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1.  Emergency Management of Diverticulitis 
ABSTRACT
The most common indications for emergency operative intervention in the treatment of sigmoid diverticulitis are peritonitis and failure of medical therapy. Primary resection and diversion (Hartmann's procedure) followed by delayed colostomy closure is the current standard of emergency surgical care. Guidelines for best operative strategy, however, remain controversial and continue to evolve based on recent comparative reviews of surgical outcomes. Primary resection and anastomosis with or without proximal diversion and laparoscopic lavage are alternatives to Hartmann's procedure that may provide an improved outcome in properly selected patients. Ongoing changes in the historical paradigm of the surgical approach to this disease mandate the need for large multicentered prospective randomized trials to determine the best surgical strategy under emergent conditions for the treatment of diverticulitis. The current literature is reviewed with suggestions for a management algorithm.
doi:10.1055/s-0029-1236160
PMCID: PMC2780262  PMID: 20676259
Diverticular peritonitis; diverticulitis; peritonitis; Hartmann's procedure; primary resection; anastomosis; laparoscopic lavage
2.  The Best Choice of Treatment for Acute Colonic Diverticulitis with Purulent Peritonitis Is Uncertain 
BioMed Research International  2014;2014:380607.
Severe stages of acute, colonic diverticulitis can progress into intestinal perforations with peritonitis. In such cases, urgent treatment is needed, and Hartmann's procedure is the standard treatment for cases with fecal peritonitis. Peritoneal lavage may be an alternative to resection for acute diverticulitis with purulent peritonitis, but ongoing randomized trials are awaited to clarify this.
doi:10.1155/2014/380607
PMCID: PMC4065711  PMID: 24995290
3.  Treatment of acute diverticulitis laparoscopic lavage vs. resection (DILALA): study protocol for a randomised controlled trial 
Trials  2011;12:186.
Background
Perforated diverticulitis is a condition associated with substantial morbidity. Recently published reports suggest that laparoscopic lavage has fewer complications and shorter hospital stay. So far no randomised study has published any results.
Methods
DILALA is a Scandinavian, randomised trial, comparing laparoscopic lavage (LL) to the traditional Hartmann's Procedure (HP). Primary endpoint is the number of re-operations within 12 months. Secondary endpoints consist of mortality, quality of life (QoL), re-admission, health economy assessment and permanent stoma. Patients are included when surgery is required. A laparoscopy is performed and if Hinchey grade III is diagnosed the patient is included and randomised 1:1, to either LL or HP. Patients undergoing LL receive > 3L of saline intraperitoneally, placement of pelvic drain and continued antibiotics. Follow-up is scheduled 6-12 weeks, 6 months and 12 months. A QoL-form is filled out on discharge, 6- and 12 months. Inclusion is set to 80 patients (40+40).
Discussion
HP is associated with a high rate of complication. Not only does the primary operation entail complications, but also subsequent surgery is associated with a high morbidity. Thus the combined risk of treatment for the patient is high. The aim of the DILALA trial is to evaluate if laparoscopic lavage is a safe, minimally invasive method for patients with perforated diverticulitis Hinchey grade III, resulting in fewer re-operations, decreased morbidity, mortality, costs and increased quality of life.
Trial registration
British registry (ISRCTN) for clinical trials ISRCTN82208287http://www.controlled-trials.com/ISRCTN82208287
doi:10.1186/1745-6215-12-186
PMCID: PMC3173351  PMID: 21806795
4.  Position paper: management of perforated sigmoid diverticulitis 
Over the last three decades, emergency surgery for perforated sigmoid diverticulitis has evolved dramatically but remains controversial. Diverticulitis is categorized as uncomplicated (amenable to outpatient treatment) versus complicated (requiring hospitalization). Patients with complicated diverticulitis undergo computerized tomography (CT) scanning and the CT findings are used categorize the severity of disease. Treatment of stage I (phlegmon with or without small abscess) and stage II (phlegmon with large abscess) diverticulitis (which includes bowel rest, intravenous antibiotics and percutaneous drainage (PCD) of the larger abscesses) has not changed much over last two decades. On the other hand, treatment of stage III (purulent peritonitis) and stage IV (feculent peritonitis) diverticulitis has evolved dramatically and remains morbid. In the 1980s a two stage procedure (1st - segmental sigmoid resection with end colostomy and 2nd - colostomy closure after three to six months) was standard of care for most general surgeons. However, it was recognized that half of these patients never had their colostomy reversed and that colostomy closure was a morbid procedure. As a result starting in the 1990s colorectal surgical specialists increasing performed a one stage primary resection anastomosis (PRA) and demonstrated similar outcomes to the two stage procedure. In the mid 2000s, the colorectal surgeons promoted this as standard of care. But unfortunately despite advances in perioperative care and their excellent surgical skills, PRA for stage III/IV diverticulitis continued to have a high mortality (10-15%). The survivors require prolonged hospital stays and often do not fully recover. Recent case series indicate that a substantial portion of the patients who previously were subjected to emergency sigmoid colectomy can be successfully treated with less invasive nonoperative management with salvage PCD and/or laparoscopic lavage and drainage. These patients experience a surprisingly lower mortality and more rapid recovery. They are also spared the need for a colostomy and do not appear to benefit from a delayed elective sigmoid colectomy. While we await the final results ongoing prospective randomized clinical trials testing these less invasive alternatives, we have proposed (based primarily on case series and our expert opinions) what we believe safe and rationale management strategy.
doi:10.1186/1749-7922-8-55
PMCID: PMC3877957  PMID: 24369826
Complicated diverticulitis; Hartmann’s procedure; Primary resection anastomosis; Laparoscopic lavage and drainage; Percutaneous drainage
5.  Avoiding or Reversing Hartmann’s Procedure Provides Improved Quality of Life After Perforated Diverticulitis 
Introduction
The existing literature regarding acute perforated diverticulitis only reports about short-term outcome; long-term following outcomes have not been assessed before. The aim of this study was to assess long-term quality of life (QOL) after emergency surgery for perforated diverticulitis.
Patients and Methods
Validated QOL questionnaires (EQ-VAS, EQ-5D index, QLQ-C30, and QLQ-CR38) were sent to all eligible patients who had undergone emergency surgery for perforated diverticulitis in five teaching hospitals between 1990 and 2005. Differences were compared between patients that had undergone Hartmann’s procedure (HP) or resection with primary anastomosis (PA) and also compared to a sex- and age-matched sample of healthy subjects.
Results
Of a total of 340 patients, only 150 patients (44%) were found still alive in July 2007 (median follow-up 71 months). The response rate was 87%. In patients with PA, QOL was similar to the general population, whereas QOL after HP was significantly lower. The presence of a stoma was found to be an independent factor related to worse QOL. The deterioration in QOL was mainly due to problems in physical function and body image.
Conclusions
Survivors after perforated diverticulitis had a worse QOL than the general population, which was mainly due to the presence of an end colostomy. QOL may improve if these stomas are reversed or not be performed in the first place.
doi:10.1007/s11605-010-1155-5
PMCID: PMC2836251  PMID: 20127201
Perforated diverticulitis; Quality of life; Hartmann’s procedure; Primary anastomosis
6.  Subclinical peritonitis due to perforated sigmoid diverticulitis 14 years after heart-lung transplantation 
Acute complicated diverticulitis, particularly with colon perforation, is a rare but serious condition in transplant recipients with high morbidity and mortality. Neither acute diverticulitis nor colon perforation has been reported in young heart-lung grafted patients. A case of subclinical peritonitis due to perforated acute sigmoid diverticulitis 14 years after heart-lung transplantation is reported. A 26-year-old woman, who received heart-lung transplantation 14 years ago, presented with vague abdominal pain. Physical examination was normal. Blood tests revealed leukocytosis. Abdominal X-ray showed air-fluid levels while CT demonstrated peritonitis due to perforated sigmoid diverticulitis. Sigmoidectomy and end-colostomy (Hartmann’s procedure) were performed. Histopathology confirmed perforated acute sigmoid diverticulitis. The patient was discharged on the 8th postoperative day after an uneventful postoperative course. This is the first report of acute diverticulitis resulting in colon perforation in a young heart-lung transplanted patient. Clinical presentation, even in peritonitis, may be atypical due to the masking effects of immunosuppression. A high index of suspicion, urgent aggressive diagnostic investigation of even vague abdominal symptoms, adjustment of immunosuppression, broad-spectrum antibiotics, and immediate surgical treatment are critical. Moreover, strategies to reduce the risk of this complication should be implemented. Pretransplantation colon screening, prophylactic pretransplantation sigmoid resection in patients with diverticulosis, and elective surgical intervention in patients with nonoperatively treated acute diverticulitis after transplantation deserve consideration and further studies.
doi:10.3748/wjg.14.3583
PMCID: PMC2716625  PMID: 18567091
Heart-lung transplantation; Acute diverticulitis; Colon perforation; Subclinical peritonitis
7.  Perforated diverticulitis following extra-abdominal surgery. 
Postgraduate Medical Journal  1997;73(865):739-740.
The peritonitis of perforated diverticular disease is a life-threatening condition. We report three cases where it occurred following unrelated extra-abdominal surgery and where surgical intervention proved to be the correct course of management. All cases were treated with a Hartmann's procedure; this is probably the safest option for purulent peritonitis in patients who are a high operative risk and have recently undergone major surgery.
PMCID: PMC2431563  PMID: 9519193
8.  Pneumomediastinum caused by colonic diverticulitis perforation 
Journal of the Korean Surgical Society  2011;80(Suppl 1):S17-S20.
A 59-year-old man presented with abdominal and left flank pain. The symptom had started 30 days before as an acute nephrolithiasis, which had worsened despite conservative management. The abdomen was slightly distended and tender over the lower abdomen, without signs of generalized peritoneal irritation. A computed tomography (CT) scan showed an abscess in left para-renal space up to the subphrenic space and an unexpected pneumomediastinum. An emergency operation was performed, which showed retroperitoneal diverticulitis perforation of the sigmoid descending junction with abscess formation. A segmental resection of the diseased colon and end-colostomy was performed (Hartmann's procedure). However, the patient's condition progressively deteriorated, and he died of sepsis and multi-organ failure on the 5th postoperative day. Although pneumomediastinum caused by colonic diverticulitis perforation is extremely rare, it could be a life-threatening condition in patients without signs of peritonitis because of delayed diagnosis.
doi:10.4174/jkss.2011.80.Suppl1.S17
PMCID: PMC3205377  PMID: 22066076
Pneumomediastinum; Diagnostic; Diverticulitis; Colonic; Perforation
9.  Acute ulcerative jejunal diverticulitis: Case report of an uncommon entity 
Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. Its reported incidence varies from 0.05% to 6%. Although there is no consensus on the management of asymptomatic jejunal diverticular disease, some complications are potentially life threatening and require early surgical treatment. We report a case of an 88-year-old man investigated for acute abdominal pain with a high biological inflammatory syndrome. Inflammation of multiple giant jejunal diverticulum was discovered at abdominal computed tomography (CT). As a result of the clinical and biological signs of early peritonitis, an emergency surgical exploration was performed. The first jejunal loop showed clear signs of jejunal diverticulitis. Primary segmental jejunum resection with end-to-end anastomosis was performed. Histopathology report confirmed an ulcerative jejunal diverticulitis with imminent perforation and acute local peritonitis. The patient made an excellent rapid postoperative recovery. Jejunal diverticulum is rare but may cause serious complications. It should be considered a possible etiology of acute abdomen, especially in elderly patients with unusual symptomatology. Abdominal CT is the diagnostic tool of choice. The best treatment is emergency surgical management.
doi:10.3748/wjg.14.6265
PMCID: PMC2761593  PMID: 18985822
Jejunal diverticulum; Diverticulitis; Surgery; Tomography
10.  Laparoscopic Sigmoidectomy for Diverticulitis: a Prospective Study 
Results of this study suggest that laparoscopic surgery for diverticular disease is a safe, feasible, and effective management strategy.
Background:
Surgical treatment of complicated colonic diverticular disease is still debatable. The aim of this prospective study was to evaluate the outcome of laparoscopic sigmoid colectomy in patients with diverticulitis. Patients offered laparoscopic surgery presented with acute complicated diverticulitis (Hinchey type I, II, III), chronically recurrent diverticulitis, bleeding, or sigmoid stenosis caused by chronic diverticulitis.
Method:
All patients who underwent laparoscopic colectomy within a 12-year period were prospectively entered into a database registry. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. A 4-trocar approach with suprapubic minilaparotomy was performed. Main data recorded were age, sex, postoperative pain, return of bowel function, operation time, duration of hospital stay, and early and late complications.
Results:
During the study period, 260 sigmoid colectomies were performed for diverticulitis. The cohort included 104 male and 156 female patients; M to F ratio was 4:6. Postoperative pain was controlled by NSAIDs or weak opioid analgesia. Fifteen patients (5.7%) required conversion from laparoscopic to open colectomy. The most common reasons for conversion were directly related to the inflammatory process, abscess, and peritonitis. Mean operative time was 130±54. Average postoperative hospital stay was 10±3 days. A longer hospital stay was recorded for Hinchey type IIb patients. Complications were recorded in 30 patients (11.5%). The most common complications that required reoperation were hemorrhage in 2 patients (0.76) and anastomotic leak in 5 patients (only 3 of them required reoperation). The mortality among them was 2 patients (0.76%).
Conclusions:
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.
doi:10.4293/108680810X12924466008088
PMCID: PMC3083034  PMID: 21605507
Sigmoid diverticulitis; Laparoscopic surgery; Hinchey classification; Colectomy
11.  The management of acute colonic diverticulitis with suppurative peritonitis. 
With improvement in the medical management of diverticular disease, perforation has become the most common indication for surgical intervention. It is a source of considerable morbidity and mortality and consequently has provoked a considerable and controversial challenge for surgeons. We are proposing that all patients found to have purulent peritonitis secondary to perforating diverticulitis at laparatomy, should be managed initially by a defunctioning transverse colostomy, drainage and the administration of appropriate antibiotics. Subsequent management should consist of simple closure of the colostomy following a check barium enema and the commencement of a high fibre diet. We substantiate this by reporting 20 cases from Dudley Road Hospital and 20 others mentioned in the current literature.
PMCID: PMC2492398  PMID: 6703636
12.  A Case of Perforated Sigmoid Diverticulitis in Which Gram Staining of Ascitic Fluid Was Useful for Diagnosis 
Case Reports in Surgery  2014;2014:417987.
An 85-year-old woman was admitted to our hospital for steroid therapy for relapsing nephrotic syndrome. During hospitalization, she complained of sudden epigastric pain at night. Although there were signs of peritoneal irritation, CT showed a large amount of ascitic fluid, but no free intraperitoneal gas. Gram staining of ascitic fluid obtained by abdominal paracentesis showed Gram-negative rods, which raised a strong suspicion of gastrointestinal perforation and peritonitis. Therefore, emergency surgery was performed. Exploration of the colon showed multiple sigmoid diverticula, one of which was perforated. The patient underwent an emergency Hartmann's procedure. Imaging studies failed to reveal any evidence of gastrointestinal perforation, presenting a diagnostic challenge. However, a physician performed rapid Gram staining of ascitic fluid at night when laboratory technicians were absent, had a strong suspicion of gastrointestinal perforation, and performed emergency surgery. Gram staining is superior in rapidity, and ascitic fluid Gram staining can aid in diagnosis, suggesting that it should be actively performed. We report this case, with a review of the literature on the significance of rapid diagnosis by Gram staining.
doi:10.1155/2014/417987
PMCID: PMC3971547  PMID: 24716075
13.  Treatment of Perforated Diverticulitis with Generalized Peritonitis: Past, Present, and Future 
World Journal of Surgery  2010;34(3):587-593.
Background
The supposed optimal treatment of perforated diverticulitis with generalized peritonitis has changed several times during the last century, but at present is still unclear.
Methods/results
The first cases of complicated perforated diverticulitis of the colon were reported in the beginning of the twentieth century. At that time the first therapeutic guidelines were postulated in which an initial nonresectional procedure was provided to be the safest plan of management. After many years in which resection had become standard practice, today, one century later, again (laparoscopic) nonresectional surgery is presented as a safe and promising alternative in treatment of complicated perforated diverticulitis. The question rises what had happened to close the circle?
Conclusions
This paper includes a historic summary of changing patterns in surgical strategies in perforated diverticulitis complicated by generalized peritonitis.
doi:10.1007/s00268-009-0372-0
PMCID: PMC2816807  PMID: 20052468
14.  Elective operation after acute complicated diverticulitis: Is it still mandatory? 
AIM: To investigate recurrence rates, patterns and complications after nonoperatively managed complicated diverticulitis (CD).
METHODS: A retrospective study of patients treated for CD was performed. CD was defined on computed tomography by the presence of a localized abscess, pelvic abscess or extraluminal air. For follow-up, patients were contacted by telephone. Numbers of elective surgeries, recurrences and abdominal pain were analyzed.
RESULTS: A total of 114 patients (median age 57 years (range 29-97)), were admitted for CD. Nine patients required surgical intervention for failure of conservative therapy (Hartmann’s procedure: n = 6; resection and colorectal anastomosis: n = 3). Of the 105 remaining patients, 24 (22.9%) underwent elective sigmoid resection. The 81 (71%) non-operated patients were all contacted after a median follow-up of 32 mo (4-63). Among them, six had developed a recurrent episode of diverticulitis at a median follow-up of 12 mo (6-36); however, no patient required hospitalization. Sixty-eight patients (84%) were asymptomatic and 13 (16%) had recurrent abdominal pain.
CONCLUSION: Conservative policy is feasible and safe in 71% of cases, with a low medium-term recurrence risk.
doi:10.3748/wjg.v20.i25.8166
PMCID: PMC4081688
Diverticulosis; Diverticular abscess; Hinchey classification; Percutaneous drainage; Recurrent diverticulitis
15.  The Sigma-trial protocol: a prospective double-blind multi-centre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis 
BMC Surgery  2007;7:16.
Backround
Diverticulosis is a common disease in the western society with an incidence of 33–66%. 10–25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis.
Method
Indication for elective resection is one episode of diverticulitis in patients < 50 years and two episodes in patient > 50 years or in case of progressive abdominal complaints due to strictures caused by a previous episode of diverticulits. The diagnosis is confirmed by CT-scan, barium enema and/or coloscopy.
It is required that the participating surgeons have performed at least 15 laparoscopic and open sigmoid resections. Open resection is performed by median laparotomy, laparoscopic resection is approached by 4 or 5 cannula. Sigmoid and colon which contain serosal changes or induration are removed and a tension free anastomosis is created. After completion of either surgical procedure an opaque dressing will be used, covering from 10 cm above the umbilicus to the pubic bone. Surgery details will be kept separate from the patient's notes.
Primary endpoints are the postoperative morbidity and mortality. We divided morbidity in minor (e.g. wound infection), major (e.g. anastomotic leakage) and late (e.g. incisional hernias) complications, data will be collected during hospital stay and after six weeks and six months postoperative. Secondary endpoints are the operative and the postoperative recovery data. Operative data include duration of the operation, blood loss and conversion to laparotomy. Post operative recovery consists of return to normal diet, pain, analgesics, general health (SF-36 questionnaire) and duration of hospital stay.
Discussion
The Sigma-trial is a prospective, multi-center, double-blind, randomized study to define the role of laparoscopic sigmoid resection in patients with symptomatic diverticulitis.
doi:10.1186/1471-2482-7-16
PMCID: PMC1955435  PMID: 17683563
16.  Emergency Management of Diverticulitis 
Diverticulitis is a common problem, and although most cases will respond to conservative measures, surgeons will frequently need to treat patients requiring emergency surgery. Surgical management has progressed over the past 30 years, with a change in practice from routine drainage and proximal diversion (necessitating two further major procedures) to primary resection and anastomosis in selected cases. In 2004, surgeons must use clinical judgment to determine which approach will optimize outcomes both in terms of morbidity and mortality and in terms of quality of life for their patients.
doi:10.1055/s-2004-832699
PMCID: PMC2780068  PMID: 20011273
Diverticulitis; surgical management; emergency
17.  Comparison between open and laparoscopic reversal of Hartmann’s procedure for diverticulitis 
AIM: To compare the open and laparoscopic Hartmann’s reversal in patients first treated for complicated diverticulitis.
METHODS: Forty-six consecutive patients with diverticular disease were included in this retrospective, single-center study of a prospectively maintained colorectal surgery database. All patients underwent conventional Hartmann’s procedures for acute complicated diverticulitis. Other indications for Hartmann’s procedures were excluded. Patients underwent open (OHR) or laparoscopic Hartmann’s reversal (LHR) between 2000 and 2010, and received the same pre- and post-operative protocols of cares. Operative variables, length of stay, short- (at 1 mo) and long-term (at 1 and 3 years) post-operative complications, and surgery-related costs were compared between groups.
RESULTS: The OHR group consisted of 18 patients (13 males, mean age ± SD, 61.4 ± 12.8 years), and the LHR group comprised 28 patients (16 males, mean age 54.9 ± 14.4 years). The mean operative time and the estimated blood loss were higher in the OHR group (235.8 ± 43.6 min vs 171.1 ± 27.4 min; and 301.1 ± 54.6 mL vs 225 ± 38.6 mL respectively, P = 0.001). Bowel function returned in an average of 4.3 ± 1.7 d in the OHR group, and 3 ± 1.3 d in the LHR group (P = 0.01). The length of hospital stay was significantly longer in the OHR group (11.2 ± 5.3 d vs 6.7 ± 1.9 d, P < 0.001). The 1 mo complication rate was 33.3% in the OHR (6 wound infections) and 3.6% in the LHR group (1 hemorrhage) (P = 0.004). At 12 mo, the complication rate remained significantly higher in the OHR group (27.8% vs 10.7%, P = 0.03). The anastomotic leak and mortality rates were nil. At 3 years, no patient required re-intervention for surgical complications. The OHR procedure had significantly higher costs (+56%) compared to the LHR procedure, when combining the surgery-related costs and the length of hospital stay.
CONCLUSION: LHR appears to be a safe and feasible procedure that is associated with reduced hospitality stays, complication rates, and costs compared to OHR.
doi:10.4240/wjgs.v5.i8.245
PMCID: PMC3753438  PMID: 23983906
Hartmann’s procedure; Hartmann’s reversal; Diverticular disease; Laparoscopy; Healthcare-related costs; Colorectal surgery
18.  Jejunal Diverticulitis: A Rare Case of Severe Peritonitis 
Case Reports in Gastroenterology  2010;4(3):492-497.
A 25-year-old African American female with no prior medical/surgical history presented with abdominal pain and fever. A computed tomography scan of the abdomen and pelvis showed jejunal wall thickening with an air-fluid-filled mass in the adjacent mesentery. At laparotomy, a segmental jejunal resection with the abscess cavity followed by primary anastomosis was performed. Pathological evaluation of the specimen revealed a large mesenteric abscess contiguous with a perforated solitary jejunal diverticulum. We provide a discussion of jejunal diverticulitis as an unusual cause of peritonitis.
doi:10.1159/000321091
PMCID: PMC2988864  PMID: 21113287
Computed tomography; Diverticulitis; Jejunum; Laparoscopy; Small bowel
19.  Diverticulitis in a Young Man with Hyper IgE Syndrome 
Southern medical journal  2010;103(12):1261-1263.
Autosomal dominant hyperimmunoglobulin E syndrome (HIES, Job syndrome) is a rare primary immunodeficiency characterized by elevated immunoglobulin E (IgE), eosinophilia, recurrent skin and pulmonary infections, dermatitis, and connective tissue and skeletal abnormalities. A 26-year-old male with known HIES presented with abdominal pain and diarrhea. Imaging showed sigmoid diverticulitis without abscess or perforation. Conservative management with antibiotics failed, and he developed a peridiverticular abscess, which was percutaneously drained with plans for elective resection. He returned four days later with progression of his diverticulitis, requiring partial colectomy with primary anastomosis. To our knowledge, this is the first case of diverticulitis in HIES. Diverticulitis is rare in younger individuals, raising the possibility that the connective tissue abnormalities of HIES patients may predispose them to colonic diverticula. Although the majority of complications are sinopulmonary and skin infections, diverticulitis should be considered in the differential of intra-abdominal processes in HIES.
doi:10.1097/SMJ.0b013e3181fa5f0e
PMCID: PMC3059239  PMID: 21037522
Hyper IgE Syndrome; diverticulitis
20.  Management of patients with stercoral perforation of the sigmoid colon: Report of five cases 
To our knowledge, stercoral perforation of the colon is rarely seen with fewer than 90 cases reported in the literature till date. We explored the principles of management to prevent impending mortality in five patients with this condition. Five patients, two males and three females, whose median age was 64 years, had sustained stercoral perforation of the sigmoid colon. Chronic constipation was the common symptom among these patients. Three patients underwent a Hartmann’s procedure and another two were treated with segmental colectomy with anastomosis and diverting colostomy. There was one surgical mortality and the other patients had an uneventful hospital stay. Timely intervention to prevent and/or treat any associated sepsis along with extensive peritoneal lavage and surgical intervention to remove diseased colonic tissue at the primary stercoral ulceration site coupled with aggressive therapy for peritonitis are key treatment modalities in salvaging patients presenting with stercoral perforation of the colon.
doi:10.3748/wjg.v12.i3.500
PMCID: PMC4066079  PMID: 16489660
Stercoral perforation; Colon; Management
21.  The influence of mechanical bowel preparation in elective colorectal surgery for diverticulitis 
Techniques in Coloproctology  2012;16(4):309-314.
Background
Mechanical bowel preparation (MBP) has been shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in elective surgery in combination with an inflammatory component such as diverticulitis is yet unclear. This study evaluates the effects of MBP on anastomotic leakage and other septic complications in 190 patients who underwent elective surgery for colonic diverticulitis.
Methods
A subgroup analysis was performed in a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP in elective colorectal surgery. Primary endpoint was the occurrence of anastomotic leakage in patients operated on for diverticulitis, and secondary endpoints were septic complications and mortality.
Results
Out of a total of 1,354 patients, 190 underwent elective colorectal surgery (resection with primary anastomosis) for (recurrent or stenotic) diverticulitis. One hundred and three patients underwent MBP prior to surgery and 87 did not. Anastomotic leakage occurred in 7.8 % of patients treated with MBP and in 5.7 % of patients not treated with MBP (p = 0.79). There were no significant differences between the groups in septic complications and mortality.
Conclusion
Mechanical bowel preparation has no influence on the incidence of anastomotic leakage, or other septic complications, and may be safely omitted in case of elective colorectal surgery for diverticulitis.
doi:10.1007/s10151-012-0852-3
PMCID: PMC3398249  PMID: 22706733
Colonic diverticulitis; Mechanical bowel preparation; Anastomotic leak; Surgical site infection
22.  Audit on complicated diverticular disease. 
Seventy-three patients were seen between 1970 and 1983 with complicated diverticular disease. There were only six hospital deaths (8%). Two out of 7 patients with faecal peritonitis died, 2 of 27 patients with purulent peritonitis died and there was one death each associated with an inflammatory mass and a peridiverticular abscess. Five of the six hospital deaths were from cardiorespiratory disease and only one was from sepsis. Three of the early deaths were in patients who were receiving steroid therapy. There were three late deaths: one from uncontrolled sepsis, one an anaesthetic death from coronary occlusion during revision of a Hartmann operation and the third was an incidental myocardial infarction. A very conservative surgical policy was adopted, primary resection only being used for an inflammatory mass and selectively for fistula and local purulent disease. Despite our apparent low hospital mortality there was a high incidence of complication; wound sepsis 29%, fistula after colostomy closure 12% and anastomotic dehiscence after primary or secondary reconstruction 12%. These findings indicate the need for a prospective audit which is now in progress.
PMCID: PMC2498162  PMID: 3947025
23.  The space between: a supralevator abscess caused by perforated diverticulitis 
Journal of Surgical Case Reports  2013;2013(6):rjt041.
Supralevator abscesses are the rarest manifestation of anorectal suppurative disease. We report a supralevator abscess in a 60-year-old male whose earliest presentation included poorly localized abdominal and pelvic pain, tenesmus, urinary retention and weight loss, initially treated as diverticular disease based upon imaging and presentation. Progressive symptoms led to the discovery of a pelvic abscess with subsequent percutaneous drainage, later followed by emergent laparotomy, where a single perforated diverticulum was revealed to be the source fistulization. He underwent a Hartmann procedure with concomitant drainage of supralevator and ischiorectal collections. Perirectal pain with neurological involvement is part of a constellation of signs and symptoms that should invoke a high index of clinical suspicion for supralevator abscess formation. Percutaneous attempts at drainage are often inadequate; definitive surgical therapy is the best approach to prevent recurrence and associated morbidity.
doi:10.1093/jscr/rjt041
PMCID: PMC3813776  PMID: 24964449
24.  Current indications and role of surgery in the management of sigmoid diverticulitis 
Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden. This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations. Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis. Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended. Rather, a more individualized approach, taking into account frequency, severity of the attacks and their impact on quality of life, should guide the indication for surgery. On the other hand, complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation. Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis. There is not sufficient evidence supporting any changes in the approach to management in younger patients. Conversely, the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals. Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.
doi:10.3748/wjg.v16.i7.804
PMCID: PMC2825327  PMID: 20143459
Sigmoid diverticulitis; Diverticulitis management; Diverticulitis surgery; Acute diverticulitis; Complicated diverticulitis; Perforated diverticulitis; Laparoscopic colectomy
25.  Peritoneal carcinomatosis mimicking a perforated diverticulitis 
Clinics and Practice  2011;1(1):e14.
We report the case of a patient with a pelvic abscess and a malignant pancreatic tumor. The management of this complicated diverticulitis included radiological drainage and surgery. This abscess was due to a peritoneal carcinomatosis originating from the pancreas, which is an extremely rare cause of intestinal perforation.
doi:10.4081/cp.2011.e14
PMCID: PMC3981210  PMID: 24765268
carcinomatosis; pelvic abscess; perforation.

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