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1.  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
2.  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
3.  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
4.  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
5.  DIRECT trial. Diverticulitis recurrences or continuing symptoms: Operative versus conservative Treatment. A MULTICENTER RANDOMISED CLINICAL TRIAL 
BMC Surgery  2010;10:25.
Background
Persisting abdominal complaints are common after an episode of diverticulitis treated conservatively. Furthermore, some patients develop frequent recurrences. These two groups of patients suffer greatly from their disease, as shown by impaired health related quality of life and increased costs due to multiple specialist consultations, pain medication and productivity losses.
Both conservative and operative management of patients with persisting abdominal complaints after an episode of diverticulitis and/or frequently recurring diverticulitis are applied. However, direct comparison by a randomised controlled trial is necessary to determine which is superior in relieving symptoms, optimising health related quality of life, minimising costs and preventing diverticulitis recurrences against acceptable morbidity and mortality associated with surgery or the occurrence of a complicated recurrence after conservative management.
We, therefore, constructed a randomised clinical trial comparing these two treatment strategies.
Methods/design
The DIRECT trial is a multicenter randomised clinical trial. Patients (18-75 years) presenting themselves with persisting abdominal complaints after an episode of diverticulitis and/or three or more recurrences within 2 years will be included and randomised. Patients randomised for conservative treatment are treated according to the current daily practice (antibiotics, analgetics and/or expectant management). Patients randomised for elective resection will undergo an elective resection of the affected colon segment. Preferably, a laparoscopic approach is used.
The primary outcome is health related quality of life measured by the Gastro-intestinal Quality of Life Index, Short-Form 36, EQ-5D and a visual analogue scale for pain quantification. Secondary endpoints are morbidity, mortality and total costs. The total follow-up will be three years.
Discussion
Considering the high incidence and the multicenter design of this study, it may be assumed that the number of patients needed for this study (n = 214), may be gathered within one and a half year.
Depending on the expertise and available equipment, we prefer to perform a laparoscopic resection on patients randomised for elective surgery. Should this be impossible, an open technique may be used as this also reflects the current situation.
Trial Registration
(Trial register number: NTR1478)
doi:10.1186/1471-2482-10-25
PMCID: PMC2928179  PMID: 20691040
6.  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
7.  Perforated midgut diverticulitis: Revisited 
AIM: To study and provide data on the evolution of medical procedures and outcomes of patients suffering from perforated midgut diverticulitis.
METHODS: Three data sources were used: the Medline and Google search engines were searched for case reports on one or more patients treated for perforated midgut diverticulitis (Meckel’s diverticulitis excluded) that were published after 1995. The inclusion criterion was sufficient individual patient data in the article. Both indexed and non-indexed journals were used. Patients treated for perforated midgut diverticulitis at Vestfold Hospital were included in this group. Data on symptoms, laboratory and radiology results, treatment modalities, surgical access, procedures, complications and outcomes were collected. The Norwegian patient registry was searched to find patients operated upon for midgut diverticulitis from 1999 to 2007. The data collected were age, sex, mode of access, surgical procedure performed and number of patients per year. Historical controls were retrieved from an article published in 1995 containing pertinent individual patient data. Statistical analysis was done with SPSS software.
RESULTS: Group I: 106 patients (48 men) were found. Mean age was 72.2 ± 13.1 years (mean ± SD). Age or sex had no impact on outcomes (P = 0.057 and P = 0.771, respectively). Preoperative assessment was plain radiography in 53.3% or computed tomography (CT) in 76.1%. Correct diagnosis was made in 77.1% with CT, 5.6% without (P = 0.001). Duration of symptoms before hospitalization was 3.6 d (range: 1-35 d), but longer duration was not associated with poor outcome (P = 0.748). Eighty-six point eight percent of patients underwent surgery, 92.4% of these through open access where 90.1% had bowel resection. Complications occurred in 19.2% of patients and 16.3% underwent reoperation. Distance from perforation to Treitz ligament was 41.7 ± 28.1 cm. At surgery, no peritonitis was found in 29.7% of patients, local peritonitis in 47.5%, and diffuse peritonitis in 22.8%. Peritonitis grade correlated with the reoperation rate (r = 0.43). Conservatively treated patients had similar hospital length of stay as operated patients (10.6 ± 8.3 d vs 10.7 ± 7.9 d, respectively). Age correlated with hospital stay (r = 0.46). No difference in outcomes for operated or nonoperated patients was found (P = 0.814). Group II: 113 patients (57 men). Mean age 67.6 ± 16.4 years (range: 21-96 years). Mean age for men was 61.3 ± 16.2 years, and 74.7 ± 12.5 years for women (P = 0.001). Number of procedures per year was 11.2 ± 0.9, and bowel resection was performed in 82.3% of patients. Group III: 47 patients (21 men). Patient age was 65.4 ± 14.4 years. Mean age for men was 61.5 ± 17.3 years and 65.3 ± 14.4 years for women. Duration of symptoms before hospitalization was 6.9 d (range: 1-180 d). No patients had a preoperative diagnosis, 97.9% of patients underwent surgery, and 78.3% had multiple diverticula. Bowel resection was performed in 67.4% of patients, and suture closure in 32.6%. Mortality was 23.4%. There was no difference in length of history or its impact on survival between Groups I and III (P = 0.241 and P = 0.198, respectively). Resection was more often performed in Group I (P = 0.01). Mortality was higher in Group III (P = 0.002).
CONCLUSION: In cases with contained perforation, conservative treatment gives satisfactory results, laparoscopy with lavage and drainage can be attempted and continued with a conservative course.
doi:10.3748/wjg.v18.i34.4714
PMCID: PMC3442209  PMID: 23002340
Intestinal; Small bowel; Jejunum; Ileum; Perforation; Diverticulitis; Conservative treatment
8.  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
9.  New and emerging treatments for the prevention of recurrent diverticulitis 
Sigmoid diverticulitis is a common benign condition which carries significant morbidity and socioeconomic burden. This article describes the management of sigmoid diverticulitis with a focus on indications for surgical intervention. The mainstay of management of uncomplicated diverticulitis is broad-spectrum antibiotic therapy. The old surgical dictum that two episodes of sigmoid diverticulitis warranted surgical intervention has been challenged by recently published data. Surgery for diverticulitis thus needs to be tailored to suit individual presentation; patients presenting with recurrent diverticulitis, severe symptoms or debilitating disease impacting patient’s quality of life mandate surgical intervention. Complicated diverticular disease typically prompts intervention to resect a diseased, strictured sigmoid colon, fistulizing disease, or a life-threatening colonic perforation. Laterally, minimally invasive surgery has been utilized in the management of this disease and recent data suggests that localized colonic perforation may be managed by laparoscopic peritoneal lavage, without resection. This review focuses discussion on available evidence for contemporary surgical and nonoperative management of diverticulitis.
doi:10.2147/CEG.S15373
PMCID: PMC3190288  PMID: 22016581
sigmoid diverticulitis; colon; laparoscopic peritoneal lavage; surgical intervention
10.  Evaluation of current surgical management of acute inflammatory diverticular disease. 
During the period 1980 to 1987, 127 patients were admitted with acute complications of diverticular disease; clinically diagnosed as acute diverticulitis in 86, peritonitis in 33 and colonic obstruction in eight. In those patients diagnosed as acute diverticulitis, conservative treatment was effective in 73 (85%), the other 13 requiring surgery. Of 31 patients, with a clinical diagnosis of peritonitis who underwent operation, 19 (61%) had free purulent or faecal fluid at laparotomy and the remainder had a localised phlegmonous mass. Sigmoid resection was performed in 34 patients and nonexcisional surgery in 18. In the earlier period of the study, there was a preference for the former procedure in patients with peritonitis rather than those with phlegmonous diverticulitis (63% vs 28%), and in the later period of the study, resection was the preferred treatment in both groups (91% vs 93%). The increase in resectional surgery significantly reduced mortality, at completion of treatment, in patients with peritonitis (P less than 0.05) but not in those with phlegmonous diverticulitis. There was an additional benefit of resection in the lower number of procedures per patient (1.5 vs 2.1), a lower median total hospital stay (32 days vs 50.5, P less than 0.01) and a lower wound infection rate (16% vs 32%, P less than 0.01) at the end of treatment. The optimum surgical approach at laparotomy for acutely complicated diverticular disease would therefore appear to be a resectional procedure. Of the patients operated on for 'peritonitis', 39% were found to have a localised diverticular mass/phlegmon.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC2499490  PMID: 1929127
11.  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
12.  Primary Anastomosis Without Colonic Lavage for the Obstructed Left Colon 
INTRODUCTION
Resection, on-table lavage (OTL) and primary anastomosis is the treatment of choice for the obstructed left colon. OTL is time-consuming, requires considerable mobilisation/bowel handling, an enterotomy and potentially exposes the patient to mesenteric vascular injury, faecal contamination and a prolonged ileus. We have assessed outcome following primary resection and anastomosis without prior lavage.
PATIENTS AND METHODS
Twenty-four consecutive, obstructed patients underwent splenic flexure mobilisation and high anterior resection (concomitant small bowel resection in 2) with primary side-to-side colorectal anastomosis without either prior lavage or covering stoma. Outcome was audited.
RESULTS
Twenty-four patients, 17 female aged 48–92 years (median. 76 years) presented with left-sided obstruction due to carcinoma (Dukes' B [3], C [6], D [1]) or chronic diverticulitis (14). Median operative time was 85 min (range, 40–105 min). Colonic ileus resolved on day 2 (29%) and day 3 (58%). Median hospital stay was 7 days (range, 6–72 days); 92% discharged by day 10. There were no deaths or re-admissions. A return to theatre followed a reactionary haemorrhage in one. This latter patient's anastomosis leaked on day 4 (no faecal contamination) and was converted to an end stoma. Urinary and wound infections were seen in two. Late complications comprised two anastomotic strictures; both responded to balloon dilatation at 5 months.
CONCLUSIONS
Resection and primary anastomosis without on-table lavage is an easy, practical, predictable and safe treatment option for left-sided colonic obstruction with minimal complications.
doi:10.1308/003588408X285874
PMCID: PMC2647191  PMID: 18492393
Obstructed colon; Primary anastomosis; On-table lavage
13.  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
14.  Open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery ERAS® programme (ORANGE II – Trial): study protocol for a randomised controlled trial 
Trials  2012;13:54.
Background
The use of lLaparoscopic liver resection in terms of time to functional recovery, length of hospital stay (LOS), long-term abdominal wall hernias, costs and quality of life (QOL) has never been studied in a randomised controlled trial. Therefore, this is the subject of the international multicentre randomised controlled ORANGE II trial.
Methods
Patients eligible for left lateral sectionectomy (LLS) of the liver will be recruited and randomised at the outpatient clinic. All randomised patients will undergo surgery in the setting of an ERAS programme. The experimental design produces two randomised arms (open and laparoscopic LLS) and a prospective registry. The prospective registry will be based on patients that cannot be randomised because of the explicit treatment preference of the patient or surgeon, or because of ineligibility (not meeting the in- and exclusion criteria) for randomisation in this trial. Therefore, all non-randomised patients undergoing LLS will be approached to participate in the prospective registry, thereby allowing acquisition of an uninterrupted prospective series of patients. The primary endpoint of the ORANGE II trial is time to functional recovery. Secondary endpoints are postoperative LOS, percentage readmission, (liver-specific) morbidity, QOL, body image and cosmetic result, hospital and societal costs over 1 year, and long-term incidence of incisional hernias. It will be assumed that in patients undergoing laparoscopic LLS, length of hospital stay can be reduced by two days. A sample size of 55 patients in each randomisation arm has been calculated to detect a 2-day reduction in LOS (90% power and α = 0.05 (two-tailed)).
The ORANGE II trial is a multicenter randomised controlled trial that will provide evidence on the merits of laparoscopic surgery in patients undergoing LLS within an enhanced recovery ERAS programme.
Trial registration
ClinicalTrials.gov NCT00874224.
doi:10.1186/1745-6215-13-54
PMCID: PMC3409025  PMID: 22559239
Laparoscopy; Open liver resection; Hepatectomy; ERAS; Left lateral sectionectomy; RCT
15.  Laparoscopic Colectomy: the Absolute Need for a Standard Operative Technique 
Background:
The aim of this study is to review our experience performing laparoscopic colon surgery and to present the operative technique as used and standardized by us.
Methods:
From April 1992 to December 1996, 158 consecutive patients underwent laparoscopic colon surgery. There were 92 females and 66 males, whose average age was 66.7 years (range 31 - 92); 134 patients (84.9%) were operated on for carcinoma, and the remaining 24 (14.1%) for benign disease.
Results:
There were 117 procedures completed laparoscopically out of 158 patients (74%); 103 colon resections (18 for benign disease and 95 for malignant disease), 7 Hartmann procedures, 3 for reversal of Hartmann's procedures, 1 rectopexy, and 3 ileotrasversostomies. Conversions were required in 41 out of 158 cases (25.9%); 19 of these cases, however, were converted to a laparoscopic-facilitated procedure. The most common causes for conversion were the presence of bulky tumors and/or tumors that contaminated adjacent structures (16/158), adhesions due to previous operations (8/158) or patient obesity (5/158). There were 31 complications (19.6%), 9 of which required re-operation. There was only one recurrence (0.9%) that manifested 15 months after the procedure, at both trocar and drainage sites, and with peritoneal carcinomatosis. This occurred in a patient with rectal neoplasia who suffered a perforation of the rectum during dis-section, with bowel spillage. The average number of lymph nodes harvested in resected specimens was 12.8 (range 1-41), whereas the mean distance of the tumor from the proximal margin of resection was 11.5 cm (range 5-35), and from the distal margin 7.5 cm (range 1-25). The average operative time was 165 minutes (range 40-360), and the mean hospital stay was 9.2 days (range 6-40). There were three mortalities out of 158 patients (1.9%).
Conclusions:
Laparoscopic colon resection for malignant lesions, performed with the highest respect for oncologic principles, has demonstrated that it is difficult to develop a barrier to wall and intraluminal recurrence. Recurrence, in our opinion, is caused by improper surgical technique. Therefore, neoplastic colon laparoscopic surgery must be the prerogative of selected and specialized centers.
PMCID: PMC3016731  PMID: 9876674
Laparoscopy; Colorectal tumors; Wall recurrence; Surgical technique of colon resections
16.  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
17.  Traditional invasive vs. minimally invasive esophagectomy: a multi-center, randomized trial (TIME-trial) 
BMC Surgery  2011;11:2.
Background
There is a rise in incidence of esophageal carcinoma due to increasing incidence of adenocarcinoma. Probably the only curative option to date is the use of neoadjuvant therapy followed by surgical resection. Traditional open esophageal resection is associated with a high morbidity and mortality rate. Furthermore, this approach involves long intensive care unit stay, in-hospital stay and long recovery period. Minimally invasive esophagectomy could reduce the morbidity and accelerate the post-operative recovery.
Methods/Design
Comparison between traditional open and minimally invasive esophagectomy in a multi-center, randomized trial. Patients with a resectable intrathoracic esophageal carcinoma, including the gastro-esophageal junction tumors (Siewert I) are eligible for inclusion. Prior thoracic surgery and cervical esophageal carcinoma are indications for exclusion. The surgical technique involves a right thoracotomy with lung blockade and laparotomy either with a cervical or thoracic anastomosis for the traditional group. The minimally invasive procedure involves a right thoracoscopy in prone position with a single lumen tube and laparoscopy either with a cervical or thoracic anastomosis. All patients in both groups will undergo identical pre-operative and post-operative protocol. Primary endpoint of this study are post-operative respiratory complications within the first two post-operative weeks confirmed by clinical, radiological and sputum culture data. Secondary endpoints are the operative data, the post-operative data and oncological data such as quality of the specimen and survival. Operative data include duration of the operation, blood loss and conversion to open procedure. Post-operative data include morbidity (major and minor), quality of life tests and hospital stay.
Based on current literature and the experience of all participating centers, an incidence of pulmonary complications for 57% in the traditional arm and 29% in the minimally invasive arm, it is estimated that per arm 48 patients are needed. This is based on a two-sided significance level (alpha) of 0.05 and a power of 0.80. Knowing that approximately 20% of the patients will be excluded, we will randomize 60 patients per arm.
Discussion
The TIME-trial is a prospective, multi-center, randomized study to define the role of minimally invasive esophageal resection in patients with resectable intrathoracic and junction esophageal cancer.
Trial registration (Netherlands Trial Register)
NTR2452
doi:10.1186/1471-2482-11-2
PMCID: PMC3031195  PMID: 21226918
18.  Complicated Jejunal Diverticulitis: A Challenging Diagnosis and Difficult Therapy 
Background/Aim:
In contrast to diverticulosis of the colon, jejunal diverticulosis is a rare entity that often becomes clinically relevant only after exacerbations occur. The variety of symptoms and low incidence make this disease a difficult differential diagnosis.
Patients and Methods:
Data from all patients who were treated in our surgical department for complicated jejunal diverticulitis, that is, gastrointestinal hemorrhage or a diverticula perforation were collected prospectively over a 6-year period (January 2004 to January 2010) and analyzed retrospectively.
Results:
The median age among the 9 patients was 82 years (range: 54–87). Except for 2 cases (elective operation for a status postjejunal peridiverticulitis and a re-perforation of a diverticula in a patient s/p segment resection with free perforation), the diagnosis could only be confirmed with an exploratory laparotomy. Perforation was observed in 5 patients, one of which was a retroperitoneal perforation. The retroperitoneal perforation was associated with transanal hemorrhage. Hemodynamically relevant transanal hemorrhage requiring transfusion were the reason for an exploratory laparotomy in 2 further cases. In one patient, the hemorrhage was the result of a systemic vasculitis with resultant gastrointestinal involvement. A singular jejunal diverticulum caused an adhesive ileus in one patient. The extent of jejunal diverticulosis varied between a singular diverticulum to complete jejunal involvement. A tangential, transverse excision of the diverticulum was carried out in 3 patients. The indication for segment resection was made in the case of a perforation with associated peritonitis (n=4) as well as the presence of 5 or more diverticula (n=2). Histological analysis revealed chronic pandiverticulitis in all patients. Median operating time amounted to 142 minutes (range: 65–210) and the median in-hospital stay was 12 days (range: 5–45). Lethality was 0%. Major complications included secondary wound closure after s/p repeated lavage and bilateral pleural effusions in one case. Signs of malabsorption as the result of a short bowel syndrome were not observed. Minor complications included protracted intestinal atony in 2 cases and pneumonia in one case. Median follow-up was 6 months (range: 1–18).
Conclusion:
Complicated jejunal diverticulitis often remains elusive preoperatively due to its unspecific clinical presentation. A definitive diagnosis can often only be made intraoperatively. The resection of all diverticula and/or the complete diverticula-laden segment is the goal in chronic cases. The operative approach chosen (tangential, transverse excision vs segment resection) should be based on the extent of the jejunal diverticulosis as well as the intraoperative findings.
doi:10.4103/1319-3767.93816
PMCID: PMC3326973  PMID: 22421718
Diverticulosis; jejunum; surgery
19.  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
20.  Laparoscopic Resection of Chronic Sigmoid Diverticulitis with Fistula 
This study indicates that patients with sigmoid diverticulitis and fistula may be successfully treated by laparoscopic excision with outcomes similar to patients without fistula.
Background and Objectives:
A growing number of operations for sigmoid diverticulitis are being done laparoscopically. There is a paucity of data on the outcome of laparoscopy for sigmoid diverticulitis complicated by colonic fistula. The aim of this study was to compare the results of laparoscopic resection of sigmoid diverticulitis with and without colonic fistula.
Methods:
A retrospective review was conducted of all patients who underwent laparoscopic resection of sigmoid diverticulitis complicated by fistula at a single tertiary care institution over a 7-year period. Comparison was made with a group of patients who underwent resection for diverticulitis without fistula during the same study period.
Results:
Forty-two patients were analyzed (group 1: diverticular fistula, group 2: no fistula). The median age was similar (49 vs. 50 years, P = .68). A chronic abscess was present in 24% of patients in group 1 and 10% in group 2 (P = .40). Fistula types were colovesical (71%), colovaginal (19%), and colocutaneous (10%). Operation types were sigmoidectomy (57% vs. 81%) and anterior resection (43% vs. 19%) in groups 1 and 2, respectively (P = .18). Ureteral catheters were used more frequently in group 1 (67% vs. 33% [P = .06]). No difference was noted in operative time, blood loss, conversion rate, length of stay, overall complications, wound infection rate, readmission rate, reoperation rate, and mortality. All patients healed without fistula recurrence.
Conclusions:
Patients with sigmoid diverticulitis with fistula can be successfully treated with laparoscopic excision, with similar outcomes for patients without fistula.
doi:10.4293/108680813X13693422520512
PMCID: PMC3866070  PMID: 24398208
Laparoscopic resection; Sigmoid diverticulitis; Colonic fistula
21.  Phase II/III multicentre randomised controlled trial evaluating a strategy of primary surgery and adjuvant chemotherapy versus peri-operative chemotherapy for resectable gastric signet ring cell adenocarcinomas – PRODIGE 19 – FFCD1103 – ADCI002 
BMC Cancer  2013;13:281.
Background
A dramatic increase in the incidence of the diffuse form of gastric adenocarcinomas and particularly signet ring cell carcinomas has been observed in Western countries. Evidence is accruing that signet ring cell carcinomas may have inherent chemo resistance leaving many clinicians unsure of the benefits of delaying surgery to pursue a neoadjuvant approach.
Methods/design
PRODIGE-19-FFCD1103-ADCI002 is a prospective multicentre controlled randomised phase II/III trial comparing current standard of care of perioperative chemotherapy (2x3 cycles of Epirubicin, cisplatin, 5-fluorouracil) with a strategy of primary surgery followed by adjuvant chemotherapy (6 cycles of Epirubicin, cisplatin, 5-fluorouracil) in patients with a stage IB-III gastric signet ring cell tumour. The principal objective of the phase II study (84 patients) is to determine if the experimental arm (primary surgery followed by adjuvant chemotherapy) has sufficient interest in terms of percentage of living patients at 24 months to be evaluated in a phase III trial. If 7 or less patients in the experimental arm are alive at 24 months, phase III will not be initiated. The primary objective of phase III (230 additional patients) is to demonstrate superiority of the experimental arm in terms of overall survival. Secondary endpoints include overall survival at 36 months, disease free survival at 24 and 36 months, R0 resection rates, treatment tolerance, postoperative mortality and morbidity evaluated by Clavien-Dindo severity index, the prognostic impact of positive peritoneal cytology and the assessment of quality of life. An ancillary study will assess the emotional and cognitive impact of surgery and perioperative chemotherapy for both the patient and their partner.
Discussion
As inherent chemo resistance of signet ring cell tumours and delay in definitive surgery may favour tumour progression we hypothesise that a policy of primary surgery followed by adjuvant chemotherapy will improve overall survival compared to a standard perioperative chemotherapeutic strategy. This randomised phase II/III trial is the first dedicated to this histological subtype. Whilst the development of new biomarkers and targeted therapies are awaited, the results of this trial should further help in devising individualised protocols of patient care in a tumour group whose diversity increasingly demands assessment of alternative strategies.
Trial registration
ClinicalTrials.gov, NCT01717924
doi:10.1186/1471-2407-13-281
PMCID: PMC3694478  PMID: 23758655
Signet ring cells; Gastric adenocarcinoma; Surgery; Perioperative chemotherapy; Randomized study; Emotion; Couple
22.  A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial) 
BMC Surgery  2010;10:23.
Background
Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects.
Methods
A randomized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis. I) A conservative strategy with antibiotics: hospital admission, supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral, if tolerated (for a total duration of antibiotic treatment of 10 days). II) A liberal strategy without antibiotics: admission only if needed on clinical grounds, supportive measures only. Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging. Only patients with stages 1a and 1b according to Hinchey's classification or "mild" diverticulitis according to the Ambrosetti criteria are included. The primary endpoint is time-to-full recovery within a 6-month follow-up period. Full recovery is defined as being discharged from the hospital, with a return to pre-illness activities, and VAS score below 4 without the use of daily pain medication. Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention, morbidity, costs, health-related quality of life, readmission rate and acute diverticulitis recurrence rate. In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85% and a confidence level of 95%. With an estimated one percent of patients lost to follow up, a total of 533 patients will be included.
Conclusion
A clinically relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected. The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach.
Trial registration
Trial registration number: NCT01111253
doi:10.1186/1471-2482-10-23
PMCID: PMC2919453  PMID: 20646266
23.  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
24.  Vesico-ileosigmoidal fistula caused by diverticulitis: report of a case and literature review in Japan. 
Journal of Korean Medical Science  2003;18(3):433-436.
Enterovesical fistula is a relatively uncommon complication of colorectal and pelvic malignancies, diverticulitis, inflammatory bowel disease, radiotherapy, and trauma in Asian countries. A case of vesico-ileosigmoidal fistula and a literature review of this disease in Japan are presented. A 70-yr-old male was referred with complaints of urinary pain and pneumaturia. On admission, urinary tract infection and pneumaturia were presented. A barium enema demonstrated multiple diverticulum in his sigmoid colon and the passage of contrast medium into the bladder and ileum. Under the diagnosis of vesico-ileosigmoidal fistula due to suspected diverticulitis of the sigmoid colon, sigmoidectomy and partial resection of the ileum with partial cystectomy were performed. The histopathology revealed diverticulosis of the sigmoid colon with diverticulitis and development of a vesico-ileosigmoidal fistula. No malignant findings were observed. Until the year 2000, a total of 173 cases of vesico-sigmoidal fistula caused by diverticulitis had been reported in Japan. Pneumaturia and fecaluria are the most common types, presenting symptoms in 63% of the cases. Computed tomography, with a sensitivity of 40% to 100%, is the most commonly used diagnostic study. For patients with vesico-sigmoidal fistula, resection of the diseased sigmoid colon and partial cystectomy with primary anastomosis are the safest and most acceptable procedures, leading to the best results.
PMCID: PMC3055041  PMID: 12808335
25.  Difficulty in differentiating two cases of sigmoid stenosis by diverticulitis from cancer 
The incidence of colonic diverticulosis with or without diverticulitis has increased in the Japanese population due to the modernization of food and aging. The rate of diverticulitis in colon diverticulosis ranges from 8.1% to 9.6%. However, few cases of stenosis due to diverticulitis have been reported. These reports suggest that the differentiation between sigmoid diverticulitis and colon cancer is difficult. This report describes two cases of colon stenosis due to diverticulitis that were difficult to differentiate from colon cancer. Case 1 was a 70-year-old woman with narrowed stools for 1 month who underwent colonofiberscopy (CFS). CFS revealed a diverticulum and circumferential stenosis in the sigmoid colon. Barium enema revealed a marked, hourglass-shaped, 2-cm circumferential stenosis in the sigmoid colon. Fluorodeoxyglucose (FDG)-positron emission tomography computed tomography (CT) revealed an increased FDG uptake at the affected portion of the sigmoid colon. Sigmoid colon cancer was suspected, and laparoscopic sigmoidectomy was performed. Pathological examination demonstrated active inflammation with no evidence of malignancy. Case 2 was a 50-year-old man who presented to a nearby clinic with reduced stool output despite the urge to defecate. CFS detected severe stenosis in the sigmoid colon approximately 25 cm from the dentate line. Contrast-enhanced abdominal CT revealed multiple diverticula, wall thickening, and swelling of the lymph nodes around the peritoneal aorta and the inferior mesenteric artery. A partial sigmoidectomy was performed. Pathological examination of the resected specimen revealed no changes in the mucosal epithelial surface, but a marked infiltration of inflammatory cells was observed.
doi:10.3748/wjg.v18.i27.3623
PMCID: PMC3400867  PMID: 22826630
Diverticulosis; Colon cancer; Colon stenosis; Positron emission tomography-computed tomography; Magnetic resonance imaging

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