80-85% remain asymptomatic, while, for unknown reasons, only three-fourths of the remaining 15-20% of patients develop symptomatic diverticular disease. Traditional concepts regarding the causes of colonic diverticula include alterations in colonic wall resistance, disordered colonic motility and dietary fiber deficiency. Currently, inflammation has been proposed to play a role in diverticular disease. Goals of therapy in diverticular disease should include improvement of symptoms and prevention of recurrent attacks in symptomatic, uncomplicated diverticular disease, and prevention of the complications of disease such as diverticulitis. Diverticulitis is the most usual clinical complication of diverticular disease, affecting 10-25% of patients with diverticula. Most patients admitted with acute diverticulitis respond to conservative treatment, but 15-30% require surgery. Predictive factors for severe diverticulitis are sex, obesity, immunodeficiency and old age. Surgery for acute complications of diverticular disease of the sigmoid colon carries significant rates of morbidity and mortality, the latter of which occurs predominantly in cases of severe comorbidity. Postoperative mortality and morbidity are to a large extent driven by patient-related factors. Copyright 2007 S. Karger AG, Basel.

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J Gastrointest Surg. 2007 Apr;11(4):542-8.
Controversies in the surgical management of sigmoid diverticulitis.
Bordeianou L, Hodin R.
Department of Surgery, Massachusetts General Hospital, ACC 460, 15 Parkman Street, Boston, MA, 02114, USA, rhodin@partners.org.

Free full text at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17436142.

The timing and appropriateness of surgical treatment of sigmoid diverticular disease remain a topic of controversy. We have reviewed the current literature on this topic, focusing on issues related to the indications and types of surgery. Current evidence would suggest that elective surgery for diverticulitis can be avoided in patients with uncomplicated disease, regardless of the number of recurrent episodes. Furthermore, the need for elective surgey should not be influenced by the age of the patient. Operation should be undertaken in patients with severe attacks, as determined by their clinical and radiological evaluation.

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Dis Colon Rectum. 2007 Apr 9; [Epub ahead of print]
Prospective, Five-Year Follow-up Study of Patients with Symptomatic Uncomplicated Diverticular Disease.
Salem TA, Molloy RG, O'dwyer PJ.
Department of Surgery, Royal Alexandra Hospital, Paisley, United Kingdom.

PURPOSE: The natural history of diverticular disease is largely unknown. Most studies are retrospective and treatment recommendations are derived from outdated literature. This study was a prospective, long-term assessment of the development of complications in patients with symptomatic diverticular disease. METHODS: All patients with a confirmed diagnosis of symptomatic diverticular disease between August 1999 and April 2001 were followed up prospectively for an average of five years. Hospital computerized discharges were assessed for any subsequent elective or emergency admission for diverticular disease-related complications, including surgical intervention. A telephone questionnaire was conducted on all patients and/or their family physician looking specifically for symptoms, complications, and surgical intervention. RESULTS: A total of 163 patients (106 females) were identified (median age, 74 (interquartile range, 64-80) years). The diagnosis was confirmed through colonoscopy (n = 106), flexible sigmoidoscopy (n = 57), and barium enema (n = 31). Nineteen were lost to follow-up and a further 19 died from unrelated causes. Twenty-five were excluded. After the initial diagnosis, two patients (1.7 percent) subsequently presented with an episode of diverticulitis, which was treated conservatively. A single patient (0.8 percent) required surgery for chronic symptoms. One hundred sixteen patients (97 percent) had no or mild symptoms after a median follow-up of 66 months. CONCLUSIONS: In this prospective long-term study, symptomatic uncomplicated diverticular disease seems to run a long-term benign course with a very low incidence of subsequent complications. Symptomatic disease, acute diverticulitis, and complicated diverticular disease seem to constitute distinct clinical entities with little crossover between groups.

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Int J Colorectal Dis. 2007 Mar 28; [Epub ahead of print]
Balsalazide and/or high-potency probiotic mixture (VSL#3) in maintaining remission after attack of acute, uncomplicated diverticulitis of the colon.
Tursi A, Brandimarte G, Giorgetti GM, Elisei W, Aiello F.
Digestive Endoscopy Unit, “Lorenzo Bonomo” Hospital, Andria (BA), Italy.

BACKGROUND AND AIMS: The role of probiotics in the treatment of diverticulitis is still not known. The aim of our study was to investigate whether balsalazide and/or VSL#3 is effective in preventing diverticulitis recurrence. MATERIALS AND METHODS: In this pilot study, 30 consecutive patients (19 males, 11 females, mean age 60.1 years, range 47-75 years) affected by uncomplicated diverticulitis of the colon were monitored. After obtaining remission, the patients were randomly assigned to one of the following groups as follows: group A, balsalazide 2.25 g daily for 10 days every month plus VSL#3 450 billions/day for 15 days every month and group B, VSL#3 alone 450 billions/day for 15 days every month. Primary end-point was considered the maintaining of remission throughout a 12-month follow-up. Secondary end-points considered were (1) the assessment of the overall scores at the end of the follow-up and (2) the effects of the two different treatments with regards to every symptom assessed. RESULTS/FINDINGS: One group A patient was withdrawn from the study at the 6th month and one group B patient was lost at the 6th month of follow-up. One group A patient (6.66%) showed relapse of symptoms at the 10th month of follow-up. At the end of follow-up, 11 patients were completely symptom-free (73.33%), whilst 2 patients complained of only mild, recurrent symptoms (13%). Two group B patients (13.33%) showed relapse of the disease at the 5th and 8th month of follow-up, respectively. At the end of follow-up, 8 patients were completely symptom-free (60%), 2 patients complained of mild, recurrent symptoms (13.33%), 1 patient (6.66%) complained of mild but continuous symptoms. No side effects were recorded throughout the follow-up in both groups. INTERPRETATION/CONCLUSIONS: Combination probiotic/anti-inflammatory drug was found better than probiotic treatment in preventing relapse of uncomplicated diverticulitis of the colon, even if without statistical significance.

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Br J Surg. 2007 Mar 22;94(7):876-879 [Epub ahead of print]
Outcome of a conservative policy for managing acute sigmoid diverticulitis.
Shaikh S, Krukowski ZH.
Department of Surgery, University of Aberdeen and Aberdeen Royal Infirmary, Aberdeen, UK.

BACKGROUND:: A conservative policy for patients presenting with acute sigmoid diverticulitis is associated with a low operation rate, and low overall and operative mortality rates. The long-term consequences of such a policy were investigated. METHODS:: Data were collected prospectively for 232 patients with acute sigmoid diverticulitis between 1990 and 2004. Details of all subsequent readmissions were obtained and survival to August 2005 was analysed. RESULTS:: Of the 232 patients admitted, 60 (25.9 per cent) were known to have diverticulosis; in 172 patients it was a new diagnosis. Thirty-eight patients (16.4 per cent) underwent sigmoid resection, with one death. Three elderly patients in whom a decision was made not to operate had perforated diverticulitis at autopsy. Of 191 patients discharged without resection, 35 (18.3 per cent) subsequently underwent sigmoid resection: 26 (13.6 per cent) elective and nine (4.7 per cent) emergency, with one death. CONCLUSION:: A conservative policy is safe in both the short term and the long term. Copyright (c) 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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Schweiz Rundsch Med Prax. 2007 Feb 14;96(7):237-42.
[Surgical therapy of diverticulitis]
[Article in German]
Bittner R, Ulrich M.
Klinik für Allgemein- und Viszeralchirurgie, Marienhospital Stuttgart.

The prevalence of sigmoid diverticular disease is increasing in western, industrialised countries. Practice parameters recommend surgical treatment for complicated disease or after the second episode of chronic recurrent disease. Surgical intervention should also be considered for younger patients after a first episode severe enough to require treatment. The preferred surgical procedure is elective sigmoid resection with primary anastomosis. Additional resection of the lower colon descendens is necessary when this region is also affected. Two-stage surgery is recommended for patients in emergency situations, i. e. severe or generalized peritonitis or extensive localized abscess formation, especially when the treating hospital is non-specialized. Segmentary resection without anastomosis and Hartmann's procedure is performed first (blind closure of the rectum with terminal colostomy). Restoration of colorectal continuity is performed at the earliest three months postoperatively. The preferred surgical technique is laparoscopy, provided the surgeon has the necessary expertise. Numerous studies have proven significant advantages of laparoscopy, although it is a completely new procedure with a long learning curve of 50-60 operations. Therefore, conversion to the conventional method should not be seen as a personal failure but rather as a responsible decision in favor of the patient's well-being.

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Schweiz Rundsch Med Prax. 2007 Feb 14;96(7):234-6.
[Course and conservative treatment of diverticular disease]
[Article in German]
Hoffmann R.
Innere Abteilung, Hohenloher Krankenhaus, Ohringen.

Diverticular disease is one of the most gastrointestinal disorders especially in developed countries. Prevalence rises with age, about two-thirds of patients in the age of 80 years are affected. In western countries diverticulosis is predominantly located in the distal colon. Only a minority of patients with diverticulosis develops symptoms. Ultrasound studies and CT scan are most important in diagnosing diverticulitis and its complications. Patients with the first attack of uncomplicated diverticulitis are treated with broad-spectrum antibiotics and in more severe case with bowel rest. Mesalazin is another choice of treatment. Recurrence of the disease is of increased risk to develop complications such as abscess formation, fistula and obstruction. These complications should be treated by operative resection. Lower gastrointestinal bleeding from divertikular sources should be treated by interventional endoscopy.

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Ann Ital Chir. 2007 Jan-Feb;78(1):61-4.
[Two-stage laparoscopic management of complicated acute diverticulitis. Initial experience]
[Article in Italian]
Galleano R, Di Giorgi S, Franceschi A, Falchero F.
U.O. di Chirurgia Generale, Ospedale di Albenga, Savona. raffagalleano@tin.it

Today no secure consensus exists about the best treatment of complicated diverticulitis. The classic surgical procedures are associated to a high immediate and delayed morbidity. In the last few years several more conservative techniques have been suggested to allow a later elective resection. Laparoscopic exploration, peritonel lavage, and drain of the abdominal cavity followed by an elective sigmoid laparoscopic resection is a new minimal invasive approach. This approach has been applied in our unit to treat four patients. All patients had an acute abdomen due to complicated diverticulitis and one patient had evidence of free air at the abdomen x-ray. At emergent operation pus was cleaned, a peritoneal lavage was carried out, a drain was placed near the colonic lesion and another one in the pelvis. Patients fully recovered without complication and 2 to 28 weeks after first operation an elective laparoscopic resection of descending and sigmoid colon with a Knight-Griffen colorectal anastomosis was performed. Neither residual abscess nor dense adhesions were found at the second operations. There were no complications and median hospital stay after the second operation was 10 days (range, 8-13 days). Laparoscopic treatment of generalized peritonitis due to perforated diverticulitis is an attractive alternative to the traditional management of this disease. Our initial results are comparable to that published in the literature. This approach can be safe and effective in selected cases of complicated acute diverticulitis.

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Clin Gastroenterol Hepatol. 2007 Jan;5(1):27-31.
Diverticular disease-associated segmental colitis.
Lamps LW, Knapple WL.
Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72212, USA. LampsLauraW@uams.edu

Diverticular disease-associated segmental colitis is a unique variant of chronic colitis limited to segments of the left colon that harbor diverticula. Histologically, this disease mimics chronic idiopathic inflammatory bowel disease and can be indistinguishable from ulcerative colitis or Crohn's colitis on histologic grounds alone. Patients typically present with hematochezia and cramping abdominal pain, and colonoscopic evaluation reveals inflammatory changes limited to the segment of bowel containing the diverticula, with rectal sparing. Although this disease does not appear to be an unusual form of diverticulitis but possibly an immunologically mediated process, many patients respond to treatment directed toward diverticulitis. A subset of patients requires immunosuppressive therapy and/or surgery, and a small subset progresses to develop classic ulcerative colitis. Because of the histologic overlap with ulcerative colitis and occasionally Crohn's colitis, it is essential that endoscopists provide a full description of the macroscopic appearance of the inflammatory changes at endoscopy, such as limitation to a segment of diverticular disease, so that the pathologist can provide a more informative interpretation of the biopsy.

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Scand J Gastroenterol. 2007 Jan;42(1):41-7.
Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory?
Hjern F, Josephson T, Altman D, Holmstrom B, Mellgren A, Pollack J, Johansson C.
Division of Surgery, Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden. fredrik.hjern@ds.se

OBJECTIVE: Most patients admitted for acute colonic diverticulitis (AD) are managed conservatively and receive antibiotics, although it is uncertain whether all patients with AD benefit from this treatment. The aim of this study was to evaluate the influence of antibiotic treatment on outcome in the conservative management of patients with mild AD. MATERIAL AND METHODS: A retrospective audit of 311 patients (64% F, mean age 60 years) hospitalized for AD was carried out. All patients were initially treated conservatively with observation and restriction of oral intake. Patients receiving antibiotics (n=118) were compared with patients treated with observation and restriction of oral intake only (n=193). Mean follow-up time (FU) was 30 months. RESULTS: Inflammation in patients treated with antibiotics was more pronounced (laboratory parameters (C-reactive protein, white blood cell count) were higher (p<0.01), fever was more common (p<0.01) and CT grading of inflammation was classified as severe in a higher proportion (p<0.01)) compared with patients treated without antibiotics. When initially treated with antibiotics, 3 patients (3%) failed to respond to treatment and had to undergo surgery. There were 7 (4%) failures in patients initially treated without antibiotics, and antibiotics were then added. During FU, 29% of patients treated with antibiotics had further events (recurrent AD and/or subsequent surgery) compared with 28% (NS) among those treated without antibiotics. In a multivariate analysis, the risk of a further event was not influenced by antibiotic treatment (OR 1.03, CI 95% 0.61-1.74). CONCLUSIONS: Our results indicate that antibiotics are not mandatory in mild AD. Treatment without antibiotics appears to be safe and seems not to change the rate of further events. These results warrant further randomized prospective studies.

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J Laparoendosc Adv Surg Tech A. 2006 Dec;16(6):551-6.
A standardized technique for robotically performed sigmoid colectomy.
DeNoto G, Rubach E, Ravikumar TS.
Department of Surgery, North Shore University Hospital, Lake Success, New York 11402, USA. gdenoto@nshs.edu

BACKGROUND: We describe a standarized eight-step technique to perform sigmoid colectomy using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA) in both the left upper and lower abdominal quadrants. MATERIALS AND METHODS: Between March 2005 and June 2006, 11 robotic sigmoid colectomies were performed on patients with diverticulitis or cancer. The procedures were performed through 4 ports, using a medial to lateral approach and involved moving the robot during the procedure. RESULTS: We describe the data and results from our first 11 robotically performed sigmoid colectomies using this technique. Operative times during each step of the procedure were collected and reported. By the eighth case, our team required only 4 minutes to undock, move, and redock the robot. The average operative time was 197 minutes and the average length of hospital stay was 3.4 days. There were no complications and no conversions to open colectomy. CONCLUSION: Robotically performed sigmoid colectomy is a feasible and safe procedure. The robot can be moved efficiently during surgery to allow a totally robotically performed sigmoid colectomy. The three-dimensional view, articulating instruments, intuitive movement, motion scaling, stable camera platform, and comfortable surgeon ergonomics facilitate splenic flexure mobilization and dissection and division of the inferior mesenteric artery and inferior mesenteric vein. Further studies will be needed to determine clinical benefit and economic feasibility.

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Cir Esp. 2006 Dec;80(6):369-72.
[Applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis.]
[Article in Spanish]
Pelaez N, Pera M, Courtier R, Sanchez J, Gil MJ, Pares D, Grandea L.
Unidad de Cirugia Colorrectal. Servicio de Cirugia General. Hospital del Mar. Barcelona. Espana.

INTRODUCTION. The aim of this study was to evaluate the applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis. PATIENTS AND METHODS. All patients diagnosed with uncomplicated acute diverticulitis based on abdominal computed tomography findings during a 2-year period were prospectively included. Patients with vomiting, severe comorbidities, or without an appropriate family environment were excluded. Ambulatory treatment consisted of oral antibiotics for 1 week (amoxicillin-clavulanic 1 g t.i.d. or ciprofloxacin 500 mg b.i.d. plus metronidazole 500 mg t.i.d. in patients with penicillin allergy). A clear liquid diet for the first 2 days and pain control with oral acetaminophen 1 g t.i.d. were also recommended. RESULTS. Fifty-three patients were diagnosed with uncomplicated acute diverticulitis and 13 patients were excluded. Therefore, ambulatory treatment was initiated in 40 patients. Only two patients (5%) required admission after outpatient therapy was started due to vomiting and persistent abdominal pain, respectively. In both patients, the inflammatory process was successfully resolved by intravenous antibiotic treatment. In the remaining 38 patients (95%), ambulatory treatment was completed without complications. CONCLUSIONS. Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective and applicable in most patients with tolerance to oral intake and with an appropriate family environment.

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Dis Colon Rectum. 2006 Dec 13; [Epub ahead of print]
Acute Diverticulitis in Very Young Patients: A Frequent Surgical Management.
Pautrat K, Bretagnol F, Huten N, de Calan L.
Department of Digestive Surgery, Trousseau Hospital, Tours cedex, 37070, France, frederic.bretagnol@wanadoo.fr.

PURPOSE: The natural history of sigmoid diverticulitis in terms of the virulence and management in young patients is an ongoing controversy. This retrospective study was designed to assess the severity and early management of acute diverticulitis according to age. METHODS: From 2000 to 2004, 284 patients were admitted for acute diverticulitis. Fifty-two patients (18 percent) were aged 50 years or younger and were divided in two groups: aged 40 years or younger (Group 1, n = 20), and patients older than aged 40 years (Group 2, n = 32). The diagnosis was confirmed by computed tomography in 49 patients (94 percent). RESULTS: Radiologic findings showed that the rate of complicated lesions (i.e., diverticular perforation and/or abscess) was significantly higher for patients younger than aged 40 years than patients older, respectively 72 and 35 percent (P = 0.02). The risk of requiring immediate surgical treatment was significantly more frequent in Group 1 than Group 2 (40 vs.13 percent; P = 0.04). There was a trend toward a higher risk of "major surgery" (i.e., Hartmann's procedure) in Group 1 than Group 2 (15 vs. 0 percent; P = 0.05). CONCLUSIONS: Diverticulitis in patients younger than aged 40 years seems to have a particularly aggressive and fulminant course and requires early surgical procedures for complications (associated abscess, colonic perforation) in 40 percent of cases. The use of "major procedure" (i.e., stoma) is more frequent in these patients.

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Surg Endosc. 2006 Nov;20(11):1713-8. Epub 2006 Aug 28.
Telerobotic surgery for right and sigmoid colectomies: 30 consecutive cases.
Rawlings AL, Woodland JH, Crawford DL.
Division of Minimally Invasive Surgery, Department of Surgery, University of Illinois College of Medicine, 420 NE Glen Oak Avenue, Suite 301, Peoria, Illinois 61603, USA.

BACKGROUND: This study aimed to evaluate the feasibility of using a robotic assistant for colon resections. This report describes the experience, advantages, and disadvantages of using the DaVinci system for a colectomy on the basis of 30 consecutive cases managed by a minimally invasive surgery fellowship-trained surgeon. METHODS: Data were prospectively collected on 30 consecutive colectomies performed using the DaVinci system from September 2002 to March 2005. RESULTS: A total of 13 sigmoid colectomies with splenic flexure mobilization and 17 right colectomies were performed for 14 men and 16 women. The preoperative diagnoses for the procedures were cancer (n = 5), diverticulitis (n = 8), polyps (n = 16), and carcinoid (n = 1). The right colectomies required 29.7 +/- 6.7 min (range, 22-44 min) for the port setup, 177.1 +/- 50.6 min (range, 103-306 min) for the robot, and 218.9 +/- 44.6 min (range, 167-340 min) for the total case. The length of stay was 5.2 +/- 5.8 days (range, 2-27 days). The robot portion was 80.9% of the total case time. The sigmoid colectomies required 30.1 +/- 9.6 min (range, 15-50 min) for the port setup, 103.2 +/- 29.4 min (range, 69-165 min) for the robot, and 225.2 +/- 37.1 min (range, 147-283 min) for the total case. The hospital length of stay was 6.0 +/- 7.3 days (range, 3-30 days). The robot portion was 45.8% of the total case time. Six complications occurred: left hip paresthesia, cecal injury, anastomotic leak, patient slipped from the operating table after the robotic portion of the case, transverse colon injury, and return of a patient to the office with urinary retention. Two sigmoid colectomies were converted to laparotomy. The specific advantages and disadvantages of using the DaVinci system for colectomies are discussed. CONCLUSIONS: The 30 consecutive cases demonstrated the technical feasibility of using the DaVinci system for a colectomy. The longevity of the DaVinci system's use for colectomy will be determined by comparison of its cost and outcomes with those for conventional laparoscopic colectomy.

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Langenbecks Arch Surg. 2006 Oct 28; [Epub ahead of print]
Surgery for right-sided colonic diverticulitis: results of a 10-year-observation period.
Hildebrand P, Kropp M, Stellmacher F, Roblick UJ, Bruch HP, Schwandner O.
Department of Surgery, University Hospital Schleswig-Holstein, Campus Lubeck, Ratzeburger Allee 160, 23538, Lubeck, Germany, philipphildebrand@yahoo.com.

INTRODUCTION: In contrast to sigmoid diverticular disease, right colonic diverticulitis is a rare disease in Western countries. The clinical presentation is often similar to acute appendicitis. OBJECTIVE: The aim of this study was to analyze surgical challenge in right-sided diverticulitis. MATERIALS AND METHODS: All patients who underwent resection for both right-sided and sigmoid diverticular disease were registered prospectively in a database (observation period, 1996-2005). A retrospective analysis of all patients who underwent resection for right-sided colonic diverticulitis (ileocolic resection, right colectomy) was performed. Special focus was set on incidence, clinical symptoms, indication, procedure, clinical outcome, and histopathologic findings including immunohistochemistry. RESULTS: From a total of 593 patients treated surgically for recurring or acute complicated diverticular disease, the majority (97.8%) suffered from sigmoid diverticulitis (n = 580), whereas 2.2% (n = 16) underwent surgery for right-sided diverticulitis (including three patients with combined sigmoid and cecal diverticulitis). Related to the total number of appendectomies (n = 1167), this represented an incidence of 1.4%. In five of 16 patients, acute appendicitis was presumed preoperatively. Most common diagnostic was ultrasonography. In the group of patients with right-sided diverticulitis, the most common procedure was right hemicolectomy (n = 10), followed by ileocolic resection (n = 3) and combined right colonic resection with sigmoid resection (n = 3). Histopathological investigation confirmed complicated diverticulitis of the cecum with local perforation or abscess in 75% of the patients (12/16). Hypoganglionosis or aganglionosis was diagnosed in seven of the 16 resected specimens. DISCUSSION: As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis may be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis. As most cases will remain clinically unimminent, surgery is only indicated in complicated right-sided cases. Resection of the inflamed colonic segment with primary anastomosis is safe and can be performed laparoscopically. It can only be speculated whether hypoganglionosis or aganglionosis is a causative factor in the etiology of right-sided diverticulitis.
 

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