Diverticulitis Research: 2002-2006
     
Dis Colon Rectum. 2006 Oct 13; [Epub ahead of print]
What is the Optimal Time of Surgical Intervention After an Acute Attack of Sigmoid Diverticulitis: Early or Late Elective Laparoscopic Resection?
Reissfelder C, Buhr HJ, Ritz JP.
Department of General, Vascular and Thoracic Surgery, Charite-General Universitatsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany.

PURPOSE: This prospective study was designed to check the ideal time of surgical intervention by comparing the results of early elective laparoscopic sigmoid resection after an inflammatory attack with those of late elective resection during the inflammation-free interval. METHODS: A total of 210 patients (114 males) underwent laparoscopic resection for acute sigmoid diverticulitis between 1999 and 2005. They were prospectively divided into two groups: Group I with an early elective sigmoid resection (5-8 days after initial antibiotic treatment); Group II in the inflammation-free interval (4-6 weeks after initial hospitalization). RESULTS: There was no difference between the groups with regard to age (55.7 years), American Society of Anesthesiologists score (1.86), previous diseases, and extent of inflammation. After surgery, 156 patients (74.3 percent) were complication-free. There was a total of ten conversions (Group I, 9; Group II, 1; P < 0.05). Minor complications developed in 42 patients (abdominal wall abscess = 24, intestinal atony = 6, hematoma = 9, urinary tract infection = 2). Eight patients in Group I (P < 0.05) developed anastomotic leaks. None of the patients died. CONCLUSIONS: In the majority of patients, laparoscopic sigmoid resection in sigmoid diverticulitis can be performed without conversion. Patients who underwent surgery in the inflammation-free interval had a lower complication rate than those submitted to early elective resection. In our patient population, we were able to show that surgery in the inflammation-free interval significantly reduces postoperative morbidity. It is thus preferable for patients with sigmoid diverticulitis to receive initial antibiotic treatment and then undergo late elective laparoscopic sigmoid resection.

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Dis Colon Rectum. 2006 Sep;49(9):1341-5.
Management of diverticulitis in younger patients.
Nelson RS, Velasco A, Mukesh BN.
Department Of General Surgery, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI 54449, USA. nelson.richard@marshfieldclinic.org

PURPOSE: This study was designed to evaluate the clinical course of sigmoid diverticulitis patients younger than aged 50 years examined by abdominal CT during the first episode of disease to elucidate whether the criteria used for older patients can safely be followed in their younger counterparts. METHODS: Retrospective review of patients with sigmoid diverticulitis treated from 1990 to 2003 was performed. Inclusion criteria: patients younger than aged 50 years with sigmoid diverticulitis documented by CT scan. Severity of disease was classified according to radiographic findings. Age, gender, treatment, recurrent disease, and need for colostomy were documented. RESULTS: A total of 5,499 patients were identified with sigmoid diverticulitis: 962 patients were younger than aged 50 years, and 411 had a CT scan on their first episode of disease. Of the 411 patients, 335 were classified as uncomplicated and 76 were complicated. Of the uncomplicated patients, 101 underwent an elective operation and 234 were followed nonoperatively. Of those followed, 67 had a recurrent uncomplicated episode, 10 had a recurrent complicated episode, of whom 5 required emergent operation and colostomy. Of the 76 patients with complicated disease, 23 had an emergent operation with colostomy, and 38 had an elective operation. Fifteen patients were followed without an operation and seven had a recurrent uncomplicated episode. None required emergent operation or colostomy. CONCLUSIONS: Younger patients with uncomplicated diverticulitis by CT criteria respond well to medical management and seldom required an emergent operation and colostomy. Young patients with diverticulitis should be treated according to the same criteria used for older patients.

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J Clin Gastroenterol. 2006 Aug;40(7 Suppl 3):S155-9.
Use of mesalazine in diverticular disease.
Di Mario F, Comparato G, Fanigliulo L, Aragona G, Cavallaro LG, Cavestro GM, Franze A.
Department of Clinical Sciences, University of Parma, 43100 Parma, Italy. francesco.dimario@unipr.it

Diverticular disease includes a spectrum of conditions sharing the underlying pathology of acquired diverticula of the colon: symptomatic uncomplicated diverticular disease, recurrent symptomatic uncomplicated diverticular disease, and complicated diverticular disease. Goals of therapy in diverticular disease should be to improve symptoms and to prevent recurrent attacks in symptomatic uncomplicated diverticular disease, and to prevent the complications of disease such as diverticulitis. Inflammation seems to play a key role in all forms of the disease. This is the rationale for the use of anti-inflammatory drugs such as mesalazine. Inflammation in such diseases seems to be generated by a heightened production of proinflammatory cytokines, reduced anti-inflammatory cytokines, and enhanced intramucosal synthesis of nitric oxide. The mechanisms of action of mesalazine are not yet well understood. It is an anti-inflammatory drug that inhibits factors of the inflammatory cascade (such as cyclooxygenase) and free radicals, and has an intrinsic antioxidant effect. Some recent studies confirm the efficacy of mesalazine in diverticular disease both in relief of symptoms in symptomatic uncomplicated forms and in prevention of recurrence of symptoms and main complications.

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J Clin Gastroenterol. 2006 Aug;40(7 Suppl 3):S150-4.
The metabolism of mesalamine and its possible use in colonic diverticulitis as an anti-inflammatory agent.
Cohen HD, Das KM.
Department of Gastroenterology and Hepatology, Crohn's and Colitis Center of New Jersey, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.

5-Aminosalicylic acid (5-ASA) is the mainstay of therapy for inflammatory bowel disease (IBD), particularly ulcerative colitis. 5-ASA is the active moiety in sulfasalazine, which was initially developed for the treatment of rheumatoid arthritis more than 60 years ago, by linking 5-ASA with sulfapyridine Because many of the side effects related to sulfasalazine were found to be due to sulfapyridine, several drugs that contain 5-ASA, and lack the side-effect profile of sulfasalazine, have been developed during the last 2 decades. These drugs have proven to be quite effective in treating mild-to-moderate symptoms of IBD, as well as inducing and maintaining remission. Although they exert anti-inflammatory effects, their exact mechanism of action remains elusive. Nonetheless, their success in treating IBD has led to studies using this class of drugs for novel indications. Several recent studies have evaluated the use of 5-ASA drugs (mesalamine) for the treatment of uncomplicated acute diverticulitis. In this review, we will briefly discuss the development of 5-ASA releasing drugs, their metabolism, side effects, indications, mechanisms of action, and the rationale for the clinical use of mesalamine in colonic diverticulitis.

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J Clin Gastroenterol. 2006 Aug;40(7 Suppl 3):S145-9.
Diagnosis and treatment of chronic and recurrent diverticulitis.
Frattini J, Longo WE.
Department of Surgery, Section of Gastrointestinal Surgery, Yale University School of Medicine, New Haven, CT 06510, USA.

In Western countries the prevalence of diverticular disease has increased over the past century. Although, most patients remain asymptomatic, among those who experience an attack of diverticulitis, one-third will have recurrent symptoms, and a further third will have a subsequent episode. The indications for surgery after treatment of acute diverticulitis is still under debate. Uncomplicated disease less commonly as thought, progresses to a life threatening situation such as free perforation. Among those who develop complicated diverticulitis, it is often their first presentation. Fistula to the urinary tract often require surgery; however, complicated disease such as an abscess or phlegmon can be managed conservatively and subsequent surgery is selective depending on the recovery from the initial episode. Patients with chronic diverticular disease (persistent pain in the absence of inflammation) have greatly improved quality of life with surgery. The question of greater virulence of disease among young patients may no longer be true and recommendations for surgery may parallel that of older patients. Immunocompromised patients should have definitive surgical therapy early on in the course of the disease. Right-sided disease remains uncommon in the Western world and a conservative approach in the absence of free perforation is recommended. In right-sided disease and in young patients, misdiagnosis is common. In the elective setting, a laparoscopic approach is rapidly becoming preferred because of less morbidity and shorter hospital stay. The treatment of diverticular disease is rapidly undergoing reevaluation, and novel therapies and increased conservative approaches are evolving. Prospective randomized trials are needed, but remain difficult owing to the uncertain natural history of the disease.

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J Clin Gastroenterol. 2006 Aug;40(7 Suppl 3):S136-44.
Diagnosis and management of acute diverticulitis.
Floch CL.
Norwalk Hospital, PC, 30 Stevens Street, Suite I, Norwalk, CT 06851, USA. docfloc60@yahoo.com

Although the diagnosis of acute diverticulitis is somewhat standardized, the scientific evidence and basis for treatment has been questioned. For years, medical and surgical management of acute diverticulitis has been based on the theory that more than 2 significant attacks of diverticulitis would lead to the recommendations of surgical resection. This should be questioned and further investigated with prospective randomized trials. Only a small number of well-published articles support the surgical management with good scientific data. Although our ability to take a history and skill of physical examination has not changed, the use of improved technology such as high-speed computerized axial tomography has afforded us the ability to make earlier and more accurate diagnoses. This may further allow us to standardize treatment and study outcomes. The time has come to further investigate and justify this management. It is possible that only the most critical situations may necessitate an operation. Clearly, the age group less than 40 years, as well as the immunocompromised, steroid-dependent, diabetic, and transplant patients, seem to be at greater risk with increased morbidity if not treated early and aggressively. And those individuals who present with perforation or compromised obstruction most likely will continue to need emergent intervention. We should try to set the rules by evidence-based medicine, while remaining within the confines of excellent and cost-effective care.

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J Clin Gastroenterol. 2006 Aug;40(7 Suppl 3):S108-11.
What do we know about diverticular disease? A brief overview.
Bogardus ST Jr.
Department of Medicine, Yale University School of Medicine, Ansonia, CT 06401, USA. Sidney.bogardus@aya.yale.edu

Diverticulosis and its complications, particularly diverticulitis, are extremely common in western countries. The major factor in the development of diverticulosis is a lack of adequate fiber intake. Diverticulitis may be complicated by abscess formation, fistula formation, peritonitis, or obstruction. Computed tomography scans are highly useful tools to plan appropriate care. Most cases of simple, uncomplicated diverticulitis respond to conservative therapy with bowel rest and antibiotics. Many controversies remain in the care of diverticulitis patients, including the optimal timing of surgery. One particularly interesting area of recent research examines the overlap of diverticulitis and inflammatory bowel disease, including the use of probiotics and mesalamine in diverticular disease.

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MMW Fortschr Med. 2006 Jul 20;148(29-30):37-41; quiz 42.
[Diverticulitis and diverticulosis]
[Article in German]
Rinas U, Adamek HE.
Medizinische Klinik 2, Klinikum Leverkusen. rinas@klinikum-lev.de

Over the last 100 years, the prevalence and incidence of diverticulosis and diverticular disease have increased dramatically in western industrialized countries. The main reasons for this are considered to be changes in eating habits, and the increasing age of the population. Conservative treatment of diverticulitis is an initial period of fasting and antibiotic treatment. For recurrence prevention, a fiber-rich diet is recommended. Studies providing evidence in support of the general recommendation of recurrence prophylaxis with poorly absorbed antibiotics, mesalazine or probiotics are to date not adequate. Elective prophylactic sigmoid resection is to be recommended following an episode of diverticulitis with complications, and after an episode of uncomplicated diverticulitis in long-term immunosuppressed patients who have already had an attack. Elective sigmoid resection after a healed second attack of uncomplicated diverticulitis is controversial.

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Colorectal Dis. 2006 Jul;8(6):501-5.
Two-stage totally minimally invasive approach for acute complicated diverticulitis.
Mutter D, Bouras G, Forgione A, Vix M, Leroy J, Marescaux J.
IRCAD, University of Strasbourg, Strasbourg, France.

OBJECTIVES: Surgical options for acute diverticulitis with peritonitis include Hartmann's procedure or resection and primary anastomosis with or without a stoma. Initial laparoscopic lavage and drainage can control the acute intra-abdominal sepsis to allow for a delayed definitive procedure in nonemergency conditions. Potential advantages include the avoidance of a laparotomy, stoma and local infections at the origin of dehiscence and incisional hernias. We evaluated this approach in a selected group of patients. METHODS: Patients with intra-abdominal pus secondary to diverticular perforation requiring surgery were included in the study. Patients with localized pus amenable to computerized tomography (CT)-guided drainage, faecal peritonitis, severe generalized peritonitis, and those in which the perforation was spontaneously visible were excluded. Standard demographic data, CT findings, intra-operative findings and postoperative outcomes were analysed. RESULTS: Ten patients were suitable for the approach. Mean patient age was 60.2 years. Mean body mass index was 28.2 m2/kg. Mean postoperative stay was 8.5 days and uneventful in all patients. One patient re-presented after 3 weeks with acute peritonitis requiring open sigmoidectomy. Six patients successfully underwent laparoscopic sigmoidectomy with primary anastomosis 2-3 months later. Two patients were not re-operated because of comorbidity and one refused surgery. CONCLUSIONS: A two-stage totally minimally invasive approach may be a safe alternative strategy for selected cases of acute complicated diverticulitis.

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Surg Endosc. 2006 Jul;20(7):1129-33. Epub 2006 Jun 3.
Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan.
Durmishi Y, Gervaz P, Brandt D, Bucher P, Platon A, Morel P, Poletti PA.
Department of Surgery, University Hospital Geneva, Rue Micheli-du-Crest 24, 1211, Geneve, Switzerland.

BACKGROUND: Percutaneous abscess drainage guided by computed tomography scan is considered the initial step in the management of patients presenting with Hinchey II diverticulitis. The rationale behind this approach is to manage the septic complication conservatively and to follow this later using elective sigmoidectomy with primary anastomosis. METHODS: The clinical outcomes for Hinchey II patients who underwent percutaneous abscess drainage in our institution were reviewed. Drainage was considered a failure when signs of continuing sepsis developed, abscess or fistula recurred within 4 weeks of drainage, and emergency surgical resection with or without a colostomy had to be performed. RESULTS: A total of 34 patients (17 men and 17 women; median age, 71 years; range, 34-90 years) were considered for analysis. The median abscess size was 6 cm (range, 3-18 cm), and the median duration of drainage was 8 days (range, 1-18 days). Drainage was considered successful for 23 patients (67%). The causes of failure for the remaining 11 patients included continuing sepsis (n = 5), abscess recurrence (n = 5), and fistula formation (n = 1). Ten patients who failed percutaneous abscess drainage underwent an emergency Hartmann procedure, with a median delay of 14 days (range, 1-65 days) between drainage and surgery. Three patients in this group (33%) died in the immediate postoperative period. Among the 23 patients successfully drained, 12 underwent elective sigmoid resection with a primary anastomosis. The median delay between drainage and surgery was 101 days (range, 40-420 days). In this group, there were no anastomotic leaks and no mortality. CONCLUSION: Drainage of Hinchey II diverticulitis guided by computed scan was successful in two-thirds of the cases, and 35% of the patients eventually underwent a safe elective sigmoid resection with primary anastomosis. By contrast, failure of percutaneous abscess drainage to control sepsis is associated with a high mortality rate when an emergency resection is performed. The current results demonstrate that percutaneous abscess drainage is an effective initial therapeutic approach for patients with Hinchey II diverticulitis, and that emergency surgery should be avoided whenever possible.

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Dis Colon Rectum. 2006 Jul;49(7):966-81.
Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: a systematic review.
Constantinides VA, Tekkis PP, Athanasiou T, Aziz O, Purkayastha S, Remzi FH, Fazio VW, Aydin N, Darzi A, Senapati A.
Imperial College of Science, Technology and Medicine, Department of Surgical Oncology and Technology, St. Mary's Hospital, London, United Kingdom.

PURPOSE: This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. METHODS: Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. RESULTS: Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. CONCLUSIONS: Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.

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Surg Endosc. 2006 Jul;20(7):1055-9. Epub 2006 May 26.
Can laparoscopically assisted sigmoid resection provide uncomplicated management even in cases of complicated diverticulitis?
Reissfelder C, Buhr HJ, Ritz JP.
Department of General, Vascular and Thoracic Surgery, Charite-Universitatsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30 12200, Berlin, Germany. christoph.reissfelder@charite.de

BACKGROUND: Laparoscopically assisted sigmoid resection has become an accepted method for treating uncomplicated diverticulitis. This prospective study aimed to compare the results of laparoscopic sigmoid resection for uncomplicated and complicated sigmoid diverticular disease used to check the indication for the complicated stages of diverticulitis. METHODS: All patients who underwent laparoscopic resection for sigmoid diverticulitis at the authors' hospital between 1999 and 2005 were divided into two groups: group 1 (uncomplicated diverticular disease) and group 2 (complicated diverticular disease). The exclusion criteria specified generalized peritonitis, signs of sepsis, and extensive previous abdominal surgery. RESULTS: Of the 203 patients (108 men and 95 women) who underwent laparoscopically assisted resection during the examination period, 112 were assigned to group 1 and 91 to group 2. Differences in favor of group 1 were found for the duration of surgery (154 vs 166 min), the conversion rate (1.8% vs 9.9%), the postoperative wound infections (2.7% vs 13.2%), and the postoperative hospitalization period (12.3 +/- 3.9 vs 15.0 +/- 5.6 days). No significant differences were seen in any other areas such as completion of nutritional buildup (4.6 vs 5.0 days) or time until the first postoperative bowel movement (2.8 vs 3.3 days). Total postoperative morbidity (16.1% vs 26.4%; p = 0.10) tended to be increased in group 2, but this difference was not statistically significant. CONCLUSIONS: Laparoscopic sigmoid resection can be performed for patients who have complicated diverticulitis without significantly increasing their overall morbidity. This group of patients could benefit from the advantages of the minimally invasive procedure despite a longer operating time and a higher conversion rate.

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Ann Surg. 2006 Jun;243(6):876-830; discussion 880-3.
Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes?
Chapman JR, Dozois EJ, Wolff BG, Gullerud RE, Larson DR.
Division of Colon & Rectal Surgery, Mayo Clinic and Mayo Foundation, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.

INTRODUCTION: Our understanding of complicated diverticulitis is based on outdated literature. Antecedent episodes of diverticulitis are felt to increase the risk of developing complicated diverticulitis, as well as its subsequent morbidity and mortality. Practice parameters recommend elective resection after 2 episodes of diverticulitis to reduce this morbidity and mortality. METHODS: A total of 150 patients with prior episodes of diverticulitis who were hospitalized with complicated diverticulitis were retrospectively analyzed. Statistical analysis was conducted using chi and Fisher exact test tests. RESULTS: Patients were separated into 2 groups for analysis: group A = those with 1 or 2 prior diverticulitis episodes (n = 118) versus group B = patients with more than 2 prior episodes (n = 32). Characteristics of the groups were similar for age and preexistent comorbid conditions. The majority of patients presented with pericolonic abscess and inflammatory phlegmon. Perforated diverticulitis occurred more often in group A compared with patients with >2 episodes of diverticulitis. Because of the higher rate of perforation, patients in group A underwent surgical diversion more often than group B patients. No significant differences in operative complications, morbidity, or mortality rates were identified between the groups. CONCLUSION: Patients with multiple (>2) episodes of diverticulitis are not at increased risk for poor outcomes if they develop complicated diverticulitis. Morbidity and mortality rates are not significantly different between patients with multiple episodes of diverticulitis compared with those with 1 or 2 prior attacks. Reevaluation of the practice of elective resection as a strategy for reducing the mortality and morbidity from complicated diverticulitis is needed.

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World J Surg. 2006 Jun;30(6):1027-32.
One-stage sigmoid colon resection for perforated sigmoid diverticulitis (Hinchey stages III and IV).
Richter S, Lindemann W, Kollmar O, Pistorius GA, Maurer CA, Schilling MK.
Clinic of General, Visceral, Vascular, and Pediatric Surgery, University Hospital of the Saarland, Kirrberger Strasse, D-66421 Homburg/Saar, Germany.

INTRODUCTION: Guidelines for the treatment of complicated sigmoid diverticulitis recommend Hartmann's procedure or anastomosis with protective colostomy for Hinchey stage III diverticulitis and Hartmann's procedure only for Hinchey stage IV diverticulitis. We evaluated the outcome of patients with perforated sigmoid diverticulitis Hinchey III/IV undergoing one-stage colon resection and primary anastomosis without protective colostomy. METHODS: After implementation of a protocol to treat Hinchey III/IV diverticulitis with primary anastomosis without protective ileocolostomy, the patients' data were recorded prospectively between August 2001 and August 2003 and analyzed retrospectively from a computer-related database. RESULTS: Of 41 patients, 34 (81%) underwent one-stage sigmoid resection and primary anastomosis, 3 of 41 patients (7%) underwent primary anatomosis with protective ileostomy, and 5 of 41 patients (12%) had a Hartmann's procedure. The mortality was 11% in patients undergoing primary anastomosis and 60% in patients with Hartmann's procedure. The relative risk of co-morbidity factors for lethal outcome after sigmoid resection was 6.94 for preceding operations, 3.75 for renal failure or renal transplantation, and 3.25 for immunosuppression. CONCLUSIONS: One-stage sigmoid resection and primary anastomosis can be performed safely in nearly 90% of all patients with perforated sigmoid diverticulitis (Hinchey III/IV) by surgeons of different training levels. Patients with immunosuppression, chronic renal failure, liver cirrhosis, or previous organ transplantation or complex cardiovascular reconstructive procedures have a significantly increased risk of dying after sigmoid resection for perforated diverticulitis.

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World J Gastroenterol. 2006 May 28;12(20):3225-8.
Management of diverticular disease is changing.
Floch MH, White JA.
Digestive Disease Section, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, CT 06520, USA. martin.floch@yale.edu

Diverticular disease of the colon is primarily a disease of humans living in westernized and industrialized countries. Sixty percent of humans living in industrialized countries will develop colonic diverticula. It is rare before the age of 40, but more prone to complications when it occurs in the young. By age 80, over 65% of humans have colonic diverticula. The cause remains uncertain, but epidemiologic studies attribute it to dietary fiber deficiency. The cause of diverticulitis remains uncertain, but new observations and hypotheses suggest that it is due to chronic inflammation in the bowel wall. Standard medical therapies of bowel rest and antibiotics are still the recommended treatment. However, changing concepts and new therapies indicate that anti-inflammatory agents such as mesalamine and possibly probiotics may be helpful in shortening the course and perhaps preventing recurrences. Standard surgical treatment for perforation for severe acute disease has developed so that two-stage procedures are recommended. In addition, laparoscopic surgery has proven safe and may slowly become the technique of choice.

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Dis Colon Rectum. 2006 Mar 18; [Epub ahead of print]
Laparoscopic vs. Hand-Assisted Laparoscopic Sigmoidectomy for Diverticulitis.
Lee SW, Yoo J, Dujovny N, Sonoda T, Milsom JW.
Department of Surgery, New York Presbyterian Hospital, Weill-Cornell Medical College, New York, New York, USA.

INTRODUCTION: Sigmoid colectomy for diverticulitis can be technically challenging because of severe inflammation in the left-lower quadrant and pelvis. We hypothesized that hand-assisted laparoscopic technique may facilitate laparoscopic completion of this surgery while retaining the short-term benefits associated with "pure" laparoscopic surgery, in which an incision is made only for extracting the specimen. This study was designed to compare the outcomes of patients who underwent totally laparoscopic or hand-assisted laparoscopic sigmoidectomy for diverticulitis. METHODS: We reviewed our prospectively collected patient database from July 2001 to June 2004 and compared the intraoperative data and postoperative outcomes of patients who underwent elective laparoscopic or hand-assisted laparoscopic sigmoidectomies for diverticulitis. Complicated patients (with abscess or fistulas) also were separately analyzed. RESULTS: The hand-assisted laparoscopic (mode age, 57 years; 48 percent male) and laparoscopic sigmoidectomy (mode age, 56 years; 90 percent male) groups were similar with regard to age and gender. Overall, patients who underwent laparoscopic (n = 21) vs. hand-assisted laparoscopic (n = 21) sigmoidectomies had a significantly longer operative time (197 +/- 42 vs. 171 +/- 34 minutes, P = 0.04) and shorter incision length (5 +/- 2.1 vs. 9.3 +/- 4.1 cm, P = 0.0001). Patients with complicated diverticulitis (n = 14; abscess, colovesical fistula, enterocolic fistula) who underwent laparoscopic sigmoidectomies (n=4) had a significantly longer operative time compared with hand-assisted laparoscopic sigmoidectomy (n = 10) group (255 +/- 18 vs. 177 +/- 34 minutes, P = 0.001). Conversion rate for the laparoscopic group was significantly higher (3/4 vs. 1/10, P = 0.04, Fisher exact) when complicated diverticulitis was present. There were no differences in postoperative outcomes or incision lengths in thecomplicated group. CONCLUSIONS: Outcomes after hand-assisted laparoscopic sigmoidectomy for diverticulitis are similar to those seen in the pure laparoscopic method, with lower conversion rates and shorter operative times. Hand-assisted laparoscopic sigmoid resection for diverticulitis is an attractive alternative to a "pure" laparoscopic method in complicated cases.

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Digestion. 2006;73 Suppl 1:58-66. Epub 2006 Feb 8.
Management of colonic diverticular disease.
Frieri G, Pimpo MT, Scarpignato C.
Gastroenterology Unit, School of Medicine and Dentistry, University of L'Aquila, L'Aquila, Italy. g.frieri@libero.it

Diverticular disease of the colon is a complex syndrome that includes several clinical conditions, each needing different therapeutic strategies. In patients with asymptomatic diverticulosis, only a fiber-rich diet can be recommended in an attempt to reduce intraluminal pressure and slow down the worsening of the disease. Fiber supplementation is also indicated in symptomatic diverticulosis in order to get symptom relief and prevent acute diverticulitis. In this regard, the best results have been obtained by combination of soluble fiber, like glucomannan, and poorly absorbed antibiotics, like rifaximin, given 7-10 days every month. For uncomplicated diverticulitis the standard therapy is liquid diet and oral antimicrobials, usually ciprofloxacin and metronidazole. Hospitalization, bowel rest, and intravenous antibacterial agents are mandatory for complicated diverticulitis. Haemorrhage is usually a self-limited event but may require endoscopic or surgical treatment. Once in remission, continuous fiber intake and intermittent course of rifaximin may improve symptoms and reduce diverticulitis recurrence. These preventive strategies will likely improve patients' quality of life and reduce management costs. A surgical approach in diverticular disease is needed in 15-30% of cases and consists of removing the intestinal segment affected by diverticula. It is indicated in diffuse peritonitis, abscesses, fistulas, stenosis and after the second to fourth attack of uncomplicated diverticulitis. Young people and immunocompromised patients are more likely to be operated. Copyright 2006 S. Karger AG, Basel.

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Int J Colorectal Dis. 2006 Jan 7;:1-7 [Epub ahead of print]
Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature.
Abbas S.
Department of Surgery, Auckland Hospital, Grafton, Auckland, New Zealand, salehabbas@yahoo.com.

OBJECTIVE: To determine the safety and feasibility of primary resection and anastomosis with or without a diverting stoma, as compared to Hartmann's procedure, for patients with acute complicated sigmoid diverticulitis. SEARCH STRATEGY: MEDLINE was searched for studies and trials conducted between 1966 and December 2003. This search revealed trials comparing primary resection and anastomosis to Hartmann's procedure. The term "diverticulitis, colonic" with the sub-heading "surgery" was used and the search was limited to human studies and clinical trials. Additional studies were found using the MeSH terms: "surgical procedures, operative", "surgical anastomosis", and "Hartmann procedure", combined with the term "diverticulitis, colonic". The author also searched EMBASE and the Cochrane database for clinical trials using similar terminology. No language restrictions were applied. RESULTS: Eighteen studies met the inclusion criteria and reported 884 patients with acute complicated diverticulitis. None of these studies were randomised; it is likely that there was a significant degree of selection bias. No significant differences were found between primary resection with anastomosis and Hartmann's procedure with respect to mortality, morbidity, sepsis, wound complications and duration of procedure and anti-biotic treatment. Some studies found that primary anastomosis and a protecting stoma, with or without intra-operative colonic lavage, have more favourable results than Hartmann's procedure. CONCLUSIONS: This review suggests that surgical resection and primary anastomosis in acute diverticulitis with peritonitis compares favourably with Hartmann's procedure in terms of peri-operative complications. The need for revision of Hartmann's procedure could be subsequently avoided. Some articles showed that patients with severe peritonitis, who had a diverting stoma, in the setting of resection and primary anastomosis, had the lowest complication rate. However, the quality of these studies was poor with the presence of selection bias.

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Ann Surg. 2005 Dec;242(6):897-901, discussion 901.
Ultrasonic versus standard electric dissection in laparoscopic colorectal surgery: a prospective randomized clinical trial.
Morino M, Rimonda R, Allaix ME, Giraudo G, Garrone C.
Department of Surgery, Minimally Invasive Surgery Center, University of Turin, Corso A.M. Dogliotti 14, 10126 Turin, Italy. mario.morino@unito.it

OBJECTIVE: To assess the safety and efficacy of the ultrasonic dissection (UC) compared with standard electrosurgery (ES) in laparoscopic colorectal surgery. BACKGROUND DATA: High-frequency ultrasound energy was introduced in laparoscopic surgery to improve dissection and coagulation. Very limited data have been published on its use in laparoscopic colorectal surgery. METHODS: Patients eligible for elective laparoscopic right or left hemicolectomy (RH and LH), sigmoidectomy (SG), or low anterior resection (LAR) were randomized to either UC or ES. The following data were collected and analyzed: preoperative data (individual patient data, indication for surgery), intraoperative data (conversion to open surgery, conversion ES to UC, operative time, blood loss, complication rate), and postoperative data (morbidity and mortality, volume of drainage, hospital stay). RESULTS: Between January 2002 and December 2003, 171 patients underwent elective laparoscopic colorectal resection. Twenty-5 patients did not satisfy the inclusion criteria and were excluded. The diagnosis of the remaining 146 patients was diverticulitis (44), colonic adenoma (31), adenocarcinoma (70), or epidermoid carcinoma (1). These patients underwent laparoscopic RH (28), LH (31), SG (47), or LAR (40). There were no differences in preoperative data. The overall conversion rate to open surgery was 11.6%, with no differences between the two groups; 20.8% undergoing ES were converted to UC, more frequently during right hemicolectomy or low anterior resection. Operative time, the primary endpoint of this study, did not differ between the two groups: UC 93 minutes versus ES 102.6 minutes (P = 0.46). Intraoperative blood loss was significantly less in UC 140.8 mL versus ES 182.6 mL (P = 0.032). No differences were observed in postoperative morbidity or other preoperative or postoperative parameters. CONCLUSIONS: UC is a useful device in laparoscopic colorectal surgery that facilitates completion of difficult cases and reduces intraoperative blood loss. Nevertheless, the majority of laparoscopic procedures can be completed with ES. Therefore, selective use of UC appears to be the most cost-effective policy.

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Br J Surg. 2005 Dec;92(12):1520-5.
French multicentre prospective observational study of laparoscopic versus open colectomy for sigmoid diverticular disease.
Alves A, Panis Y, Slim K, Heyd B, Kwiatkowski F, Mantion G; Association Francais de Chirurgie.
Department of Digestive Surgery, Hopital Lariboisiere, 2 rue Ambroise Pare, 75475 Paris, Cedex 10, France.

BACKGROUND: The aim of this study was to compare in-hospital morbidity and mortality rates after elective laparoscopic and open colorectal surgery for sigmoid diverticular disease (SDD). METHODS: This prospective national multicentre observational study included all consecutive patients undergoing open or laparoscopic elective colectomy for SDD in a 4-month period between June and September 2002. Postoperative in-hospital mortality and morbidity in the two groups were compared. RESULTS: Three hundred and thirty-two consecutive patients undergoing either laparoscopic (163 patients) or open (169 patients) colectomy for SDD were analysed. Overall postoperative mortality and morbidity rates were 0.3 and 23.8 per cent respectively. The morbidity rate was significantly higher in the open than in the laparoscopic group (P < 0.001), leading to a significantly longer hospital stay (P < 0.001). The morbidity rate remained significantly higher in the open group when the patients were matched for age (P = 0.015) or American Society of Anesthesiologists score (P = 0.028). An open procedure (relative risk (RR) 2.13 (95 per cent confidence interval (c.i.) 1.29 to 3.45)), age over 70 years (RR 1.62 (95 per cent c.i. 1.14 to 2.30)) and intraperitoneal contamination (RR 2.54 (95 per cent c.i. 1.18 to 5.50)) were identified as independent risk factors for morbidity. CONCLUSION: A laparoscopic approach to elective treatment of SDD may be associated with reduced postoperative morbidity and hospital stay. A randomized study is required to confirm these results. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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JSLS. 2005 Oct-Dec;9(4):382-5.
Laparoscopic sigmoid colectomy for chronic diverticular disease.
Blake MF, Dwivedi A, Tootla A, Tootla F, Silva YJ.
Department of Surgery, North Oakland Medical Centers, Pontiac, Michigan, USA.

BACKGROUND: The feasibility of laparoscopic sigmoid colectomy for diverticular disease has now been well established. We report herein our experience with laparoscopic sigmoid colectomy in 100 patients who underwent laparoscopic colectomy for chronic diverticular disease. METHODS: A retrospective review was performed of a 7-year period from January 1995 to June 2002. Chronic diverticular disease was treated with laparoscopic sigmoid colectomy in 100 patients. The setting was a community hospital. All cases were performed by 1 of 2 colorectal surgeons. All laparoscopic sigmoid colectomy patients received lighted ureteral stents placed preoperatively that were removed at the end of surgery. RESULTS: Mean age was 61.6 years. The male to female ratio was 38:62. The mean estimated blood loss was 138 mL, liquid diet was tolerated for 2.4 days, and hospital length of stay was 4.6 days. The mean operative time for laparoscopic sigmoid colectomy was 196 minutes. Relative complications for laparoscopic sigmoid colectomy are as follows: anastomotic leak in 2 (3.0%) patients, hematuria in 95 (95%) with an average duration for 3.1 days, urinary tract infection in 6 (6%), and ureteral injury in 1 (1%). The mean operating room charges in the laparoscopic sigmoid colectomy patients was dollars 9,643. CONCLUSION: We recommend laparoscopic sigmoid colectomy as the modality of treatment for chronic diverticular disease. Laparoscopic sigmoid colectomy appears to be a reliable, safe, and efficacious treatment modality for chronic diverticular disease. The operative time for laparoscopic sigmoid colectomy is decreasing as surgeons gain more experience.

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Surg Endosc. 2005 Oct 24; [Epub ahead of print]
Laparoscopy for abdominal emergencies Evidence-based guidelines of the European Association for Endoscopic Surgery.
Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski A, Champault G, Fingerhut A, Isla A, Johansson M, Lundorff P, Navez B, Saad S, Neugebauer EA.
Institute for Research in Operative Medicine, University of Witten/Herdecke, Ostmerheimer Strasse 200, D 51109, Cologne, Germany, Sekretariat-Neugebauer@uni-koeln.de.

BACKGROUND: Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. METHODS: A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. RECOMMENDATIONS: Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. CONCLUSIONS: Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

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Am Fam Physician. 2005 Oct 1;72(7):1229-34.
Diverticular disease: diagnosis and treatment.
Salzman H, Lillie D.
Department of Family and Preventive Medicine, University of California, San Diego, School of Medicine, San Diego, California, USA. hsalzman@ucsd.edu

Diverticular disease refers to symptomatic and asymptomatic disease with an underlying pathology of colonic diverticula. Predisposing factors for the formation of diverticula include a low-fiber diet and physical inactivity. Approximately 85 percent of patients with diverticula are believed to remain asymptomatic. Symptomatic disease without inflammation is a diagnosis of exclusion requiring colonoscopy because imaging studies cannot discern the significance of diverticula. Fiber supplementation may prevent progression to symptomatic disease or improve symptoms in patients without inflammation. Computed tomography is recommended for diagnosis when inflammation is present. Antibiotic therapy aimed at anaerobes and gram-negative rods is first-line treatment for diverticulitis. Whether treatment is administered on an inpatient or outpatient basis is determined by the clinical status of the patient and his or her ability to tolerate oral intake. Surgical consultation is indicated for disease that does not respond to medical management or for repeated attacks that may be less likely to respond to medical therapy and have a higher mortality rate. Prompt surgical consultation also should be obtained when there is evidence of abscess formation, fistula formation, obstruction, or free perforation.

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Ann Surg. 2005 Oct;242(4):576-81; discussion 581-3.
Complicated diverticulitis: is it time to rethink the rules?
Chapman J, Davies M, Wolff B, Dozois E, Tessier D, Harrington J, Larson D.
Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.

INTRODUCTION: Much of our knowledge and treatment of complicated diverticulitis (CD) are based on outdated literature reporting mortality rates of 10%. Practice parameters recommend elective resection after 2 episodes of diverticulitis to reduce morbidity and mortality. The aim of this study is to update our understanding of the morbidity, mortality, characteristics, and outcomes of CD. METHODS: Three hundred thirty-seven patients hospitalized for CD were retrospectively analyzed. Characteristics and outcomes were determined using chi-squared and Fisher exact tests. RESULTS: Mean age of patients was 65 years. Seventy percent had one or more comorbidities. A total of 46.6% had a history of at least one prior diverticulitis episode, whereas 53.4% presented with CD as their first episode. Overall mortality rate was 6.5% (86.4% associated with perforation, 9.5% anastomotic leak, 4.5% patient managed nonoperatively). A total of 89.5% of the perforation patients who died had no history of diverticulitis. Steroid use was significantly associated with perforation rates as well as mortality (P< 0.001 and P = 0.002). Comorbidities such as diabetes, collagen-vascular disease, and immune system compromise were also highly associated with death (P = 0.006, P = 0.009, and P = 0.003, respectively). Overall morbidity was 41.4%. Older age, gender, steroids, comorbidities, and perforation were significantly associated with morbidity. CONCLUSION: Today, mortality from CD excluding perforation is reduced compared with past data. This, coupled with the fact that the majority of these patients presented with CD as their first episode, calls into question the current practice of elective resection as a stratagem for reducing mortality. Immunocompromised patients may benefit from early resection. New prospective data is needed to redefine target groups for prophylactic resection.

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Ultrasound Q. 2005 Sep;21(3):175-85.
Transrectal and transvaginal sonographic intervention of infected pelvic fluid collections: a complete approach.
Sudakoff GS, Lundeen SJ, Otterson MF.
Radiology and Urology, Medical College of Wisconsin, Milwaukee, USA. gsudakof@mcw.edu

Infected pelvic fluid collections are relatively common particularly after abdominal or pelvic surgery or in patients suffering from benign intestinal disease such as diverticulitis, appendicitis, or Crohn's disease. Historically the treatment of pelvic abscess has been either laparotomy with lavage or blind surgical incision and drainage through the rectal or vaginal wall. More recently, computed tomography and ultrasound-guided percutaneous drainage has become the procedure of choice, when feasible, for the treatment of pelvic abscess. However, many deep pelvic collections are not amenable to percutaneous technique. Transrectal or transvaginal ultrasound-guided abscess drainage is a safe and effective method used in the treatment of deep pelvic abscesses. The purpose of this article is to review the techniques, patient selection, pre- and post-procedural care, and monitoring aspects of transrectal or transvaginal ultrasound-guided drainage.

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Internist (Berl). 2005 Sep;46(9):974-81.
[Acute abdomen]
[Article in German]
Mossner J.
Medizinische Klinik und Poliklinik II der Universitat Leipzig. moej@medizin.uni-leipzig.de

Acute abdomen is not a disease entity on its own but describes a critical state of the patient which can be caused by numerous diseases. The surgeon and internist have to apply an interdisciplinary approach to enable a rapid decision on whether immediate laparotomy is mandatory. Few appropriate diagnostic procedures support decision making. In many cases there is an indication for immediate surgery, such as perforated gastric or duodenal ulcer, acute appendicitis, diverticulitis, ruptured aortic aneurysm, mechanic ileus, infarction of the mesenteric artery. This review is mainly focused on diseases which may present as acute abdomen but for which surgery is usually not indicated, such as acute pancreatitis. Furthermore, one also has to consider rare diseases in which laparotomy would clearly be a mistake, such as acute intermittent porphyria or intestinal pseudo-obstruction.

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Ultrasound Q. 2005 Sep;21(3):175-185.
Transrectal and Transvaginal Sonographic Intervention of Infected Pelvic Fluid Collections: A Complete Approach.
Sudakoff GS, Lundeen SJ, Otterson MF.

*Associate Professor of Radiology and Urology, Medical College of Wisconsin, Department of Radiology, Director of GU Imaging at Froedtert Memorial Lutheran Hospital, Milwaukee, Wisconsin; daggerNurse Practitioner, Medical College of Wisconsin, Department of Surgery, Section of Minimally Invasive Surgery (Gastrointestinal Surgery) at Froedtert Memorial Lutheran Hospital, Milwaukee, Wisconsin; and double daggerProfessor of Surgery, Medical College of Wisconsin, Department of Surgery, Section of Minimally Invasive Surgery (Gastrointestinal Surgery) at Froedtert Memorial Lutheran Hospital, Milwaukee, Wisconsin, USA.

Infected pelvic fluid collections are relatively common particularly after abdominal or pelvic surgery or in patients suffering from benign intestinal disease such as diverticulitis, appendicitis, or Crohn's disease. Historically the treatment of pelvic abscess has been either laparotomy with lavage or blind surgical incision and drainage through the rectal or vaginal wall. More recently, computed tomography and ultrasound-guided percutaneous drainage has become the procedure of choice, when feasible, for the treatment of pelvic abscess. However, many deep pelvic collections are not amenable to percutaneous technique. Transrectal or transvaginal ultrasound-guided abscess drainage is a safe and effective method used in the treatment of deep pelvic abscesses. The purpose of this article is to review the techniques, patient selection, pre- and post-procedural care, and monitoring aspects of transrectal or transvaginal ultrasound-guided drainage.

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J Pediatr Surg. 2005 Jul;40(7):1215.
Diverticulectomy is inadequate treatment for short Meckel's diverticulum with heterotopic mucosa.
Holland AJ.

The authors retrospectively reviewed adult and paediatric patients that had resection of a Meckel's diverticulum (MD) between January 1992 and May 2003 at an adult and paediatric teaching hospital. They sought to determine whether the resection technique should depend upon the external appearance of the MD. The authors measured the length of the resected MD and compared this to the width to obtain a height to diameter ration (HDR), with a ratio of >/=2 considered 'long'. Overall, 77 patients between 1 day of age to 92 years (median 8 years) had a MD resected, with a nearly 3:1 male to female ratio. A minority of patients (n = 33, 43%), more commonly male and in the first decade of life, were symptomatic; usually with diverticulitis or haemorrhage. A Meckel's scan was positive in only 2 out of 8 patients: in 7 of these patients heterotopic gastric mucosa was present. The majority (62%) of patients had a limited small bowel resection, with the remainder a diverticulectomy. Heterotopic gastric mucosa was commoner in males (4:1) and in symptomatic MD. Of those MD with gastric mucosa, there were 5 MD with a HDR of >/=2: in all of these ectopic mucosa involved the tip or body of the MD only and would have been completely resected by a diverticulectomy. In those MD with a HDR of <2, the ectopic mucosa was variously located but in 60% involved the base and would not have been completely resected by diverticulectomy alone. Clinical assessment of 'thickening' of the MD at time of operation was positive for gastric mucosa in only 54% of cases. The authors concluded that MD likely to become symptomatic usually did so within the first decade of life. The sensitivity of a Meckel's scan was low, severely limiting the predictive value of a negative study. A 'long' MD could be safely resected diverticulectomy, as any gastric mucosa present will not be located at the base. Conversely, a 'short' diverticulum should be formally resected with a portion of small bowel to ensure complete removal of any ectopic gastric mucosa present. Comment: Although interesting, the value of this study was limited by its retrospective nature. Patients in whom an MD was found but not resected were excluded; the assessment of "thickening" of an MD was based on comments made in operation records and measurements on pathology reports of fixed rather than fresh specimens.

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Am J Surg. 2005 Jul;190(1):48-50.
Feasibility of colectomy with mini-incision.
Hsu TC.
Division of Colon and Rectal Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan. tzuchi@ms2.mmh.org.tw

BACKGROUND: Laparoscopic resection has been advocated as a method of colectomy for various colon and rectal disease. One advantage claimed by laparoscopy is its smaller incision size. The aim of the present study is to evaluate whether mini-incision is feasible along with the advantage of adequate exploration of the peritoneal cavity. METHODS: From December 2000 to November 2003, 316 patients with various colorectal diseases receiving colectomies through a skin incision less than 7 cm were analyzed. All of the colectomies were performed by a single surgeon. Exploration of the entire peritoneal cavity was possible for all the cases. There were 153 men and 163 women. Ages ranged from 19 to 90 years, averaging 62.4 years. Two hundred ninety-five patients were operated on for carcinoma of the colon or rectum; 4 had operations for villous tumors with severe dysplasia; 3 each for radiation enterocolitis and diverticulitis; 2 each for malignant stromal tumor and rectal prolapse; and 1 each for lymphoma, actinomycosis, volvulus, angiodysplasia, Crohn's disease, ulcerative colitis, and ovarian cancer with rectal invasion. There were 15 abdominoperineal resections, 97 low anterior resection, 49 anterior resections, 64 sigmoidectomies, 7 left hemicolectomies, 81 right hemicolectomies, 2 subtotal colectomies, and 1 restorative proctocolectomy. No Harmonic scalpel or laser was used during surgery. No hand-port or laparoscope was used in the series. RESULTS: Five patients died of acute respiratory failure, 2 patients died of terminal cancer, and 1 patient died of hypoglycemia due to poor control of diabetes mellitus. Complications included 11 urinary tract infections, 8 intestinal obstructions, 6 anastomotic leakages, 6 wound infections, 5 respiratory failures, 5 pelvic bleedings, 2 pneumonias, 2 gastrointestinal bleedings, and 1 pancreatitis. Small incisions did not prolong operation time. CONCLUSION: This experience suggests that the majority of colectomies can be accomplished by an incision of less than 7 cm, which is no larger than the incision size used in a laparoscope colectomy if multiple incisions made for trocars are added to the main incision length. The advantages of mini-incision include lower cost, faster completion of procedure, reduced bulkiness of equipment, and the possibility of exploring the entire peritoneal cavity by hand without loss of tactile sensation.

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Eur J Gastroenterol Hepatol. 2005 Jun;17(6):649-54.
Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon.
Mueller MH, Glatzle J, Kasparek MS, Becker HD, Jehle EC, Zittel TT, Kreis ME.
Department of Surgery, Ludwig-Maximilian University, Munich-Grosshadern, Germany.

INTRODUCTION: The indication for surgery after conservative treatment of acute diverticulitis is still under debate. This is partly as a result of limited data on the outcome of conservative management in the long run. We therefore aimed to determine the long-term results of conservative treatment for acute diverticulitis. METHODS: The records of all patients treated at our institution for diverticulitis between 1985 and 1991 were reviewed (n=363, median age 64 years, range 29-93). Patients who received conservative treatment were interviewed in 1996 and 2002 [follow-up time 7 years 2 months (range 58-127 months) and 13 years 4 months (range 130-196 months). RESULTS: A total of 252 patients (69%) were treated conservatively, whereas 111 (31%) were operated on. At the first follow-up, 85 patients treated conservatively had died, one of them from bleeding diverticula. A recurrence of symptoms was reported by 78 of the remaining 167 patients, and 13 underwent surgery. At the second follow-up, one patient had died from sepsis after perforation during another episode of diverticulitis. Thirty-one of the 85 patients interviewed reported symptoms and 12 had been operated on. In summary, at the second follow-up interview, 34% of patients treated initially had had a recurrence and 10% had undergone surgery. No predictive factors for the recurrence of symptoms or later surgery could be determined. CONCLUSION: Despite a high rate of recurrences after conservative treatment of acute diverticulitis, lethal complications are rare. Surgery should thus mainly be undertaken to achieve relief of symptoms rather than to prevent death from complications.

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Rev Med Suisse. 2005 Jun 15;1(24):1600-3.
[Actual treatment of acute diverticulitis]
[Article in French]
Vuilleumier H, Nordback P, Givel JC.
Service de chirurgie viscerale CHUV, 1011 Lausanne.

In Western countries, diverticular disease is a frequent condition and the prevalence of which increases with age. Acute diverticulitis is its most frequent complication. CT-scan is now the best exam for diagnosis of acute diverticulitis, classification of its severity, and for follow-up. It can also, when necessary, allow percutaneous drainage of pericolic abscesses. Treatment of acute diverticulitis is most often conservative. Surgery outside acute events is now considered as a technique with extremely low morbidity and mortality. In this situation, laparoscopy represents nowadays the technique of choice for safe sigmoid surgery.

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G Chir. 2005 Apr;26(4):143-52.
[Surgery for complicated colonic diverticulitis. Our experience]
[Article in Italian]
Fornaro R, Canaletti M, Terrizzi A, Davini MD, Sticchi C, Stabilini C, Moraglia E, Picori E, Larghero GC, Giannetta E.
Dipartimento di Chirurgia, Cattedra di Semeiotica Chirurgica, Universita degli Studi di Genova.

During the last two decades were observed 422 symptomatic patients with various degree of diverticular disease of the colon. 51 patients underwent surgery: 29 for stenosis (24) or occlusion (5), 4 for fistulas, 18 for perforation. The operations (26 emergencies, 25 elective) included: 21 cases of one-stage resection and anastomosis without protective colostomy, 16 with colostomy, 8 Hartmann's procedures, 7 Mikulicz's operations, 1 suturing of the diverticulum with colostomy. The incidence of complications was 17.6% (9 cases, 7 following emergency surgery and 2 after elective procedures). The intraoperative mortality was zero, while postoperative 5.8% (3 cases, 2 after emergency procedures and 1 following elective surgery). The best results (lowest morbidity and mortality rates) occurred with the radical procedures, especially the resection-anastomosis with or without colostomy, which allowed the removal of the septic focus from the peritoneal cavity and thus a shorter recovery in a high number of cases.

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Chemotherapy. 2005;51 Suppl 1:110-4.
Management of diverticular disease: is there room for rifaximin?
Papi C, Koch M, Capurso L.
Department of Gastroenterology and Internal Medicine, S. Filippo Neri Hospital, Rome, Italy. c.papi@tin.it

Treatment of symptomatic diverticular disease of the colon is aimed at the relief of symptoms and the prevention of major complications. The efficacy of fiber supplementation and of anticholinergic and spasmolytic agents remains controversial. Antibiotics are commonly used in the treatment of inflammatory complications of diverticular disease. Data from open labelled and randomized controlled trials do suggest the efficacy of rifaximin in obtaining symptomatic relief in patients with diverticular disease. Approximately 30% therapeutic gain compared to fiber supplementation only can be expected after one year of intermittent treatment with rifaximin. Considering the safety and tolerability of rifaximin, this drug can be recommended for patients with symptomatic uncomplicated diverticular disease. Copyright (c) 2005 S. Karger AG, Basel.

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Zentralbl Chir. 2005 Apr;130(2):123-7.
[Surgical therapy in right-sided diverticulitis]
[Article in German]
Hildebrand P, Birth M, Bruch HP, Schwandner O.
Klinik fur Chirurgie, Universitatsklinikum Schleswig-Holstein, Campus Lubeck, Lubeck. PhilippHildebrand@yahoo.com
 
INTRODUCTION: Left-sided diverticulitis is a common disease in Western countries, whereas right-sided diverticultitis is rare and symptoms are often similar to the clinical signs of an acute appendicitis. It was the aim of this study to analyse surgical experience in right-sided diverticulitis. METHODS: All patients who underwent resectional surgery for both right-sided and sigmoid diverticular disease were entered prospectively in a registry database (8-year observation period, 1996-2003). For the current study, a retrospective analysis of all patients who underwent ileocolic resection or right colectomy for right-sided colonic diverticulitis was performed, specifically focussing on incidence, clinical symptoms, indication for surgery, type of procedure, and histopathological parameters including immunohistochemistry, and outcome in right-sided diverticulitis. RESULTS: Within eight years, 481 patients were treated surgically for chronically recurrent or acute complicated diverticular disease: 468 patients with sigmoid diverticulitis, 12 patients with right-sided diverticulitis, and 1 patient with combined right-sided and sigmoid diverticular disease. This corresponds to an incidence of right-sided diverticulitis of 2.5 % related to the total number of resections for diverticulitis, and an incidence of 1.3 % in relation to the appendectomies in our patients. In 4 patients, acute appendicitis was presumed preoperatively. Most common diagnostic tool was ultrasonography. Right colectomy was performed in 9 patients with complicated cecal diverticulitis, whereas ileocolic resection was performed in 2 patients and simultaneous ileocolic and sigmoid resection was carried out in one patient. Postoperatively, no morbidity occurred. Histopathological assessment showed local perforation in 75 % (9/12). Hypoganglionosis or aganglionosis was detected in 5 of 12 resected specimen. DISCUSSION: As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis can be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis, and surgery is only indicated in complicated right-sided diverticulitis. Resection of the inflamed colon with primary anastomosis is safe and can be performed by laparoscopy in experienced centers. At present, it can only be speculated whether hypoganglionosis or aganglionosis are causative factors in the etiology of right-sided diverticulitis.

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J Surg Res. 2005 Apr;124(2):318-23.
Temporal changes in the management of diverticulitis.
Salem L, Anaya DA, Flum DR.
Department of Surgery, University of Washington, Seattle, WA 98195-6410, USA.

PURPOSE: This study was designed to evaluate temporal trends in the use and type of operative and non-operative interventions in the management of diverticulitis. METHODS: A retrospective cohort using a statewide administrative database was used to identify all patients hospitalized for diverticulitis in the state of Washington (1987-2001). Poisson and logistic regression were used to calculate changes in the frequency of hospitalization, operative and percutaneous interventions, and colostomy over time. RESULTS: Of the 25,058 patients hospitalized non-electively with diverticulitis (mean age 69 +/- 16, 60% female) there were only minimal changes in the frequency of admissions over time (0.006% increase per year-IRR 1.00006 95% CI 1.00004, 1.00008). The odds of an emergency colectomy at initial hospitalization decreased by 2% each year (OR 0.98 95% CI 0.98, 0.99) whereas the odds of percutaneous abscess drainage increased 7% per year (OR 1.07 95% CI 1.05, 1.1). Among patients undergoing percutaneous drainage, the odds of operative interventions decreased by 9% compared to patients who did not have a percutaneous intervention (OR 0.91 95% CI 0.87, 0.94). The proportion of patients undergoing colostomy during emergency operations remained essentially stable over time (range 49-61%), as did the proportion of patients undergoing prophylactic colectomy after initial non-surgical management (approximately 10%). CONCLUSIONS: There was a minimal increase in the frequency of diverticulitis admissions over time. A rise in percutaneous drainage procedures was associated with a decrease in emergency operative interventions. The proportion of patients undergoing colostomy remained stable, and there does not seem to be a significant increase in the use of one-stage procedures for diverticulitis.

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Zentralbl Chir. 2005 Apr;130(2):123-7.
[Surgical therapy in right-sided diverticulitis.]
[Article in German]
Hildebrand P, Birth M, Bruch HP, Schwandner O.
Klinik fur Chirurgie, Universitatsklinikum Schleswig-Holstein, Campus Lubeck, Lubeck.

INTRODUCTION: Left-sided diverticulitis is a common disease in Western countries, whereas right-sided diverticultitis is rare and symptoms are often similar to the clinical signs of an acute appendicitis. It was the aim of this study to analyse surgical experience in right-sided diverticulitis. METHODS: All patients who underwent resectional surgery for both right-sided and sigmoid diverticular disease were entered prospectively in a registry database (8-year observation period, 1996-2003). For the current study, a retrospective analysis of all patients who underwent ileocolic resection or right colectomy for right-sided colonic diverticulitis was performed, specifically focussing on incidence, clinical symptoms, indication for surgery, type of procedure, and histopathological parameters including immunohistochemistry, and outcome in right-sided diverticulitis. RESULTS: Within eight years, 481 patients were treated surgically for chronically recurrent or acute complicated diverticular disease: 468 patients with sigmoid diverticulitis, 12 patients with right-sided diverticulitis, and 1 patient with combined right-sided and sigmoid diverticular disease. This corresponds to an incidence of right-sided diverticulitis of 2.5 % related to the total number of resections for diverticulitis, and an incidence of 1.3 % in relation to the appendectomies in our patients. In 4 patients, acute appendicitis was presumed preoperatively. Most common diagnostic tool was ultrasonography. Right colectomy was performed in 9 patients with complicated cecal diverticulitis, whereas ileocolic resection was performed in 2 patients and simultaneous ileocolic and sigmoid resection was carried out in one patient. Postoperatively, no morbidity occurred. Histopathological assessment showed local perforation in 75 % (9/12). Hypoganglionosis or aganglionosis was detected in 5 of 12 resected specimen. DISCUSSION: As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis can be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis, and surgery is only indicated in complicated right-sided diverticulitis. Resection of the inflamed colon with primary anastomosis is safe and can be performed by laparoscopy in experienced centers. At present, it can only be speculated whether hypoganglionosis or aganglionosis are causative factors in the etiology of right-sided diverticulitis.

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J Surg Res. 2005 Apr;124(2):318-23.
Temporal changes in the management of diverticulitis.
Salem L, Anaya DA, Flum DR.
Department of Surgery, University of Washington, Seattle, WA 98195-6410, USA.

PURPOSE: This study was designed to evaluate temporal trends in the use and type of operative and non-operative interventions in the management of diverticulitis. METHODS: A retrospective cohort using a statewide administrative database was used to identify all patients hospitalized for diverticulitis in the state of Washington (1987-2001). Poisson and logistic regression were used to calculate changes in the frequency of hospitalization, operative and percutaneous interventions, and colostomy over time. RESULTS: Of the 25,058 patients hospitalized non-electively with diverticulitis (mean age 69 +/- 16, 60% female) there were only minimal changes in the frequency of admissions over time (0.006% increase per year-IRR 1.00006 95% CI 1.00004, 1.00008). The odds of an emergency colectomy at initial hospitalization decreased by 2% each year (OR 0.98 95% CI 0.98, 0.99) whereas the odds of percutaneous abscess drainage increased 7% per year (OR 1.07 95% CI 1.05, 1.1). Among patients undergoing percutaneous drainage, the odds of operative interventions decreased by 9% compared to patients who did not have a percutaneous intervention (OR 0.91 95% CI 0.87, 0.94). The proportion of patients undergoing colostomy during emergency operations remained essentially stable over time (range 49-61%), as did the proportion of patients undergoing prophylactic colectomy after initial non-surgical management (approximately 10%). CONCLUSIONS: There was a minimal increase in the frequency of diverticulitis admissions over time. A rise in percutaneous drainage procedures was associated with a decrease in emergency operative interventions. The proportion of patients undergoing colostomy remained stable, and there does not seem to be a significant increase in the use of one-stage procedures for diverticulitis.

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Am J Gastroenterol. 2005 Apr;100(4):910-7.
The management of complicated diverticulitis and the role of computed tomography.
Kaiser AM, Jiang JK, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C, Essani R, Beart RW Jr.
Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.

PURPOSE: Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis. METHODS: We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, "diverticulitis" mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (<40 yr, >40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis. RESULTS: In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%. CONCLUSIONS: CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patient's age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.

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Dis Colon Rectum. 2005 Mar 2; [Epub ahead of print]
Long-Term Outcome of Mesocolic and Pelvic Diverticular Abscesses of the Left Colon: A Prospective Study of 73 Cases.
Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F.
Clinic of Digestive Surgery, University Hospital of Geneva, Geneva, Switzerland, pambrosetti@gntmed.ch.

PURPOSE: The aim of of this study was to evaluate prospectively the long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon. METHODS: Between October 1986 and October 1997, a total of 465 patients urgently admitted to our hospital with a suspected diagnosis of acute left-sided colonic diverticulitis had a CT scan. Of 76 patients (17 percent) who had an associated mesocolic or pelvic abscess, 3 were lost to follow-up. The remaining 73 patients (45 with a mesocolic abscess and 28 with a pelvic abscess) were followed for a median of 43 months. RESULTS: of the 45 patients with a mesocolic abscess, 7 (15 percent) required surgery during their first hospitalization versus 11 (39 percent) of the 28 patients with a pelvic abscess (P = 0.04). At the end of follow-up, 22 (58 percent) of the 38 patients with a mesocolic abscess who had successful conservative treatment during their first hospitalization did not need surgical treatment vs. 8 (47 percent) of the 17 who had a pelvic abscess. Altogether, 51 percent of the patients with a mesocolic abscess had surgical treatment versus 71 percent of those with a pelvic abscess (P = 0.09). CONCLUSIONS: Considering the poor outcome of pelvic abscess associated with acute left-sided colonic diverticulitis, percutaneous drainage followed by secondary colectomy seems justified. Mesocolic abscess by itself is not an absolute indication for colectomy.

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JSLS. 2005 Jan-Mar;9(1):63-7.
Factors associated with complications of open versus laparoscopic sigmoid resection for diverticulitis.
Simon T, Orangio GR, Ambroze WL, Armstrong DN, Schertzer ME, Choat D, Pennington EE.
Georgia Colon and Rectal Surgical Associates, Atlanta, Georgia, USA.

BACKGROUND: This study critically reviews sigmoid colon resection for diverticulitis comparing open and laparoscopic techniques. METHODS: We conducted a retrospective review of all open and laparoscopic cases of diverticulitis between 1992 and 2001. Data analyzed included the following: indications for operation, postoperative complications, and incidence of laparoscopic conversion to laparotomy. Major and minor complications were analyzed in relation to patients' preoperative diagnosis, age, presence or absence of splenic flexure mobilization, length of stay, and laparoscopic sigmoid resection versus open sigmoid resection. RESULTS: Over a 10-year period, 166 resections for diverticulitis were performed including 126 open cases and 40 laparoscopic cases. No significant differences existed in patient characteristics between the groups. Major complications occurred in 14% of patients, and the laparoscopic conversion rate was 20%. The presence of abscess, fistula, or stricture preoperatively was associated with a higher complication rate only in patients > or =50 years old undergoing open sigmoid resection. The length of stay between patients undergoing laparoscopic resection was significantly less than in patients having open resection. CONCLUSION: Advanced laparoscopic sigmoid resection is an alternative to open sigmoid resection in patients with diverticulitis and its complications. Open sigmoid resection in patients >50 years may have a higher complication rate in complicated diverticulitis when compared with laparoscopic sigmoid resection (all patient ages) and open sigmoid resection (patients <50 years old). Regarding complications, no difference existed between the length of stay in patients with open vs. laparoscopic resection.

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Adv Anat Pathol. 2005 Mar;12(2):74-80.
Diverticulosis coli: update on a "western" disease.
Ye H, Losada M, West AB.
>From the Department of Pathology, New York University, New York, New York.

Diverticular disease affects upwards of 50% of the population over the age of 60 years in Western countries and is becoming more common as the population ages. Studies from the 1970s and 1980s related its occurrence to the use of low-fiber diets and to the prolonged colonic transit time and increased intraluminal pressure associated with low-volume stools. Pulsion diverticula (pseudodiverticula) emerge through the thickened circular layer of the muscularis propria of the left colon at points of penetration of the vasa recta that supply the submucosa and mucosa. Complications of diverticular disease such as hemorrhage, diverticulitis, peridiverticular abscess, fistula, and perforation are well recognized. More recently, attention has been drawn to the polypoid prolapsing mucosal folds that may develop as the affected segment of bowel (usually the sigmoid) becomes shorter and to changes in the mucosa surrounding the diverticula and in the bowel wall that may result in confusion with ulcerative colitis or Crohn disease (sigmoid colitis-associated diverticulosis [SCAD]). Distinguishing SCAD from these entities is extremely important, and pathologists should be aware of the possibility of overdiagnosing chronic inflammatory bowel disease in biopsies or resection specimens of sigmoid colon with diverticular disease.

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Expert Opin Pharmacother. 2005 Jan;6(1):69-74.
Mesalazine for diverticular disease of the colon - a new role for an old drug.
Tursi A.
Lorenzo Bonomo' Hospital, Digestive Endoscopy Unit, Andria (BA), Italy. antotursi@tiscali.it.

Colonic diverticulosis is among the most common diseases of developed countries. Its prevalence is approximately 5 - 10% of the population by age 50, and 30, 50 and 66% of those > 50, > 70 and > 85years of age, respectively. Antibiotics have been successfully used in the treatment of uncomplicated diverticular disease; however, the use of mesalazine (alone or in combination with antibiotics) in treating uncomplicated diverticulitis has been successfully developed in recent years. Indeed, mesalazine (with or without antibiotics) showed significant superiority in improving the severity of symptoms, bowel habits, and in preventing symptomatic recurrence of diverticulitis over antibiotics alone. More-over, in light of some preliminary results, it is probable that the association of mesalazine with probiotics may in the future be the first-choice treatment for mild-to-moderate uncomplicated attacks of acute diverticulitis.

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Dis Colon Rectum. 2005 Jan;48(1):148-52.
Laparoscopic sigmoidectomy for fistulized diverticulitis.
Laurent SR, Detroz B, Detry O, Degauque C, Honore P, Meurisse M.
Department of Abdominal Surgery, CHU Sart Tilman B35, Liege, Belgium.

PURPOSE: Nowadays laparoscopic colorectal surgery has demonstrated its advantages, including reduced postoperative pain, decreased duration of ileus, and shorter hospital stay. Few studies report results of laparoscopic surgery in complicated diverticulitis. This study was designed to analyze the results of laparoscopic sigmoidectomy in patients with fistulized sigmoiditis. METHODS: The authors retrospectively reviewed 16 patients who had laparoscopic sigmoidectomy for fistulized diverticulitis between 1992 and 2003 in a series of 247 laparoscopic colectomies. Eleven patients presented with colovesical, four with colovaginal, and one with colocutaneous fistulas; all were caused by sigmoiditis. The procedure always consisted of celioscopic sigmoidectomy with stapled transanal suture and, when indicated, closure of the cystic or vaginal fistula orifice. RESULTS: Mean age was 60 (range, 39-78) years. Mean number of episodes of diverticulitis before operation was three (range, 1-5). Mean time between the last episode and operation was 46 (range, 2-250) weeks. In our first three years of experience, three cases (18.7 percent) were converted to laparotomy. Reasons for conversion were the necessity for intestinal resection, splenectomy, and a wound of the anterior rectum. The mean operative time was 172 (range, 100-280) minutes. Mean hospital stay was 5.7 (range, 3-12) days. There was no mortality. Postoperative morbidity (2 patients, 12.5 percent) consisted of one pulmonary infection and one splenectomy. Long-term follow-up revealed no recurrence of diverticulitis and one incisional hernia. CONCLUSIONS: In experienced hands, laparoscopic sigmoidectomy may be a safe and effective procedure for fistulized sigmoiditis.

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Br J Surg. 2005 Jan 31;92(2):133-142 [Epub ahead of print]
Elective surgery after acute diverticulitis.
Janes S, Meagher A, Frizelle FA.
Colorectal Unit, Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.

BACKGROUND:: Diverticulitis is a common condition. Practice guidelines from many organizations recommend bowel resection after two attacks. The evidence for such a recommendation is reviewed. METHODS:: A Medline literature search was performed to locate English language articles on surgery for diverticular disease. Further articles were obtained from the references cited in the literature initially reviewed. RESULTS:: Most people with diverticulosis are asymptomatic. Diverticular disease occurs in over 25 per cent of the population, increasing with age. After one episode of diverticulitis one-third of patients have recurrent symptoms; after a second episode a further third have a subsequent episode. Perforation is commonest during the first episode of acute diverticulitis. After recovering from an episode of diverticulitis the risk of an individual requiring an urgent Hartmann's procedure is one in 2000 patient-years of follow-up. Surgery for diverticular disease has a high complication rate and 25 per cent of patients have ongoing symptoms after bowel resection. CONCLUSION:: There is no evidence to support the idea that elective surgery should follow two attacks of diverticulitis. Further prospective trials are required. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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Aust Fam Physician. 2004 Dec;33(12):983-6.
Colonic diverticular disease.
Steel M.
Box Hill Hospital, Victoria. msteel@gisurgical.com.au

BACKGROUND: Diverticular disease of the colon is common and the spectrum is broad, ranging from asymptomatic diverticulosis to perforation and massive haemorrhage requiring emergency colectomy. OBJECTIVE: This article discusses the epidemiology, pathophysiology, symptomatology and management of common presentations of diverticular disease including a brief review of surgical management. DISCUSSION: Management is based on the patient's symptoms and signs with assistance from findings at colonoscopy, computerised tomography scanning and occasionally bleeding localisation studies. For minimally symptomatic patients, a high fibre diet is the mainstay of management. Those with diverticulitis require antibiotics and bowel rest, and hospitalisation may be required. Surgery is indicated for recurrent diverticulitis, complicated diverticulitis, perforation and severe bleeding. This involves resection of the affected colon segment and can be performed laparoscopically or open.

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Dis Colon Rectum. 2004 Nov;47(11):1953-64.
Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review.
Salem L, Flum DR.
Department of Surgery, University of Washington, Seattle, Washington 98195-6410, USA.

PURPOSE: This systematic literature review was designed to summarize and compare the reported outcomes of one-stage and two-stage operations for the treatment of perforated diverticulitis with peritonitis. METHODS: This review identified 98 published studies (1957-2003) dealing with the surgical management of perforated diverticulitis with peritonitis, either with primary resection and anastomosis or with the Hartmann's procedure. Aggregated results of adverse outcomes were calculated but statistical comparisons were not appropriate because of data and design heterogeneity. RESULTS: Operative mortality data from patients with diverticular peritonitis undergoing Hartmann's procedure (n = 1,051) were derived from 54 studies. Considering the Hartmann's procedure and its reversal procedures together, the mortality rate was 19.6 percent (18.8 percent for the Hartmann's procedure and 0.8 percent for its reversal), the wound infection rate was 29.1 percent (24.2 percent for the Hartmann's procedure and 4.9 percent for its reversal), and stoma complications and anastomotic leaks (in the reversal operation) occurred in 10.3 and 4.3 percent, respectively. Of 569 reported cases of primary anastomosis from 50 studies, the aggregated mortality rate was 9.9 (range, 0-75) percent with an anastomotic leak rate of 13.9 (range, 0-60) percent and a wound infection rate of 9.6 (range, 0-26) percent. CONCLUSIONS: Reported mortality and morbidity in patients with diverticular peritonitis who underwent primary anastomosis were not higher than those in patients undergoing Hartmann's procedure were. This suggests that primary anastomosis is a safe operative alternative in certain patients with peritonitis. Despite inclusion of only patients with peritonitis in this analysis, selection bias may have been a limitation and a prospective, randomized trial is recommended.

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Arch Surg. 2004 Nov;139(11):1221-4.
Impact of primary resection on the outcome of patients with perforated diverticulitis.
Chandra V, Nelson H, Larson DR, Harrington JR.
Departments of General Surgery, Mayo Clinic, Rochester, Minn. 55905, USA.

BACKGROUND: Primary resection has replaced the conventional drainage procedure in the management of patients with generalized peritonitis complicating diverticular disease of the colon. This study investigates the impact of primary resection on operative mortality, identifies predictors of mortality, and compares the results with those of our earlier experience. HYPOTHESIS: Primary resection of the perforated diseased segment of the colon is associated with lower mortality rates than the drainage procedure in patients with Hinchey stages 3 and 4 diverticulitis. DESIGN: Retrospective analysis. SETTING: Tertiary care referral center. PATIENTS: We included 138 consecutive patients who underwent emergent operation for generalized peritonitis complicating diverticular disease of the colon (Hinchey stages 3 and 4) during a period of 16 years (January 1983 to May 1999). MAIN OUTCOME MEASURES: The 30-day mortality rate was analyzed and predictors of mortality identified. RESULTS: Patients were classified as having spreading purulent peritonitis (n = 44, 31.9%), diffuse peritonitis (n = 64, 46.4%), or fecal peritonitis (n = 30, 21.7%). One hundred thirty-one patients (94.9%) underwent primary resection, 6 patients (4.3%) underwent resection and primary anastomosis, and 1 patient required total colectomy and end ileostomy. Thirteen of the 138 patients in the present group died (1983-1998), representing a perioperative mortality rate of 9%. There was no significant difference in mortality when compared with our earlier study (1972-1982), which had a mortality rate of 12%, considering that more than 25% of the patients in that group were managed by colostomy and drainage alone. Factors identified univariately as predictors of mortality were age of more than 70 years (P = .047), 2 or more comorbid conditions (P<.01), obstipation at initial examination (P = .02), use of steroids (P = .01), and perioperative sepsis (P<.001). CONCLUSIONS: Primary resection has become the standard practice for patients with generalized peritonitis complicating diverticulitis. Mortality rates have not significantly declined despite more aggressive surgical management of the septic source. Because advanced age, comorbid conditions, and perioperative sepsis predict mortality, it is suggested that further reduction in mortality will require improvement in medical management of perioperative sepsis and comorbid conditions.

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Am Surg. 2004 Oct;70(10):932-5.
Diverticulitis: truly minimally invasive management.
Macias LH, Haukoos JS, Dixon MR, Sorial E, Arnell TD, Stamos MJ, Kumar RR.
Department of Surgery, Division of Colon and Rectal Surgery, Harbor-UCLA Medical Center, Torrance, California 90509, USA.

The purpose of this study is to evaluate the treatment of patients with acute diverticulitis in the inpatient setting using minimal intervention. This was a retrospective study of 75 patients admitted over a 3-year period with acute diverticulitis as evidenced by computed tomography (CT) and clinical scenario. Of the patients enrolled, 24 (32%) had abscesses identified on their initial CT scan. An additional four patients had abscesses noted on a subsequent CT scan obtained because of lack of complete improvement with medical management, thus raising the total number of abscesses to 28 (37%). Of the patients with abscesses, 10 (36%) underwent drainage using a CT-guided percutaneous or ultrasound-guided transrectal approach an average of 6 days after admission. Of the 75 patients, five (7%) required operative intervention during the initial hospitalization for failure of medical management, two (40%) of whom had abscesses on presentation. The overall median length of hospitalization was 5 (interquartile range [IQR] 4-9) days, and 18 patients (24%) had recurrences during the study period. Our conservative approach to percutaneous and surgical intervention resulted in relatively low percutaneous drainage, a low operative rate, and a reasonable length of hospitalization and recurrence rate.

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Surgery. 2004 Oct;136(4):725-30.
Laparoscopic sigmoid colectomy after acute diverticulitis: when to operate?
Natarajan S, Ewings EL, Vega RJ.
Department of Surgery, University of Winsconsin Medical School, and Meriter Hospital, Madison, WI 53715, USA.

BACKGROUND: Laparoscopic sigmoid colectomy has become an acceptable method of surgical treatment for diverticulitis. However, an optimal waiting period before attempting elective laparoscopic colectomy has not been established. We sought to evaluate the relationship between the time interval from an acute episode of diverticulitis to laparoscopic colectomy and surgical outcomes. METHODS: All patients undergoing laparoscopic colectomy during a period of 10 years in a single institution were studied. Retrospectively collected data included patient demographics, American Society of Anesthesiologists score, prior episodes of diverticulitis, interval between last attack and operation, operative time, complications, conversion, and recovery period. RESULTS: A total of 120 patients were included; 89 had a primary diagnosis of diverticulitis. Mean interval from acute diverticulitis to operation was 64 days (range, 1 to 240). Median number of episodes of diverticulitis before colectomy was 3 (range, 1 to 10). Ten patients (11%) required conversion from laparoscopic to open colectomy. Neither interval from acute attack to operation nor number of prior episodes of diverticulitis was associated with any significantly increased rate of conversion to open colectomy, complication rate, operative time, or recovery period (P=not significant). CONCLUSIONS: Our study showed no direct relationship between surgical timing after acute diverticulitis and complication or conversion rates after elective laparoscopic sigmoid colectomy.

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Int J Colorectal Dis. 2004 Sep 4; [Epub ahead of print]
Surgical management of cecal diverticulitis: is diverticulectomy enough?
Papaziogas B, Makris J, Koutelidakis I, Paraskevas G, Oikonomou B, Papadopoulos E, Atmatzidis K.
Second Surgical Clinic of the Aristotle University of Thessaloniki, Fanariou Street 16, 55133, Thessaloniki, Greece.

INTRODUCTION. Cecal diverticulitis is a rare condition in the western population. The optimal management of this condition is still controversial, ranging from conservative antibiotic treatment to aggressive resection. We present our experience of the surgical management of eight cases of cecal diverticulitis over a 25-year period. PATIENTS AND METHODS. The mean age of the patients was 54.2 years. Five patients underwent diverticulectomy, 2 patients underwent ileocecal resection, and 1 patient underwent suture of the perforated diverticulum. RESULTS. The postoperative course of all patients was uneventful. At long-term follow-up (mean 14.6 years, range 1-25 years) none of the patients who underwent diverticulectomy, mentioned any symptom or complication. CONCLUSION. We conclude that diverticulectomy, if technically feasible, could be considered as adequate therapy for cecal diverticulitis. Aggressive resection should be considered in cases of extensive inflammatory changes.

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Dis Colon Rectum. 2004 Jul;47(7):1187-90; discussion 1190-1. Epub 2004 May 19.
Diverticulitis in young patients: is resection after a single attack always warranted?
Guzzo J, Hyman N.
Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont, USA.

PURPOSE: Diverticulitis has been described as a more virulent disease in young patients, necessitating an aggressive surgical approach. We hypothesized that the subgroup of young patients who do not require surgery on their initial presentation are unlikely to present at a later date with perforation and do not always require prophylactic resection as commonly recommended. METHODS: A retrospective chart review was conducted of all patients presenting to Fletcher Allen Health Care, the teaching hospital of the University of Vermont, from January 1, 1990 to June 30, 2001. Outcomes in patients aged 50 years or younger (Group 1) were compared with patients older than aged 50 years (Group 2) using a log-rank test. RESULTS: A total of 762 patients were admitted with sigmoid diverticulitis during the study period, 238 (31 percent) of whom underwent surgery. Two hundred fifty-nine patients (34 percent) were younger than aged 50 years (Group 1). The risk of requiring surgery on initial hospital presentation was similar between the two groups (24 vs. 22 percent, respectively; P = 0.8). However, Group 1 patients were more likely to be treated operatively at some point during the study period (40 vs. 26 percent; P = 0.001) because of an increase in elective resections. Of 196 patients in Group 1 who had an initial medically managed admission, only 1 presented at a later date with perforation (0.5 percent). CONCLUSIONS: The risk of subsequent diverticular perforation in medically managed young patients with sigmoid diverticulitis is very low. As such, the frequently espoused policy of routine surgery after a single attack of diverticulitis in young patients may not be warranted. A more selective approach seems to be safe.

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Dig Liver Dis. 2004 Jul;36(7):435-45.
Diverticulitis: when and how to operate?
Aydin HN, Remzi FH.
Department of Colorectal Surgery, Cleveland Clinic Foundation, A30 9500 Euclid Avenue, Cleveland, OH 44195, USA.

Diverticular disease, and particularly diverticulitis, has increasing incidence in industrialised countries. Diverticular disease can be classified as symptomatic uncomplicated disease, recurrent symptomatic disease, and complicated disease. Conservative or medical management is usually indicated for acute uncomplicated diverticulitis. Indications for surgery include recurrent attacks and complications of the disease. Surgical treatment options have changed considerably over the years along with the inventions of new diagnostic tools and new surgical therapeutic approaches. Indications and timing for surgery of diverticular disease are determined mainly by the stage of the disease. In addition to this major factor, the individual risk factors of the patient along with the course of the disease after conservative or operative therapy do play a big role in decision-making and treatment of this disease. In this context, the purpose of this article is to review the surgical treatment of diverticulitis with regard to indications, timeliness of operative intervention, operative options and techniques, and special circumstances.

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J Heart Lung Transplant. 2004 Jul;23(7):845-9.
Severe diverticulitis after heart, lung, and heart-lung transplantation.
Qasabian RA, Meagher AP, Lee R, Dore GJ, Keogh A.
Department of Colorectal Surgery, St Vincent's Hospital, Sydney, Australia.

BACKGROUND: In this study, we reviewed our experience with severe diverticulitis in patients who have undergone heart and/or lung transplantation to assess whether transplant recipients are at increased risk of having severe diverticulitis compared with the general population. METHODS: We reviewed the records of patients who underwent heart and/or lung transplantation from 1984 to 2000, inclusive, and identified patients with severe diverticulitis that required surgery or that resulted in death. We compared this incidence with the incidence of such complications in the general population, served by the same institution during a 2-year period, 1999 to 2000. RESULTS: A total of 953 patients underwent transplantation in the study period. The mean follow-up was 57 months, a total follow-up of 4528 patient-years. Nine patients (mean age, 54 years) had severe diverticulitis that required surgical intervention (8 patients) or that resulted in death (1 patient died without surgical intervention). During 1999 to 2000, 16 patients (mean age, 66 years) from the general population were treated for severe diverticulitis that required surgical intervention, 3 of whom died. From census and area health data, we found that the study institution serves approximately 90000 people older than 40 years, with a total follow-up of 180000 patient-years. The incidence rate ratio for severe diverticulitis when comparing the transplant with the non-transplant groups was 22.2 (95% confidence interval; 9.9-50.0; p < 0.001). CONCLUSIONS: Patients with severe diverticulitis who have undergone heart and/or lung transplantation can be treated surgically with a small mortality rate. Transplant recipients probably are at substantially increased risk of experiencing severe diverticulitis.

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J Clin Gastroenterol. 2004 May-Jun;38(5 Suppl):S2-7.
The natural history of diverticulitis: fact and theory.
Floch MH, Bina I.
Digestive Disease Section, Yale University School of Medicine/Norwalk Hospital, 30 Stevens Street, Suite E, Norwalk, CT 08650, USA. martinfloch@snet.net

Epidemiological and anatomic evidence indicates that approximately 60% of humans of westernized societies living into the sixth decade will develop diverticulosis of the colon. The cause remains unknown, but epidemiological studies indicate it is a combination of decreased dietary fiber intake and increased intracolonic pressure. The intraluminal pressure exerted on the wall causes a diverticular outpocketing at any one of the three areas in which vessels enter the wall. In this paper, we advance a hypothesis that fiber deficiency not only leads to diverticula formation but also causes a change in the microecology that results in decreased colon immune response and permits a low-grade chronic inflammatory process that precedes a full-blown acute diverticulitis. Pathophysiologic studies reveal that complications do not occur until there is microperforation through the wall of the diverticulum into the pericolic tissue. The perforation might be small and cause a microabscess, or extend to a phlegmon, or extend to a large abscess formation. Free perforation occurs rarely, but fistulization does occur and most commonly to the bladder. The clinical findings vary. Most often, the clinical picture is one of fever, abdominal pain, a change in bowel habit, and localizing findings associated with leukocytosis. Computerized tomography scanning has become the procedure of choice to evaluate the symptoms since it is of less risk than a barium enema and obtains more information. The differential diagnosis may be difficult but usually can be made with accuracy. Medical treatment is preferred with appropriate antibiotic therapy and variations in fiber intake. When abscess occurs, percutaneous drainage may be tried, but when it is unsuccessful, surgical intervention is necessary. Sudden hemorrhage from a vessel in diverticula may also occur. It is estimated that approximately 20% of all patients that develop diverticula will have either inflammatory or bleeding episodes. In conclusion, fiber deficiency results in diverticular formation and a chronic inflammation that may progress to acute or chronic diverticulitis that can be treated medically but may require surgical intervention.

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J Clin Gastroenterol. 2004 May-Jun;38(5 Suppl):S11-6.
The pathology of diverticulosis coli.
West AB, Losada M.
Department of Pathology, New York University, 560 First Avenue, TH-461, New York, NY 10016, USA. Brian.west@med.nyu.edu

Left-sided diverticulosis coli is a common condition in western communities, with 30% to 50% of adults over the age of 60 being affected. It predominantly involves the sigmoid colon. The diverticula (pseudodiverticula) are pockets of mucosa bounded by muscularis mucosae and invested with a thin layer of submucosa, that are forced out through weak points in the muscularis propria, the tips ending in the colonic subserosa. The weak points in the muscle coat are the sites of entry of the nutrient vessels of the colonic mucosa. Diverticulosis is attributed to increased colonic intraluminal pressure while straining at stool in individuals who eat low-fiber diets. Muscular hypertrophy, shortening of the bowel, and thickened mucosal folds due to mucosal redundancy are characteristic of this condition. Complications of diverticulosis include bleeding, diverticulitis, peridiverticular abscess, perforation, stricture, and fistula formation. However, most individuals with diverticulosis are asymptomatic, without evidence of complications. Mucosal changes in the diverticula in uncomplicated diverticulosis include an increased lymphoid infiltrate, development of lymphoglandular complexes, mucin depletion, mild cryptitis, architectural distortion, Paneth cell metaplasia, and ulceration. The mucosa of the remainder of the sigmoid colon (ie, the nondiverticular mucosa) is usually normal, but in about 1% of cases it has features that are indistinguishable from ulcerative colitis or from Crohn's disease (segmental colitis associated with diverticular disease, SCAD). Such cases pose a difficult diagnostic challenge as patients with SCAD respond to medical or surgical therapy for diverticular disease, whereas those with ulcerative colitis or Crohn's disease will develop other manifestations of their disease in time and require different treatment. In SCAD, the mucosal changes are confined to the area of diverticulosis; therefore, histologic evaluation of the rectum (which is unaffected by diverticulosis) and more proximal bowel can be helpful in the differential diagnosis.

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Med Sci Monit. 2004 May 1;10(5):PI70-PI73. Epub 2004 Apr 28.
Rifaximin plus mesalazine followed by mesalazine alone is highly effective in obtaining remission of symptomatic uncomplicated diverticular disease.
Brandimarte G, Tursi A.
Department of Internal Medicine, Division of Gastroenterology, Cristo Re Hospital, Rome, Italy.

Background: Rifaximin plus mesalazine has been showed to be more effective than rifaximin alone in the treatment of recurrent and complicated diverticulitis of the colon. We investigated the effectiveness of the combination rifaximin/mesalazine followed by mesalazine alone to evaluate tolerability and effectiveness in symptomatic remission in uncomplicated diverticular disease. Material/Methods: We studied 90 consecutive patients (39 M, 51 F, mean age 67.2 yrs, range 32-91 yrs) with symptomatic uncomplicated diverticular disease. We assessed the following symptoms, scoring them on a quantitative scale: 1) constipation, 2) diarrhea, 3) abdominal pain, 4) rectal bleeding, and 5) mucus with stools. All were treated with 800 mg/day rifaximin plus 2.4 gr/day mesalazine for 10 days, followed by 1.6 gr/day mesalazine for 8 weeks. They were re-evaluated at the end of mesalazine-alone treatment. Results: Eighty-six patients completed the study (95.56%): the total score decreased from 1439 to 44 (p<0.001). 70 patients (per-protocol: 81.40% (C.I.: 67-94%); on intention-to-treat: 77.78% (C.I.: 60-85%)) were completely asymptomatic after the 8th week of treatment with mesalazine alone (total symptomatic score: 0), while 16 (per-protocol: 18.60%; on intention-to-treat: 17.77%) showed only slight symptoms (total score: 44). Two (2.22%) showed recurrence of diverticulitis after 4 and 6 weeks of treatment with mesalazine alone. Two patients (2.22%) were withdrawn from the study for diarrhea after starting mesalazine. Two others (2.22%) showed transitory pruritus (one) and epigastric pain (one). Conclusions: The results show that rifaximin/mesalazine followed by mesalazine alone is extremely effective in resolving symptoms in patients with symptomatic uncomplicated diverticular disease.

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Int Surg. 2004 Jan-Mar;89(1):35-8.
Surgical treatment of perforated diverticular disease: evaluation of factors predicting prognosis
in the elderly.
Pisanu A, Cois A, Uccheddu A.
Dipartimento Chirurgico, Materno-Infantile e di Scienze dell'Immagine, Sezione di Semeiotica Chirurgica, Iniversita Degli Studi di Cagliari, Italy.

Diverticulitis free perforation carries a high mortality rate in the elderly, and this motivates the search for specific prognostic factors. The aim of this study was to assess prognostic factors in patients over 70 years of age that were operated on for generalized peritonitis caused by perforated colonic diverticulitis. A retrospective study in 22 patients was performed: demographic data, American Society of Anaesthesiology grading, site and diameter, degree of perforation according to Hinchey's classification, duration of symptoms, Manheim Peritonitis Index (MPI) score, and surgical treatment were evaluated. Patients over 70 years of age were grouped in deceased and not deceased. In this subgroup, postoperative mortality rate was 40%, and diameter of perforation, duration of symptoms, and MPI score seemed significantly related to postoperative death. In the elderly, prognosis is strongly related to duration of symptoms, and treatment delay is caused by late hospitalization because of a low sensibility to the disease symptoms in old people.

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Chir Ital. 2004 Jan-Feb;56(1):95-8.
Laparoscopic colorrhaphy, irrigation and drainage in the treatment of complicated acute diverticulitis: initial experience.
Da Rold AR, Guerriero S, Fiamingo P, Pariset S, Veroux M, Pilon F, Tosato S, Ruffolo C, Tedeschi U.
Surgical Unit, San Martino Hospital, Belluno, Italy.

The natural history of diverticulosis is worthy of note for its acute, sometimes recurrent, attacks of diverticulitis and the significant risk of serious complications, such as abscess, fistula and peritonitis. Most mild attacks of diverticulitis respond well to medical therapy while surgical treatment is indicated in the complicated forms of the disease. We evaluate the results of treatment of complicated acute diverticulitis by laparoscopic colorrhaphy, irrigation and drainage as a minimal surgical approach in 7 selected patients. We retrospectively analyzed all patients admitted to our institute for acute diverticulitis from 1996 to 2001. One hundred and thirty-five patients were admitted for acute sigmoid diverticulitis. Ninety-eight patients (72%) had their diverticular disease completely resolved after medical therapy, while 37 (28%) required a surgical approach. Seven patients underwent a laparoscopic colorrhaphy with irrigation and drainage. Laparoscopic procedures were completed in 6 patients. No perioperative morbidity or mortality was observed. All patients were discharged with no further re-operation. The technique could be considered a valid alternative for the management of complicated and perforated diverticulitis in selected patients.

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Mo Med. 2004 Jan-Feb;101(1):61-3.
Diverticular bleeding: novel treatment with band ligation.
Tucker LE.

Diverticulosis accounts for 50% of adult cases of lower gastrointestinal bleeding. Recurrent or persistent bleeding usually is treated surgically. Recent studies suggest that 20% of patients with diverticular bleeding can have the site identified and treated endoscopically. Treatment modalities include injection techniques, thermal therapy and hemoclips. This paper reports three cases successfully treated with band ligation, after initial epinephrine injection therapy had failed.

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Drugs Aging. 2004;21(4):211-28.
Epidemiology and management of diverticular disease of the colon.
Kang JY, Melville D, Maxwell JD.
Department of Gastroenterology, St George's Hospital and Medical School, London, England.

Colonic diverticula are protrusions of the mucosa through the outer muscular layers, which are usually abnormally thickened, to form narrow necked pouches. Diverticular disease of the colon covers a wide clinical spectrum: from an incidental finding to symptomatic uncomplicated disease to diverticulitis. A quarter of patients with diverticulitis will develop potentially life-threatening complications including perforation, fistulae, obstruction or stricture. In Western countries diverticular disease predominantly affects the left colon, its prevalence increases with age and its causation has been linked to a low dietary fibre intake. Right-sided diverticular disease is more commonly seen in Asian populations and affects younger patients. Its pathogenesis and relationship to left-sided diverticular disease remains unclear. Diverticular disease of the colon is a significant cause of morbidity and mortality in the Western world and its frequency has increased throughout the whole of the 20th century. Since it is a disease of the elderly, and with an aging population, it can be expected to occupy an increasing portion of the surgical and gastroenterological workload. It is uncertain what symptoms uncomplicated diverticular disease gives rise to: there is an overlap with irritable bowel syndrome. Diagnosis is primarily by barium enema and colonoscopy, but more sophisticated imaging procedures such as computed tomography (CT) are increasingly being used to assess and treat complications such as abscess or fistula, or to provide alternative diagnoses if diverticulosis is not confirmed.Initial therapy for uncomplicated diverticulitis is supportive, including monitoring, bowel rest and antibacterials. CT is used to guide percutaneous drainage of abscesses to avoid surgery or allow it to be performed as an elective procedure. Surgery is indicated for complications of acute diverticulitis, including failure of medical treatment, gross perforation, and abscess formation that cannot be resolved by percutaneous drainage. Complications of chronic diverticulitis (fistula formation, stricture and obstruction) are also usually treated surgically. However, the indications for, and the timing and staging of operations for diverticular disease are often difficult decisions requiring sound clinical judgement. Factors such as the number of episodes of inflammation, the age of the patient, and his/her overall medical condition play a role in determining whether or not a patient should undergo surgical resection. Laparoscopic surgery may be associated with less pain, less morbidity and shorter hospital stays, but its exact role is yet to be defined. Diverticular disease of the colon is the most common cause of acute lower gastrointestinal haemorrhage, which can be massive. Although the majority of patients stop bleeding spontaneously, angiographic and surgical treatment may be required, while the place of endoscopic haemostasis remains to be established.

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Lancet. 2004 Feb 21;363(9409):631-9.
Diverticular disease of the colon.
Stollman N, Raskin JB.
Division of Gastroenterology, San Francisco General Hospital, and University of California San Francisco, San Francisco, CA 94110, USA. NStollman@medsfgh.ucsf.edu

Colonic diverticulosis refers to small outpouchings from the colonic lumen due to mucosal herniation through the colonic wall at sites of vascular perforation. Abnormal colonic motility and inadequate intake of dietary fibre have been implicated in its pathogenesis. This acquired abnormality is typically found in developed countries, and its prevalence rises with age. Most patients affected will remain entirely asymptomatic; however, 10-20% of those affected can manifest clinical syndromes, mainly diverticulitis and diverticular haemorrhage. As our elderly population grows, we can anticipate a concomitant rise in the number of patients with diverticular disease. Here, we review the incidence, pathophysiology, clinical presentation, and management of diverticular disease of the colon and its complications.

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Langenbecks Arch Surg. 2004 Feb 17 [Epub ahead of print]
Laparoscopic colectomy for recurrent and complicated diverticulitis: a prospective study of 396 patients.

Schwandner O, Farke S, Fischer F, Eckmann C, Schiedeck TH, Bruch HP.

Department of Surgery, University Hospital of Schleswig-Holstein, Luebeck Campus, Ratzeburger Allee 160, 23538, Luebeck, Germany.

BACKGROUND. It was the aim of this prospective study to evaluate the outcome of laparoscopic surgery for diverticular disease. METHODS. All patients who underwent elective laparoscopic colectomy for diverticular disease within a 10-year period were prospectively entered into a PC database registry. Indications for laparoscopic surgery were acute complicated diverticulitis (Hinchey stages I and IIa), chronically recurrent diverticulitis, sigmoid stenosis or outlet obstruction caused by chronic diverticulitis. Surgical procedures (sigmoid and anterior resection, left colectomy and resection rectopexy) included intracorporeal dissection and colorectal anastomosis. Parameters studied included age, gender, stage of disease, procedure, duration of surgery, intraoperative technical variables, transfusion requirements, conversion rate, total complication rate including major (requiring re-operation), minor (conservative treatment) and late-onset (post-discharge) complication rates, stay on ICU, hospitalisation, mortality, and recurrence. For objective evaluation, only laparoscopically completed procedures were analysed. Comparative outcome analysis was performed with respect to stage of disease and experience. RESULTS. A total of 396 patients underwent laparoscopic colectomy. Conversion rate was 6.8% ( n=27), so that laparoscopic completion rate was 93.2% ( n=369). Most common reasons for conversion were directly related to the inflammatory process, abscess or fistulas. The most common procedure was sigmoid resection ( n=279), followed by anterior resection ( n=36) and left colectomy ( n=29). Total complication rate was 18.4% ( n=68). Major complication rate was 7.6% ( n=28), whereas the most common complication requiring re-operation was haemorrhage in 3.3% ( n=12). Anastomotic leakage occurred in 1.6% ( n=6). Minor complications were noted in 10.7% ( n=40), late-onset complications occurred in 2.7% ( n=10). Mortality was 0.5% ( n=2). Mean duration of surgery was 193 (range 75-400) min, return to normal diet was completed after 6.8 (range 3-19) days. Mean hospital stay was 11.8 (range 4-71) days. No recurrence of diverticulitis occurred. CONCLUSION. Laparoscopic surgery for diverticular disease is safe, feasible and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.

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Am J Surg. 2004 Feb;187(2):233-7.
Toward therapeutic guidelines for patients with acute right colonic diverticulitis.
Komuta K, Yamanaka S, Okada K, Kamohara Y, Ueda T, Makimoto N, Shiogama T, Furui J, Kanematsu T.
Division of Colon and Rectal Surgery, Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Ngasaki 852-8102, Japan. komuta@net.negasaki-u.ac.jp

BACKGROUND: At present, little information is available on the outcome of medical therapy for patients with acute right colonic diverticulitis, and this has meant a gap in constructing guidelines for its treatment. METHODS: The records of patients with acute right colonic diverticulitis at Nagasaki University Graduate School and affiliated hospitals were reviewed and analyzed with the goal of establishing therapeutic guidelines. The time frame of the data analyzed was from 1984 to 2002. RESULTS: Of the 81 patients included in the data, 80 patients who were suffering a first attack were successfully treated with bowel rest and antibiotics. Two of these 80 patients underwent an elective operation at the surgeon's discretion during the original hospitalization and 1 (1.2%) needed an urgent operation. Of the 78 patients who responded to medical therapy, 16 (20.5%) developed recurrent right colonic diverticulitis. All 16 patients who had a second attack were successfully treated with medical therapy. Three of the 16 patients underwent an elective operation during this rehospitalization period. Of the 13 patients who had had a second attack and had responded to medical therapy, there was a third attack in 2 patients (15.4%). Both of these patients were again successfully treated with medical therapy. There has been no morbidity and no mortality related to recurrence to date. The average time from the first attack to us contacting the patient was 35.2 months. CONCLUSIONS: Unlike acute uncomplicated left colonic diverticulitis, our findings indicate that after two documented episodes, medical treatment alone rather than elective surgery may be considered as an effective guideline for the treatment of acute uncomplicated right colonic diverticulitis.

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Expert Opin Pharmacother. 2004 Jan;5(1):55-9.
Acute diverticulitis of the colon--current medical therapeutic management.
Tursi A.
Digestive Endoscopy Unit, Lorenzo Bonomo Hospital, Galleria Pisani, 4 70031 Andria (BA), Italy. antotursi@tiscali.it

Diverticular disease of the colon is very common in developed countries with its prevalence increasing with age, varying from < 10% in those < 40 years of age, to an estimated 50-66% of patients > 80 years of age. Diverticulitis, defined as inflammation and/or infection associated with diverticula, is the most common clinical complication of this disorder, affecting an estimated 10-25% of patients with colonic diverticula. The therapeutic measures aim at putting the intestine 'at rest', thus resolving the infection, the consequences of the inflammation and preventing or limiting complications. For patients with severe and complicated diverticulitis, ampicillin, gentamicin, metronidazole, piperacillin and tazobactam are the antibiotics successfully used in clinical practice, whereas ciprofloxacin, metronidazole and more recently, rifaximin, have been successfully used in the treatment of uncomplicated diverticular disease. Mesalazine (alone or in association with antibiotics) and probiotics are the two latest therapies for the treatment of diverticulitis which have been developed in the last few years. In fact, the combination of mesalazine and an antibiotic showed significant superiority in improving the severity of symptoms, bowel habits and in preventing symptomatic recurrence of diverticulitis than antibiotics alone, but probiotics also seem to be effective in preventing recurrence of the disease. In light of the excellent results obtained in the treatment of inflammatory bowel disease and irritable bowel syndrome, it is probable that probiotics may be the future best treatment also for mild-to-moderate uncomplicated attacks of acute diverticulitis, especially if used with salycilates.

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Semin Laparosc Surg. 2003 Dec;10(4):177-83.
Laparoscopy for diverticulitis.
Patel NA, Bergamaschi R.
Department of Surgery, Allegheny General Hospital, Drexel University College of Medicine Clinical Campus, Pittsburgh, Pennsylvania 15212-4772, USA.

Although the literature on laparoscopic surgery for diverticulitis includes data on more than 1800 patients, the quality of the studies is insufficient to draw definitive evidence-based conclusions. Nonrandomized evidence suggests that laparoscopic resection for uncomplicated diverticulitis of the sigmoid may fare better than its conventional counterpart not only in short-term outcome (preservation of the abdominal wall, shorter disability), but also in the long term (decreased rates of late symptomatic small bowel obstruction). Five-year recurrence rates show that a laparoscopic or conventional access is unlikely to have an impact, provided that the oral bowel end is anastomosed to the proximal rectum rather than to the distal sigmoid. The superiority of laparoscopy should be proven by measuring health-related and patient-centered outcome rather than surrogate endpoints. Areas of concern include replacing a conventional resection with laparoscopic suture, drainage, and colostomy in patients with free perforation and peritonitis. The role of laparoscopic surgery should be limited to resection for uncomplicated diverticulitis of the sigmoid performed by adequately trained surgeons. Benefits can be expected with this procedure, provided that indications for surgery are not influenced by the mode of access and that postoperative complication rates remain within the range of that for traditional colorectal surgery.

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Chir Ital. 2003 Nov-Dec;55(6):871-7.
[Complicated diverticular disease of the right colon. Diagnostic and therapeutic difficulties: our experience]
[Article in Italian]
Piccolini M, Francia L, Rosa C, Battaglia A, Biandrate F, Pesenti Campagnoni A, Pandolfi U.
Unita Operativa di Chirurgia Generale, Ospedale Civile di Vigevano, Azienda Ospedaliera della Provincia di Pavia.

Right colon diverticulitis is an uncommon disease in Western countries. Often the disease is congenital and the clinical manifestations presenting at onset simulate the signs and symptoms typical of other diseases, such as acute appendicitis, appendicular abscess or caecal carcinoma. Since the diagnosis is usually intraoperative, diverticulectomy is recommended only in particular cases, with no complications resulting from inflammatory reactions. In the other cases, right hemicolectomy or segmental resection are the elective surgical treatments, depending on the patient's clinical condition and on the local anatomical situation. The authors describe 8 cases of complicated right colon diverticulitis, one of which with haemorrhagic complications, observed over the period from January 1999 to March 2003. The rareness and diagnostic and therapeutic difficulties of this disease are emphasised.

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Colorectal Dis. 2003 Nov;5(6):528-43.
Laparoscopy and its current role in the management of colorectal disease.
Chung CC, Tsang WW, Kwok SY, Li MK.
Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China.

OBJECTIVE: To evaluate the current place of laparoscopy in the management of colorectal disease. METHOD: A literature search was undertaken on Medline between the period 1991 and 2002. RESULTS: From the literature there is good evidence that the laparoscopic approach is associated with at least some short-term advantages. Improved cosmesis and better patient's satisfaction are also evident. Because of this laparoscopy has been widely employed in various benign conditions. Among others, laparoscopic stoma formation, laparoscopic resection for diverticular disease and Crohn's disease, laparoscopic rectopexy, as well as laparoscopic assisted reversal of Hartmann's procedure were commonly reported. As port site recurrence and oncological safety are of less concern, there have been increasing reports on laparoscopic resection for colorectal cancer. Although long-term follow up data is still limited, results of large prospective studies as well as various randomized trials show that recurrence and survival rates of the laparoscopic approach were at least comparable to open surgery. As experience and confidence accumulates, there are also increasing reports on technically demanding, laparoscopic sphincter-saving rectal excision. Articles on functional aspects following this type of resection also start to appear, which might be one of the future directions. CONCLUSION: The applicability of laparoscopy to colorectal disease continues to expand. Laparoscopic approach should be considered for patients with benign conditions. For colorectal cancer, results from randomized trials so far have been favourable. Hence, the authors suggest the utility of laparoscopy in potentially curable cancer can also be judiciously relaxed.

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MMW Fortschr Med. 2003 Oct 2;145(40):32-5.
[Sigmoid diverticulitis -- indications for surgery and choice of procedure]
[Article in German]
Haring RU, Salm R.
Abt. fur Allgemein- und Viszeralchirurgie, Endoskopische Chirurgie, St.-Josefs-Krankenhaus, Freiburg. Rudolf.Haring@rkk-sjk.de

The first attack of uncomplicated diverticulitis is treated conservatively. Sigmoid resection is indicated for recurrent diverticulitis, in patients with manifest stenosis or fistula and for such emergencies as perforation, ileus or bleeding. Early surgery after the first episode is recommended for patients under 50 years of age, or immunocompromised patients. This is particularly true for patients with radiological signs of severe diverticulitis. Today elective sigmoid resection is a laparoscopic procedure. Properly carried out, the operation effects a definitive cure. The morbidity and mortality of the operation is low, and re-operations for recurrent diverticulitis are the exception. In the emergency situation a two-stage procedure is often necessary.

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Surg Today. 2003;33(11):823-7.
Long-term results of subtotal colectomy with antiperistaltic cecoproctostomy.
Sarli L, Costi R, Iusco D, Roncoroni L.
Institute of General Surgery, University of Parma, School of Medicine, Azienda Ospedale, Via Gramsci 14, 43100, Parma, Italy.

PURPOSE: To evaluate the clinical role of subtotal colectomy with cecorectal anastomosis (CRA) and its postoperative results, based on our surgical experience. METHODS: We retrospectively analyzed 26 patients who underwent subtotal colectomy with CRA during an 8-year period (1992-1999) in our university hospital. The indications for CRA were intractable constipation, colon tumors, diverticulitis, Crohn's disease, and postactinic colitis. CRA was performed using a new technique of end-to-end antiperistaltic anastomosis. Postoperative and late complications, and functional results, defined as the number of bowel movements per day and quality of life, were evaluated. RESULTS: None of the patients experienced postoperative or late complications. Two patients died from progression of colon cancer. The mean follow-up period was 4.5 years (range 1-8 years). By 1 month after surgery, 58% of the patients were passing frequent bowel movements, and by 1 year after surgery, only 23% of the patients were passing frequent bowel movements. The last follow-up revealed a mean 1.7 bowel movements per day, and only one patient was taking medication for diarrhea. All patients were satisfied with the results of their surgery and reported that their quality of life was good or improved, and even very good in six cases. CONCLUSIONS: Subtotal colectomy with our new CRA technique is appropriate for treating inflammatory diseases of the bowel, colon tumors, and intractable constipation in selected patients.

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Surg Laparosc Endosc Percutan Tech. 2003 Oct;13(5):325-7.
Recurrence rates at minimum 5-year follow-up: laparoscopic versus open sigmoid resection for uncomplicated diverticulitis.
Thaler K, Weiss EG, Nogueras JJ, Arnaud JP, Wexner SD, Bergamaschi R.
Department of Colorectal Surgery/Cleveland Clinic Florida, USA.

The aim of the study was to compare the impact of surgical access to sigmoid resection on recurrence rates in patients with uncomplicated diverticulitis of the sigmoid (UDS) at a minimum follow-up of 5 years. Recurrence after surgery was defined as left lower quadrant pain, fever, and leucocytosis with consistent CT and enema findings on admission and at 6 weeks, respectively. Outcome measures included splenic flexure mobilization, specimen length, inflammation at proximal resection margin, and presence of teniae coli at distal resection margin. Seventy-nine patients undergoing laparoscopic sigmoid resection (LSR) were compared with 79 matched controls with open sigmoid resection (OSR) operated on at 2 institutions during the same period. Patients were well matched for age, gender, body mass index, ASA grading, and symptoms duration, but not for follow-up length (81.9 versus 86.9 months, P = 0.046). Differences in rates of splenic flexure mobilization (19 versus 41, P < 0.001), specimen length (16.1 versus 18.3 cm, P = 0.048), inflammation at proximal resection margin (21 versus 4, P < 0.001), and teniae coli at distal resection margin (4 versus 53, P < 0.001) did not show an impact on recurrence rates when comparison was made between LSR and OSR. Three LSR patients and 7 OSR patients had 1 recurrence (P = 0.19). There were no significant differences in rates of flexure mobilization, specimen length, and rates of inflammation present at proximal resection margin in 10 recurring and 145 non-recurring patients. The rate of teniae coli present at distal resection margin was significantly increased in recurring patients (7 versus 43, P = 0.03). Median time of recurrence after surgery was 29 (range 18-74) months. Two of 11 recurrences occurred after 5 years. Surgical access to sigmoid resection for UDS is unlikely to have an impact on recurrence rates provided that the oral bowel end is anastomosed to the proximal rectum rather than to the distal sigmoid.

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Ulus Travma Derg. 2003 Oct;9(4):246-9.
[Complicated meckel's diverticulum]
[Article in Turkish]
Akcakaya A, Alimoglu O, Ozkan OV, Sahin M.
S.S.K. Vakif Gureba Teaching Hospital, 1st Surgical Clinic, Istanbul, Turkey, aakcakaya@hotmail.com

Background: In this study we present our experience in the surgical treatment of complicated Meckel's diverticulum. Methods: The data of eight patients who underwent surgery due to complications of Meckel's diverticulum between 1994-2001 was retrospectively assessed. Results: There were six males and two females with a mean age of 31 years (range 13 to 65). Preoperative diagnoses were acute surgical abdomen in six and incarcerated inguinal hernias in two patients. Intraoperative diagnoses were as follows; Littre's hernia in two, diverticulitis in two, perforation of the diverticulum in one and intestinal obstruction in three patients (there was a band extending from diverticulum to the umblicus in two patients and a mesodiverticular band in the remaining one). While diverticulectomies were performed in five patients, three had small bowel resections. The mean diameter of the diverticulas was 2.3 cm (range 2 to 4) and the mean lenght was 3.5 cm (range 3 to 8). Postoperative intestinal obstruction was observed in one patient who had underwent diverticulectomy and subsequently a small bowel resection was performed. Conclusion: Being aware of the complications of the Meckel's diverticulum is necessary in correct timing of the surgery and selecting the proper incision in patients with acute abdomen. This will result in decreased morbidity. Keywords: Meckel's diverticulum, complication, treatment.

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Hepatogastroenterology. 2003 Sep-Oct;50(53):1367-9.
Sandostatin as a "hormonal" temporary protective ileostomy in patients with total or subtotal colectomy.
Spiliotis J, Tambasis E, Christopoulou A, Rogdakis A, Siambaliotis A, Zografos K, Datsis A.
Department of Surgery, Department of Anesthesiology, Hippocrates Medical Center, Pirgos, Greece.

BACKGROUND/AIMS: We describe our experience with the use of a new method of so-called "hormonal" ileostomy by using Octreotide, a long-acting analog of the inhibitory peptide Somatostatin (Sandostatin Novartis), aiming to advocate protective ileostomy or colostomy, in patients who underwent total or subtotal colectomy for ulcerative colitis or obstruction of left colon, due to carcinoma or diverticulitis. METHODOLOGY: "Hormonal" protective ileostomy by using Sandostatin (Novartis) was performed in 10 patients after subtotal colectomy for ulcerative or left colon obstruction without a protective ileostomy or colostomy. Sandostatin 0.5 mg/mL was given from the day of operation to the 10th postoperative day, in a dose of 2 x 3 per day subcutaneously. The time of return of peristalsis, number of bouts of diarrhea and postoperative complications were evaluated. RESULTS: The patients were classified in two groups: First group (40% of all patients) with bowel obstruction and second group (60% of all patients) with ulcerative colitis. In the first group the mean time of return of peristalsis was 4.5 days and the mean number of bouts of diarrhea was 4.2 per day. One patient was reoperated for intraabdominal abscess and the morbidity was 50% with minor postoperative complications. In the second group the mean time of peristalsis return was 5 days and the mean number of bouts of diarrhea was 5.4 per day. One patient was reoperated for intestinal bleeding and the morbidity was 60% with minor postoperative complications. CONCLUSIONS: The use of Octreotide appears to serve as a useful adjunctive and important role in controlling intestinal output, so that it is an available method of "hormonal" protective ileostomy in very low rectal or anal anastomosis, by avoiding a second operation for ileostomy or colostomy closure and reducing the median hospital stay and total socioeconomic cost.

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Arch Intern Med. 2003 Sep 22;163(17):2093-6.
Meckel diverticulum: a geriatric disease masquerading as common gastrointestinal tract disorders.
Feller AA, Movson J, Shah SA.
Department of Medicine, Brown Medical School, Providence, RI 02904, USA.

BACKGROUND: Meckel diverticulum (MD) is traditionally considered a pediatric disease that is associated with intestinal hemorrhage or perforation. Symptomatic MD is rarely a consideration in the geriatric population. OBJECTIVE: To notify clinicians of the clinical variety and diagnostic uncertainty of MD in the elderly, we report 7 cases of complicated MD that presented as common disorders of the gastrointestinal (GI) tract in patients older than 65 years. METHODS: A retrospective record review at 2 university-affiliated hospitals revealed 7 patients older than 65 years with MD and abdominal complaints necessitating laparotomy. The patients represented a subset of 27 adults (age range, 21-89 years; mean age, 39 years) with symptomatic MD who required surgery during a 7-year period. RESULTS: The presenting complaints represented a variety of common GI presentations, including nausea, vomiting, and acute abdominal pain (n = 3); acute abdominal pain with peritonitis (n = 2); crampy abdominal pain lasting several weeks (n = 1); and rectal bleeding (n = 1). Meckel diverticulum was a preoperative consideration in only 2 of 7 cases. The preoperative diagnoses were consistent with common disorders of the GI tract in the elderly, including small-bowel obstruction (n = 2), ischemic colitis (n = 1), unrelenting bleeding in the GI tract (n = 1), perforated viscus (n = 1), diverticulitis (n = 1), and appendicitis (n = 1). In contradistinction to the pediatric age group, only 1 of 7 patients had an MD with ectopic mucosa. CONCLUSIONS: Many different mechanisms can be responsible for complications due to MD in the geriatric population. Misdiagnosis occurs frequently in the elderly because of the poor sensitivity of diagnostic tests, nonspecificity of complaints, and lack of recognition that this anomaly can present in this age group. Clinicians must be cognizant of this common pediatric disease and its varied guises when they are evaluating unexplained acute or intermittent abdominal pain, nausea and vomiting, rectal bleeding, peritonitis, or obstruction in geriatric patients.

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J Reprod Med. 2003 Jul;48(7):489-95.
Colovaginal fistulas. Etiology and management.
Bahadursingh AM, Longo WE.
Section of Colon and Rectal Surgery, Department of Surgery, Saint Louis University Health Sciences Center, St. Louis, Missouri, USA.

OBJECTIVE: To review the diagnosis and treatment of colovaginal fistulas from various causes. DATA SOURCES: Papers on colovaginal fistulas were identified using Ovid and PubMed. The search terms used were as follows: colovaginal fistulas, rectovaginal fistulas, diverticular disease and fistulas. METHODS OF STUDY: Articles were selected based on their relevance to colovaginal fistulas and were then further subdivided into epidemiology, etiology, presentation, diagnosis and management. RESULTS: English-language papers were selected based on their relevance to all aspects of colovaginal fistulas. CONCLUSION: Optimizing nutrition is paramount prior to surgery. Medical management rarely corrects the problem. Diverticular colovaginal fistulas arise in patients who have previously undergone a hysterectomy. Radiation-related fistulas often involve the distal sigmoid colon and rectum, and recurrent cancer must be ruled out. Often symptoms are associated with radiation cystitis and terminal ileitis. When indicated, restoration of intestinal continuity is preferred. Malignant fistulas carry a poor prognosis, and when surgical removal is not practical, they are treated palliatively with fecal diversion or an endoluminal stent. Those arising from inflammatory bowel disease most frequently arise due to Crohn's disease, and extirpation of diseased bowel and associated abscess will successfully treat the condition. Fistulas arising from ulcerative colitis can be malignant. There remains a small role for colostomy as a nondefinitive procedure to alleviate symptoms. Colovaginal fistulas require a multidisciplinary approach and focused diagnostics, successful treatment can dramatically improve the patient's quality of life.

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Am Surg. 2003 Jun;69(6):499-503; discussion 503-4.
Laparoscopic versus open sigmoid colectomy for diverticulitis.
Lawrence DM, Pasquale MD, Wasser TE.
Department of Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania 18105-1556, USA.

This study compared laparoscopic with open sigmoid colectomy for patients with a diagnosis of diverticulitis. Increased use of less invasive techniques makes it vitally important to evaluate outcomes of these techniques as compared with standard open procedures. Patients undergoing sigmoid colectomy for diverticulitis without hemorrhage (code 56211) between January 1997 and December 2001 were reviewed. Two groups were identified: those undergoing open sigmoid colectomy and those undergoing laparoscopic sigmoid colectomy; American Society of Anesthesiologists (ASA) scores, operative time, intensive care unit (ICU) and hospital length of stay, morbidity/mortality, and hospital charges were compared. During the study period 271 sigmoid colectomies were performed for diverticulitis without hemorrhage: 56 laparoscopically and 215 with the standard open technique. Four patients required conversion from laparoscopic to open colectomy. Mean ASA scores were: open group 2.4; laparoscopic group, 1.9 (P < 0.001). Mean operative times were: laparoscopic group, 170 +/- 45 minutes; open group, 140 +/- 49 minutes (P < 0.001). In the open group 39 patients required transfer to the ICU; one patient in the laparoscopic group required transfer to the ICU. Average hospital lengths of stay for the open and laparoscopic groups were 9.06 and 4.12 days, respectively (P < 0.001). Complications were recorded in 57 (27%) of 215 patients who underwent an open procedure versus 5 (9%) of 56 patients who underwent laparoscopic sigmoid colectomy (P < 0.01). There were three deaths in the open group and none in laparoscopic group. Average total hospital charges were 25,700 dollars for open sigmoid colectomy and 17,414 dollars for laparoscopic colectomy. Laparoscopic sigmoid colectomy compares favorably with open sigmoid colectomy for patients with a diagnosis of diverticulitis.

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J Chin Med Assoc. 2003 May;66(5):282-7.
A potential alternative treatment of uncomplicated painful diverticular disease by trans-colonoscopic irrigation technique: a preliminary report.
Chen WS, Lin JK.
Division of Colorectal Surgery, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan, ROC. wschen@vghtpe.gov.tw

BACKGROUND: Colonic diverticular disease is a common disorder in elder patients. Medical treatment was usually recommended as the first line management for this disease. However, the recurrence rate of such disorder is still high. In patients with severe complications such as abscess or fulminant inflammation, non-invasive diagnostic examination, abdominal CT scan for example, is recommended. Its most common symptom is repeated abdominal pain with disturbance of bowel habit. Many patients are found to be with diverticular disease only after colonoscopic examination. The aim of this study is to introduce a new irrigation-draining method and to evaluate its efficacy in treatment of uncomplicated painful colonic diverticular disease. METHODS: To reduce the risk of recurrence of acute diverticulitis and other severe complications, we introduce a transcolonoscopic irrigation technique for patients of uncomplicated diverticular disease by flushing out the obstructed fecalith from the diverticular sac in order to improve the drainage from the obstructed diverticular sac. RESULTS: Thirty-two patients of uncomplicated painful diverticular disease with obstructed fecalith impacted were treated by this technique. Clinical symptom improved in all of them and no complications developed during the mean follow-up period of 46 months. CONCLUSION: The results of this preliminary study suggest that this technique accomplished in the colonoscopic examination without additional therapeutic procedures. It provides another potential alternative to the conventional medical treatment for patients with uncomplicated diverticular disease.

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Chir Ital. 2003 Mar-Apr;55(2):207-12.
[Surgical treatment of complicated sigmoid diverticulitis: our experience]
[Article in Italian]
Capasso L, Bucci G, Casale LS, Pagano G, Iarrobino G, Borsi E.
U.O. di Chirurgia d'Urgenza Azienda Ospedaliera San Sebastiano di Caserta di Rilievo Nazionale e di Alta Specializzazione.

Traditionally, surgical sigmoid diverticular emergencies used to be treated in stages, but more recently there has been a trend towards definitive surgery with immediate resection plus anastomosis under certain conditions. The aim of this study was to define the morbidity and mortality of resection plus anastomosis with on-table antegrade irrigation and of the Hartmann procedure for complicated sigmoid diverticulitis in relation to the type of peritonitis and to the American Society of Anesthesiologists (ASA) grade of the patients. From April 1999 to April 2002, 38 emergency operations for complicated sigmoid diverticulitis were performed at the San Sebastiano Hospital in Caserta. Six patients underwent operations for obstructions and 32 for perforation (19 Hinchley stage III and 13 Hinchley stage IV). Surgical therapy for obstruction consisted in 4 resections plus anastomosis, 1 subtotal colectomy and 1 Hartmann procedure. Surgical therapy for perforation consisted in 14 resections plus anastomosis and 18 Hartmann procedures. There was 1 case (5%) of anastomotic dehiscence out of 19 primary anastomoses versus 2/19 surgical complications (10%) after the Hartmann procedure. The mortality amounted to 1 death out of 38 (2.6%) in a patient treated with the Hartmann procedure. Left-sided colonic obstruction should be treated by resection plus anastomosis or by subtotal colectomy for ASA II-III patients and by Hartmann's procedure for ASA IV-V patients. ASA II-III patients with localised or generalised non-faecal peritonitis should be treated by resection plus anastomosis, while a Hartmann procedure should be the reasonable option for generalised faecal peritonitis and for ASA IV-V patients with localised or generalised non-faecal peritonitis.

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Chir Ital. 2003 Mar-Apr;55(2):153-60.
[Deferred elective colonic resection in complicated acute diverticulitis]
[Article in Italian]
Piardi T, Ferrari Bravo A, Giampaoli F, Porro M, Azzini C, Faidiga MC, Pouche A.
Dipartimento di Scienze Mediche e Chirurgiche Cattedra di Semeiotica Chirurgica, Universita degli Studi, Spedali Civili, Brescia.

Twenty-three patients with acute diverticulitis complicated by pericolic or paracolic abscesses (Hinchey stage I-II) after a first phase of medical treatment were treated with deferred elective resection of the descending colon and sigmoid plus colorectal anastomosis performed on average 30 days after the onset of the acute episode. The pathologist's investigation of the surgical specimens demonstrated persistence of severe inflammatory lesions despite the apparently satisfactory clinical outcome. These data explain the frequent recurrences and indicate surgical treatment as being the only therapy capable of definitively resolving the condition. As compared with the emergency surgery performed by others, deferred elective resection makes it possible to operate on patients who, once the acute phase has been overcome, can have their hydroelectrolytic balance perfectly restored and be adequately monitored with treatment of associated diseases and perfect colon preparation. This strategy has allowed us to eliminate operative mortality and reduce the postoperative morbidity, both of which are significantly present in emergency surgical operations. Also the overall hospital stay in the two admissions, the interval between which can be reduced in ideal cases, does not significantly differ from that reported for emergency operations.

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Ann Chir. 2003 Mar;128(2):81-7.
[Laparoscopic sigmoid resection for diverticulitis: is learning phase associated with increased morbidity?]
[Article in French]
De Chaisemartin C, Panis Y, Mognol P, Valleur P.
Service de chirurgie generale et digestive, hopital Lariboisiere, 2, rue Ambroise-Pare, 75475 cedex 10, Paris, France.

AIM: To assess retrospectively the results of laparoscopic sigmidectomy for diverticulitis, with intent to treat, in 58 consecutive patients operating by one surgeon compared with a control group operating by laparotomy. MATERIALS AND METHODS: From 1995 to 2001, 90 consecutive patients undergoing elective sigmoid resection for diverticulitis were divided into 3 groups: laparotomy (Group 1 : n = 32), first cases of laparoscopy (Group 2 : n = 29) and last cases of laparoscopy (Group 3 : n = 29). These 3 groups were similar according to age, sex, Body Mass Index (BMI), American society of anesthesia score (ASA), previous abdominal surgery, number of attacks of diverticulitis, and time between last attack and surgery. Following criteria were studied: operating time, conversation rate, intra-operative and post-operative morbidity, return of intestinal transit, and hospital stay. RESULTS: During laparoscopy, conversion was mandatory in 24% of the cases (7/29) in group 2 and 14% in group 3 (4/29; NS). No intra-operative morbidity was noted in the 58 laparoscopies. Mean operative time was 240 min in group 1, 259 min in group 2, and 241 min in group 3 (NS). Postoperative morbidity was observed in 31% of patients in group 1, 34% in group 2, and 10% in group 3 (p = 0.02). Returm of intestinal transit and oral ingestion and mean hospital stay were significantly shorter in group 2 and group 3 versus group 1 (p < 0.05). CONCLUSION: Our results confirm previous data demonstrating faisability of laparoscopic sigmodectomy for diverticulitis and its benefice in terms of return of intestinal transit and hospital stay. Furthermore, our study suggest that when surgeon gain experience, conversion rate, morbidity and operative time can be reduced.

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Am J Surg 2003 Feb;185(2):135-40
Aggressive resection is indicated for cecal diverticulitis.
Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF.
First Division of Trauma and Emergency Surgery, Department of Surgery, Chang-Gung Memorial Hospital, Chang-Gung University, 5 Fushing St., Kweishan, Taoyuan, Taiwan.

BACKGROUND: Because of the difficulties in preoperative diagnosis and controversies in the management, cecal diverticulitis has received much discussion in the literature. There, however, are still many questions that remain unanswered. METHODS: During a 5-year period, 112 patients with a clinical diagnosis of cecal diverticulitis were treated. Twenty-seven patients were excluded because of uncertainty in diagnosis or incomplete data collection, leaving 85 patients as the study group. The diagnosis of cecal diverticulitis was made by pathology, surgical findings, or image study. RESULTS: Nonoperative management was applied to 18 patients initially. Three patients had recurrent diverticulitis during follow up. These patients responded satisfactorily to another course of medical treatment. Laparotomy was performed in 67 patients. Acute appendicitis was the preoperative diagnosis in 47 patients (70%). Of the other 20 patients, 6 received operation because of repeated attack of diverticulitis, 7 had preoperative computed tomography (CT) diagnosis of cecal diverticulitis with perforation, 5 had preoperative diagnosis of cecal tumor, and 2 had medical treatment failure. All these 20 patients received right hemicolectomy. In the 47 patients with a preoperative diagnosis of acute appendicitis, 24 received appendectomy, 9 received diverticulectomy, and 14 received right hemicolectomy. Overall, 34 patients received right hemicolectomy, 9 received diverticulectomy, and 24 received appendectomy only. In the right hemicolectomy group, there were 2 deaths with underlying diseases and 5 complications. In the appendectomy group, there was no postoperative mortality, but in 7 patients recurrent diverticulitis developed. Three of them required right hemicolectomy. CONCLUSIONS: The natural history of cecal diverticulitis varies from benign and self-limiting to fulminant in the oriental population. Less than 40% (32 of 85) of patients were successfully treated with conservative methods initially and had no recurrence during the follow-up period. We recommend aggressive surgical resection for patients with a definite diagnosis. Adjuvant appendectomy without resection of the lesion should be considered only in uncomplicated patients whose diagnosis is in doubt.

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Am J Surg 2002 Jan;183(1):7-11
Clinical and functional results after elective colonic resection in 75 consecutive patients with diverticular disease.
Thorn M, Graf W, Stefansson T, Pahlman L.
Department of Surgery, University Hospital, SE-751 85 Uppsala, Sweden. magnus.thorn@kirurgi.uu.se

BACKGROUND: Functional results after elective colonic resection in patients with diverticular disease have seldom been studied. METHODS: Seventy-five consecutive patients were reviewed and sent a questionnaire about abdominal symptoms and functional results. Possible associations between patients' characteristics and postoperative complications or functional outcome were analyzed. RESULTS: Major complications including anastomotic leakage, bleeding, and bowel obstruction occurred in 10 patients (13%). Six patients (8%) had recurrent diverticulitis. No significant associations were found between clinical characteristics and postoperative complications or recurrent disease. Fifty patients classified their final result as excellent or good. Functional symptoms or symptoms suggestive of irritable bowel syndrome before the operation predicted a less successful result (P <0.05). CONCLUSIONS: Elective surgery in patients with diverticular disease was hampered by postoperative complications but resulted in most cases in good functional outcome and a low rate of recurrent disease. Those with functional bowel symptoms before surgery had significantly worse results.

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Minerva Chir 2002 Feb;57(1):1-5
[Laparoscopic surgery for colon diverticulitis]
[Article in Italian]
Lauro A, Alonso Poza A, Cirocchi R, Doria C, Gruttadauria S, Giustozzi G, Wexner SD, Gruttaduria S.
Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, USA.

BACKGROUND: Laparoscopic surgery is used with increasing frequency to treat colorectal pathologies and some groups have also attempted to treat the complicated forms of diverticulitis (abscesses and/or fistulas). The results reported in the international literature are still controversial, especially in terms of the duration of surgery, the frequency of laparotomic conversions and postoperative morbidity. The aim of this study was to analyse the results of laparoscopic or laparotomic treatment of diverticular disease of the colon in patients admitted to the Department of Colorectal Surgery at the Cleveland Clinic in Florida over a three-year period. METHODS: A retrospective analysis was made of 57 patients with diverticular disease of the colon who were admitted to CCF (Cleveland Clinic Florida) between January 1996 and December 1998 and underwent elective laparoscopic or laparotomic surgery. A comparative analysis was made of the results in the two groups. RESULTS: Of the 57 patients treated only 15 underwent laparoscopic surgery; the majority were treated for uncomplicated diverticulitis. 22 out of 42 patients (53%) undergoing laparotomic surgery presented complicated diverticulitis (abscesses, fistulas or stenosis), whereas 12 out of 15 patients undergoing laparoscopic surgery (80%) were treated for uncomplicated diverticulitis. Statistically significant differences were found in relation to the duration of surgery: 152 min in the laparotomic group vs 209 in the laparoscopic group. No differences were found in the frequency of intraoperative complications, transfusions and the number of drainages inserted (p=0.66). The postoperative period showed significant differences in terms of the reappearance of intestinal peristalsis, use of PCA and postoperative stay. CONCLUSIONS: This retrospective study confirms that the laparoscopic treatment of colon diverticulitis offers a number of advantages: reduced postoperative pain, more rapid recovery of intestinal peristalsis and shorter postoperative stay. Laparoscopic sigma colectomy represents the treatment of choice for diverticulitis in uncomplicated cases.

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Br J Surg 2003 Feb;90(2):232-6
Factors and consequences of conversion in laparoscopic sigmoidectomy for
diverticular disease.
Le Moine MC, Fabre JM, Vacher C, Navarro F, Picot MC, Domergue J.
Chirurgie Digestive A, Hopital Caremeau, Nimes, Nimes, France. marie.christine.lemoine@chu-nimes.fr

BACKGROUND: The disadvantages of laparoscopic elective sigmoidectomy for diverticular disease include the risk of conversion to open operation and longer operative time. The aim of this study was to analyse the causes and consequences of conversion in 168 consecutive patients who underwent a laparoscopically assisted colectomy between January 1994 and June 2001. METHODS: Data were collected prospectively to analyse the causes and consequences of conversion to open surgery in terms of postoperative morbidity and patient recovery. RESULTS: Postoperative mortality, morbidity, conversion and reoperation rates were zero, 21.4 per cent (n = 36), 14.3 per cent (n = 24) and 3.0 per cent (n = 5) respectively. The reasons for conversion were presence of intraperitoneal adhesions and/or inflammatory pseudotumour (n = 21), an intraoperative diagnosis of sigmoid cancer (n = 1), hypercapnia (n = 1) and abdominal bleeding (n = 1). Three preoperative factors were associated with a significant higher risk of conversion: surgical expertise, the presence of sigmoid stenosis or fistula, and the severity of diverticulitis on pathological examination. Morbidity was no different between laparoscopic sigmoidectomy (30 of 144; 20.8 per cent) and converted procedures (six of 24; 25.0 per cent). Open conversion was associated with a longer operative time and significantly delayed patient recovery and hospital discharge. CONCLUSION: Surgical experience and severe diverticular disease are predictive factors for conversion in laparoscopic elective sigmoidectomy. Even if necessary, conversion does not increase the morbidity rate.

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Chirurg 2002 Dec;73(12):1218-20
[Multiply recurrent perforated jejunal diverticulitis]
[Article in German]
Franzen D, Gurtler T, Metzger U.
Chirurgische Klinik,Stadtspital Triemli, Zurich,Schweiz.

Jejunal diverticulitis is a very rare cause of acute abdomen.The treatment of choice in acute perforated jejunal diverticulitis is intestinal resection with primary anastomosis of the affected area.Data on long-term results, postoperative complications and the nature of this illness is limited.To our knowledge, a recurrent perforated jejunal diverticulitis has never have been reported in the literature. In this case,we present a patient who suffered from a recurrence of perforated jejunal diverticulitis 13 weeks after the initial intestinal resection.After the second intestinal resection (due to the recurrent infection), the patient suffered from a third period of jejunal diverticulitis.

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Chir Ital 2002 Sep-Oct;54(5):693-8
[Diverticular disease: complications and treatment]
[Article in Italian]
Cavallaro A, Loschiavo V, Potenza AE, Modugno P, Fabbri MC, Revelli L, Colli R.
Istituto di Semeiotica Chirurgica, Universita Cattolica del Sacro Cuore, Roma.

This study reports on 10 years of experience in observing diverticular disease. The study considers 77 patients, 41 males and 36 females, aged from 50 to 88 years (mean age: 70 years), observed from January 1991 to December 2001. Sixty-two patients were admitted from the Accident and Emergency Unit and 15 were elected patients. Five patients underwent emergency surgery, while 72 received only antibiotic therapy. The overall mortality rate was 0. The morbidity rate was 22% in those patients undergoing emergency surgery. In only one of the elected patients was wound suppuration detected. Diverticular disease, in most cases, is treated by antibiotic therapy alone, but in 30% of cases surgery is necessary. Colon resection and immediate anastomosis are the first choice operation also in the emergency setting, provided local conditions (inflammation, septic contamination) make anastomosis safe. In patients with major peritoneal contamination, Hartman's operation and subsequent recanalization after 6 months are to be preferred.

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Int J Colorectal Dis 2003 Jan;18(1):55-62
Rifaximin improves symptoms of acquired uncomplicated diverticular disease of the colon.
Latella G, Pimpo MT, Sottili S, Zippi M, Viscido A, Chiaramonte M, Frieri G.
Cattedra di Gastroenterologia, Universita di L'Aquila, Via S. Sisto 22E, 67100 L'Aquila, Italy, giolatel@tin.it

BACKGROUND AND AIMS. We examined the efficacy of cyclic long-term administration of rifaximin, a broad spectrum, poorly absorbable antibiotic, in obtaining symptom relief in a large series of patients with uncomplicated diverticular disease, and compared the incidence of episodes of diverticulitis in the group treated with rifaximin to that in a group receiving fiber supplementation only. PATIENTS AND METHODS. In a multicenter, prospective, open trial, 968 outpatients with uncomplicated symptomatic diverticular disease were randomized to either fiber supplementation with 4 g/day glucomannan plus 400 mg rifaximin twice daily for 7 days every month ( n=558) or 4 g/day glucomannan alone ( n=346). Clinical evaluation was performed on admission and at 4-month intervals for 12 months. RESULTS. After 12 months the group treated with glucomannan + rifaximin showed fewer symptoms (abdominal pain/discomfort, bloating, tenesmus, diarrhea, abdominal tenderness) and a lower global symptomatic score. Overall 56.5% of the patients treated with glucomannan + rifaximin and 29.2% of those treated with glucomannan alone were asymptomatic at 12 months ( P<0.001). The rate of complications (diverticulitis and rectal bleeding) was 1.34% in the rifaximin + glucomannan group and 3.22% in the glucomannan alone group ( P<0.05). CONCLUSION. Cyclic administration of rifaximin is effective in obtaining symptom relief in uncomplicated diverticular disease of the colon. The incidence of episodes of diverticulitis in the group treated with rifaximin was lower than that in the group treated with glucomannan alone.

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Khirurgiia (Mosk) 2002;(10):39-42
[Video-laparoscopic surgeries in Meckel diverticulum in children]
[Article in Russian]
Dronov AF, Poddubnyi IV, Kotlobovskii VI, Al'-Mashat NA, Iarustovskii PM.

>From 1992 to 2001 laparoscopic diagnosis and treatment of various pathologic changes of Meckel diverticulum were carried out in 58 children aged from 3 weeks to 14 years. Bleeding from the diverticulum was in 33 patients, diverticulitis--in 21, intestinal obstruction--in 4 patients. Diagnostic laparoscopy was performed carefully with trochars of small diameters (3-5 mm). Conversion to open operation was necessary in 2 patients due to inflammation in the diverticulum and adjacent parts of the intestine. Circulatory resection of the intestine with the diverticulum in the limits of healthy tissues was performed. All 33 patients with intestinal bleeding were examined with 99mTc before surgery. Only 15 (45.4%) patients demonstrated pathologic accumulation of radionuclide in the zone of the diverticulum. Laparoscopic resection of the diverticulum was performed in 56 patients. Three methods of endoscopic resection were used: with suture device Endo-Gia-30 (31 patients), with application of Roeder's loop on the base of the diverticulum when it was 1-1.5 cm wide maximum (23), with suturing of intestine with two-layer intracorporel endoscopic suture (2). All the started laparoscopic operations were finished successfully. There were no conversions to open surgery. Mean time of surgery was 45 min. There were no intraoperative complications. In postoperative period one patient showed acute adhesive intestinal obstruction which was treated with laparoscopy. Mean hospital stay was 6.1 bed-days. There were no lethal outcomes. Cosmetic effect was excellent in all the cases.

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G Ital Nefrol 2002 Sep-Oct;19(5):540-4
[Diverticular disease of the colon in peritoneal dialysis]
[Article in Italian]
Buemi M, Aloisi C, Romeo A, Sturiale A, Barilla' A, Cosentini V, Aloisi E, Corica F, Ruello A, Frisina N.
Cattedra di Nefrologia, Dipartimento di Medicina Interna, Universita' di Messina, Messina, Italy. Buemim@Unime.it

Colon diverticular disease is a very common pathology in western countries and represents a risk factor for septic-type complications, especially in peritoneal dialysis patients. We examined both diagnostic procedure and therapeutics options, either pharmacological or surgical. Ultrasonography, which is useful for the diagnosis of diverticulosis and diverticular disease, has been supported in the last few years by new imaging techniques, such as NMR and CT, that also find applications in the treatment of diverticulitis complications like peritoneal abscesses. Our emphasis is on the therapeutic perspective, either dietetic - based on the use of a fibre-rich diet and the infusion of liquids by intravenous injection - or surgical, such as the Hartmann procedure, single anastomosis with stomia conservation and laparoscopic and endoscopic treatment. These therapeutic approaches have reduced both morbidity and mortality rate and have emphasized how the reduction of surgical stress on the mesothelium promotes the recovery of the functional integrity and, consequently, faster resumption of peritoneal dialysis. In conclusion, diverticulosis alone is not a contraindication for peritoneal dialysis, but constitutes a risk factor for the continuation of this alternative treatment.

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Best Pract Res Clin Gastroenterol 2002 Aug;16(4):649-62
Complicated diverticulosis.
Boulos PB.
Department of Surgery, University College London, Charles Bell House, 67-73 Riding House Street, London W1W 7EJ, UK.

"Uncomplicated" diverticulitis can be prevented from progressing into "complicated" diverticulitis by early diagnosis and active medical treatment. Complicated diverticulitis develops from a peridiverticular abscess, to a perforation with peritonitis, to fistulation into adjacent viscera, to luminal narrowing by inflammation or stricture formation causing obstruction. Computer tomography (CT) scanning is the diagnostic imaging modality when diverticulitis is suspected and allows percutaneous drainage of peridiverticular abscesses that will enhance the effect of antibiotic therapy with resolution of the acute episode in 75% of patients. Thus, an emergent or urgent operation is converted to an elective operation and a two-stage operative procedure, namely a temporary stoma and a second operation, is avoided.Interventional surgery is urgent for perforation and obstruction. While a Hartmann's resection and temporary colostomy has been the favoured operative procedure, under favourable conditions resection with primary anastomosis is preferable. Although a temporary stoma may be required with primary anastomosis, and hence the procedure is a two-stage one similar to a Hartmann's, the closure of the stoma is less demanding and has a lower morbidity. A single-stage resection and anastomosis is the standard elective treatment for symptomatic fistulas and strictures.

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Best Pract Res Clin Gastroenterol 2002 Aug;16(4):635-47
Diverticulitis.
Buchanan GN, Kenefick NJ, Cohen CR.
St Mark's Hospital, Harrow Road, London HA1 3UJ, UK.

Although diverticular disease is common in the Western world, few patients who develop diverticulitis require surgery. The use of appropriate broad-spectrum antibiotics in uncomplicated diverticulitis can be an effective treatment, avoiding the need for acute surgical intervention. In the event of surgery the choice of procedure is dictated by the degree of contamination and the expertise of the operating surgeon.This chapter will outline the modern management of diverticulitis, from steps in diagnosis to different surgical options in each clinical scenario, thus aiding clinicians on a practical level.

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Chirurg 2002 Jul;73(7):675-80
[Sigmoid diverticulitis. Emergency intervention in abscess, hemorrhage and stenosis]
[Article in German]
Bertram P, Truong S, Schumpelick V.
Chirurgische Klinik und Poliklinik, Universitatsklinikum der RWTH, Pauwelsstrasse 30, 52057 Aachen. p.bertram@chir.rwth-aachen.de

Interventional techniques in treatment of complicated diverticulitis gain more and more importance. In particular abscesses and bleeding are treated successfully. In case of diverticular abscess (Hinchey classification stage I and II) percutaneous drainages are placed sonographically or CT guided. Interventional drainage offers the possibility of elective one-stage surgical treatment of diverticulitis with significant reduce of mortality and morbidity rates. Diverticular bleeding is usually diagnosed and treated endoscopically. Only if endoscopy is not able to manage bleeding, angiography or nuclear scan is demanded. In case of stenosis endoscopic treatment has not jet gained clinical relevance.

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Dig Liver Dis 2002 Jul;34(7):510-5
Long-term treatment with mesalazine and rifaximin versus rifaximin alone for patients with recurrent attacks of acute diverticulitis of colon.
Tursi A, Brandimarte G, Daffina R.
Emergency Division, L. Bonomo Hospital, Andria BA, Italy. antotursi@tiscalinet.it

BACKGROUND/AIMS: To compare efficacy of combined therapy with rifaximin and mesalazine versus rifaximin alone in treatment of patients with recurrent diverticulitis in order to evaluate: 1) rapidity in improvement of symptoms, 2) regulation of bowel attacks, 3) prevention of recurrence of diverticulitis. METHODS: A total of 218 consecutive eligible patients (131 males, 87 females age 64.3 years, range 51-79), affected by diverticulitis were monitored. Of these, 109 patients were treated with rifaximin 400 mg bid plus mesalazine 800 mg tid for 7 days, followed by rifaximin 400 mg bid plus mesalazine 800 mg bid for 7 days/month (group A); 109 patients were treated with rifaximin 400 mg bid for 7 days, followed by rifaximin 400 mg bid for 7 days/month (group B). Colonoscopy was performed after 3, 6 and 12 months of therapy. RESULTS: At end of follow-up, 193 patients were fully compliant to therapy Two patients died during study (1 in group A, 1 in group B), while four patients were lost to follow-up [1 in group A (0.91%) and 3 in group B (2.75%)]. The only side-effects recorded were transient urticaria (1 in group B, 0.91%) and epigastric pain (9 in group A, 8.25%). Severity of symptoms improved significantly in group A vs group B within 3 months (p < 0.005, p < 0.001 and p < 0.0001 and p < 0.0005 at 3, 6, 9 and 12 months, respectively). Bowel habits inproved significantly in group A vs group B within 3 months (p < 0.005, p < 0.0005, p < 0.001 and p < 0.0001 at 3,6,9 and 12 months respectively). Symptomatic recurrence of diverticulitis occurred in 3 patients in group A, while 13 patients showed recurrence of diverticulitis in group B (p < 0.005) during follow-up. CONCLUSIONS: This study clearly shows that rifaximin plus mesalazine are more effective than rifaximin alone in resolution of symptoms and prevention of recurrence of diverticulitis.

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Br J Surg 2002 Sep;89(9):1137-41
Acute colonic diverticulitis in patients under 50 years of age.
Biondo S, Pares D, Marti Rague J, Kreisler E, Fraccalvieri D, Jaurrieta E.
Department of Surgery, Ciudad Sanitaria y Universitaria de Bellvitge, University of Barcelona, Barcelona, Spain.

BACKGROUND: There is ongoing controversy concerning the virulence and management of diverticulitis in young patients. This study reports on the management of acute diverticulitis with reference to the virulence and outcome of the disease with respect to age. METHODS: Between January 1994 and June 1999, 327 patients were treated for acute left colonic diverticulitis. Patients were divided in two groups: those aged 50 years or less (group 1, 72 patients) and those older than 50 years (group 2, 255 patients). The diagnosis was confirmed histologically or radiologically in all patients. RESULTS: There were differences in gender distribution related to age (P < 0.001). During the first hospital stay, 226 patients (69.1 per cent) had successful conservative treatment, 78 (23.9 per cent) needed emergency surgery and 23 (7.0 per cent) had a semielective operation (P = 0.47). The recurrence rate was 25.5 per cent in group 1 and 22.3 per cent in group 2 (P = 0.93). The type of surgical procedure and grade of peritonitis in emergency patients were similar in the two groups. Overall the mortality rate in patients who underwent an operation was 16.3 per cent. The mortality rate was zero in group 1 and 2.2 per cent in group 2 after elective or semielective operation (P = 1.0), and zero in group 1 and 34.9 per cent in group 2 after emergency operation (P < 0.001). CONCLUSION: Diverticulitis in young patients does not have a particularly aggressive course and the risk of recurrence is similar to that of older patients.

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Dis Colon Rectum 2002 Jul;45(7):962-6
Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgery mandatory?: a prospective study of 118 patients.
Chautems RC, Ambrosetti P, Ludwig A, Mermillod B, Morel P, Soravia C.
Clinic of Digestive Surgery, University Hospital, Geneva, Switzerland.

PURPOSE: This study was designed to evaluate the long-term natural history of sigmoid diverticulitis in patients treated nonoperatively after a first acute episode and to assess the role of elective colectomy. METHODS: Between 1986 and 1991, 144 patients were admitted for acute diverticulitis diagnosed by abdominal computed tomography and had a successful nonoperative treatment. Remote complications (persisting or recurring diverticulitis) were also diagnosed by computed tomography. Patients had a poor outcome if they had one of these complications. Diverticulitis was graded mild or severe on computed tomography according to Ambrosetti's criteria. We determined statistically whether young age (< or =50 years old) and severe diverticulitis were risk factors for a poor outcome. RESULTS: One hundred eighteen patients with a contributive computed tomographic scan at admission were followed up. Median age was 63 (range, 23-93) years, with a median follow-up of 9.5 (range, 0.2-13.8) years. Eighty patients had no complications, and 38 had remote complications. The incidence of remote complications was the highest (54 percent at 5 years) for young patients with severe diverticulitis on computed tomography and the lowest (19 percent at 5 years) for older patients with mild disease. Young age and severe diverticulitis taken separately were both statistically significant factors of poor outcome (P = 0.007 and P = 0.003, respectively), although age was no longer significant after stratification for disease severity on computed tomography (P = 0.07). Twenty-four patients died. The cause of death was unrelated to diverticulitis in 21 cases and unknown in the remaining 3. CONCLUSIONS: We propose that after a first acute episode of diverticulitis treated nonoperatively, elective colectomy should be offered to young patients (< or =50 years old) with severe diverticulitis on computed tomography.

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Zentralbl Chir 2002 Apr;127(4):329-31
[Acute hemorrhage from Meckel's diverticulum--Laparotomy or laparoscopy?]
[Article in German]
Knoop M, Vorwerk T, Friedrichs KS.
Klinik fur Allgemein- und Viszeralchirurgie, Johanniter Krankenhaus der Altmark, Stendal, Akademisches Lehrkrankenhaus der Otto-von-Guericke Universitat Magdeburg, Germany. Mdrknoop@aol.com

Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract with a potential risk to develop complications such as obstruction, diverticulitis or intussusception. Lower gastrointestinal bleeding due to ulceration of heterotopic gastric tissue of the diverticulum is a known phenomenon in children and young adults. We present two cases of a 15-year-old girl and a 20-year-old man that revealed a massive lower gastrointestinal hemorrhage of unknown origin. In this emergency situation laparotomy was performed in combination with lower endoscopy as rendezvous manouver. In both cases a Meckel's diverticulum with peptic ulceration was the source of hemorrhage, in one case the bleeding was active and visible. After resection of a short small bowel segment and end-to-end anastomosis the postoperative course was uneventful. We prefer in the case of lower gastrointestinal hemorrhage with hemodynamic instability laparotomy with intraoperative endoscopy instead of laparoscopy.

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Hepatogastroenterology 2002 May-Jun;49(45):664-7
Intraoperative colonic lavage with primary anastomosis vs. Hartmann's procedure for perforated diverticular disease of the colon: a consecutive study.
Regenet N, Tuech JJ, Pessaux P, Ziani M, Rouge C, Hennekinne S, Arnaud JP.
C.H.U. Angers, Department of Visceral Surgery, 4 rue Larrey, 49033 Angers, France. nicoregenet@yahoo.fr

BACKGROUND/AIMS: The ideal treatment for complicated diverticulitis is still controversial. The Hartmann's procedure remains the favored option in patients with acute complicated sigmoid disease but there has been increasing interest in primary resection and anastomosis with intraoperative colonic lavage. A prospective study was carried out on 71 patients with peritonitis, comparing primary resection with intraoperative colonic lavage, and Hartmann's procedure. METHODOLOGY: Between January 1994 and September 1999, 71 patients underwent emergency laparotomy for diverticular peritonitis. Primary resection and anastomosis with intraoperative colonic lavage was performed in 29 patients (group I) and Hartmann's procedure in 42 patients (group II). All data were collected on standardized forms. RESULTS: There were no differences between the two groups according to clinical features, biology, severity of disease and operative delay. The mortality rate in group I and group II was, respectively, 7 and 10% (P = 0.6). The incidence of postoperative complication was higher after Hartmann's procedure (P < 0.05). The mean hospital stay was significantly longer for the Hartmann's procedure compared to primary resection with intraoperative colonic lavage. CONCLUSIONS: Primary resection with intraoperative colonic lavage compares favorably with Hartmann's procedure for local or diffuse purulent peritonitis in complicated diverticulitis. It should be an alternative to the Hartmann's procedure in stercoral peritonitis.

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Chir Ital 2002 Mar-Apr;54(2):203-8
[Emergency surgical treatment of complicated acute diverticulitis]
[Article in Italian]
Bezzi M, Lorusso R, Forte A, Leonetti G, Gallinaro LS, Urbano V.
S.S. Chirurgia Laparoscopica e Mininvasiva Dipartimento di Scienze Chirurgiche e Technologie Mediche Applicate, Universita degli Studi di Roma La Sapienza Policlinico Umberto I, Roma.

Twenty-five percent of patients undergoing surgery for acute complicated diverticulitis represent emergencies. This condition is currently treated by colonic resection with primary anastomosis with or without colostomy, or by a Hartmann operation. We report on our experience with 52 consecutive patients with generalized peritonitis (8 cases), peri- and paracolonic abscesses (19 cases), severe pelvic abscesses (12 cases) and multiple abscesses with visceral fistulas (13 cases). All patients had emergency surgery. In 50/52 patients (96.2%) we performed a colonic resection with primary anastomosis using a mechanical stapler and in 2/52 a Hartmann operation. The overall mortality rate was 5.8%. The morbidity rate was 22% with 9 anastomotic leakages. A diverting colostomy was constructed in 16 patients and opened in only 8 patients. In 4 cases a parastomal hernia occurred after late closure and reduction of the colostomy. This data suggest that colonic resection with primary anastomosis, even without colostomy, is a safe procedure for the emergency treatment of acute complicated diverticulitis.

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Am J Surg 2002 May;183(5):525-8
Surgical management of acute sigmoid diverticulitis.
Blair NP, Germann E.
Division of General Surgery, Royal Columbian Hospital, 210-245 E. Columbia Street, New Westminster, British Columbia, Canada V3L 3W4.

PURPOSE: To determine the frequency of use of resection and primary anastomosis in the management of acute sigmoid diverticulitis at Royal Columbian Hospital. METHODS: A retrospective chart review of all patients undergoing emergency surgery for acute sigmoid diverticulitis between 1989 and 2000 at the Royal Columbian Hospital, New Westminster, BC, was carried out in order to determine the frequency of resection and primary anastomosis. Patients who underwent bowel preparation were excluded. RESULTS: Ninety-seven cases met the criteria. There were 33 cases of resection and primary anastomosis (34%). Five of these cases were protected with a proximal diverting stoma giving an incidence of 85% unprotected primary anastomosis in a group of patients undergoing emergency surgery for acute sigmoid diverticulitis. There was 1 anastomotic leak, 7 wound infections, and 3 deaths with an average length of stay of 9 days. CONCLUSIONS: The practice of resection and primary anastomosis for acute sigmoid diverticulitis at the Royal Columbian Hospital has an acceptable morbidity and mortality.

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J R Coll Surg Edinb 2002 Apr;47(2):481-2, 484
The natural history diverticular disease: is there a role for elective colectomy?
Somasekar K, Foster ME, Haray PN.
Prince Charles Hospital, Merthyr Tydfil, Mid Glamorgan.

BACKGROUND: The natural history of colonic diverticular disease is unclear leading to a debate on the value of elective colectomy in preventing complications of the disease. AIM: To assess whether the complications of diverticular disease requiring emergency surgery are related to previous episodes of diverticulitis and whether elective colectomy might prevent such complications. MATERIALS AND METHODS: A retrospective study was done on all patients admitted with complicated diverticular disease in two adjacent district general hospitals between 1995 and 2000. Information was collected on the details of management of the complications and past history of the investigations and treatment for diverticular disease in these patients. RESULTS: A total of 108 patients were admitted with complicated diverticular disease. Ninety eight (91%) patients were admitted as an emergency for perforated diverticular disease and rectal bleeding. Ten patients were urgent admissions for fistulae and diverticular phlegmons. Ninety eight patients underwent a Hartmann's operation, two had a subtotal colectomy and 4 patients had a sigmoid colectomy. Thirty four (31.4%) patients died in hospital post-operatively. Of the 108 patients, only 28 (26%) patients were known to have diverticular disease previously. Only three (2.7%) patients had had an episode of acute diverticulitis before they presented with further complications. CONCLUSIONS: Complications of diverticular disease occur de novo in the majority of patients who have no previous history of the disease. Further studies are needed to identify risk factors for complicated diverticular disease before adopting a policy of elective interval colectomy.

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