Transcript Level of central arterial ligation in total mesorectal

Operatie-indicaties bij diverticulose en diverticulitis
Johan Lange, Afdeling Heelkunde Erasmus MC
Famous sufferers
Epidemiologie diverticulitis
 50% van volwassen bevolking:
diverticulosis (<40jr: 5%; >85: 65%)
 20% van patiënten met diverticulosis
: diverticulitis (10.000 opnamen/jaar)
 25% van patiënten met diverticulitis:
gecompliceerde diverticulitis (bijna
altijd de novo)
 90%: sigmoid
 Vergrijzing: toename incidentie
vas rectum
vas rectum
vas rectum
vas rectum
Oorzaak diverticulitis: faecale obstructie divertikel
Stadia vgl Hinchey
O.K.
A.B.
M.D.L
H.A.
Klassieke operatie-indicaties diverticulose, diverticulitis
 Symptomatische diverticulose
 Gecompliceerde diverticulitis (vrije
perforatie, abces, fistel, stenose)
 >1-2 geobjectiveerde aanvallen
 Jonge patiënten
 Immuungecompromitteerde
patiënten
If in doubt cut it out
In dubio abstine
Ongecompliceerde diverticulose
Electieve sigmoidresectie na diverticulitis
Pro
Contra
 Eliminatie pathologie
 Naadlekkage: 10%
 33% na aanval opnieuw aanval
 Risico van perforatie na aanval nihil
 66% na 2e aanval nooit meer aanval
 Persisterende klachten na
sigmoidresectie
 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,
Ontwikkeling therapie voor diverticulitis: minder operaties
 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, USA.
 Aliment Pharmacol Ther. 2007;26 Suppl 2:67-76
- Review article: Management of diverticulitis.
- Szojda MM, Cuesta MA, Mulder CM, Felt-Bersma RJ.
- Department of Gastroenterology and Hepatology, VU University
Medical Centre, Amsterdam, The Netherlands.
Geen harde indicatie voor electieve resectie na één of
meerdere aanvallen diverticulitis (retrospectieve studies)

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.

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.

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.

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 USA

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, USA.

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
Diverticulitis <50jr geen agressiever beloop: zelfde
(conservatieve) beleid
 Br J Surg 2002; 89:1137-41
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
 Dis Colon Rectum. 2004; 47:1187-90; discussion 1190-1Diverticulitis 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
 Dis Colon Rectum. 2006; 49:1341-5
Nelson RS, Velasco A, Mukesh BN.
Department Of General Surgery, Marshfield Clinic, North Oak
Diverticulitis met abces: percutane punctie; meestal geen
electieve resectie nodig
 Am Surg. 2004;70:932-5
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, USA.
 Dis Colon Rectum. 2005 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
Rechtszijdige diverticulitis: zelfde (conservatieve) beleid
 1: Am Surg. 2007;73:1237-41
Conservative treatment for
patients with acute right colonic
diverticulitis.
- Moon HJ, Park JK, Lee JI, Lee
JH, Shin HJ, Kim WS, Kim
MS, Jeong JH.
- Department of Surgery,
Myoungji Hospital, Kwandong
University College of Medicine,
Goyang, Korea.
Chirurgie bij high risk patiënten?
 J Clin Gastroenterol. 2006; 40(7 Suppl 3):S136-44.
Diagnosis and management of acute diverticulitis.
Floch CL.
Norwalk Hospital, Norwalk, USA
the obese, 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.
Correlatie tussen distale colorectale neoplasie en distale
ernstige diverticulose bij vrouwen
 Am J Gastroenterol 2004;99:2007-11
- Is diverticulosis associated with colorectal neoplasia? A
cross-sectional colonoscopic study.
- Kieff BJ, Eckert GJ, Imperiale TF.
- Divisions of Gastroenterology, General Internal Medicine, and
Biostatistics, Department of Medicine, School of Medicine, Indiana
University, Indianapolis, USA
- CONCLUSION: In this study women with EDD were more likely to
have advanced distal neoplasia.
Jacobs DO.
Clinical practice. Diverticulitis.
N Engl J Med. 2007; 357(20):2057-66. Review
Richtlijnen Am Soc Colon and Rectal Surgeons
Vermeulen J, Akkersdijk GP, Gosselink MP, Hop WC, Mannaerts GH, van der Harst E, Coene PP, Weidema WF, Lange JF.
Outcome after emergency surgery for acute perforated diverticulitis in 200 cases.
Dig Surg. 2007;24:361-6
Watchful waiting
Asymptomatische galblaasstenen
pancreatitis
Ulcus pepticum
Watchful waiting: hernia inguinalis (INCA-trial)
RCT’s ?
 Profylactische resectie vs Expectatief: achterhaald?
 In voorbereiding: geperforeerde diverticulitis: anastomose vs Hartmann
(Jefrey Vermeulen: [email protected])
Delft
Diverticulitis
(diverticulosis sigmoid)
Diverticulosis kan voorkomen in het hele colon t/m/ het coecum
Maar meestal in het li colon m.n. het sigmoid
Diverticulitis
(divertikels)
Diverticulosis ontstaat door verhoogde druk in het colon, versterkt door
laag residu (vezelarm)-dieet; er is zeker een genetische predispositie;
Typische aandoening van de westerse wereld (te weinig vezels)
Diverticulitis
(diverticulosis)
Diverticulitis (peridiverticulitis)
ontstaat als faeces als in een fuik
het divertikel niet meer kan
verlaten; vaak is er in dat geval
sprake van obstipatie wat de
evacuatie van het divertikel
bemoeilijkt: vandaar dat, als de
diverticulitis is afgekoeld een
vezelrijk dieet wordt voorgeschreven)
blaasfistel
Diverticulitis
(X=colon: post-diverticulitis-stenose sigmoid)
Diverticulitis
(CT: verdikt sigmoid+ infiltratie vet)
=verdikte wand
=vetinfiltratie
diverticulitis
Ongecompl diverticulitis
Verdikte appendices epiploica bij diverticulitis
abces
abces
Diverticulitis
(CT: infiltratie+luchtfiguurtjes)
perforatie
Rechts: vaker bij jongere mensen: relatie met sigmoiddiverticulose onbekend
Vetinfiltratie (witte pijlen) t.g.v. ontstoken divertikel (zwarte pijlen)
Diverticulitis
(pathogenese diverticulosis)
Divertikel=herniatie thv taeniae
door muscularis heen, ter plekke
van perforerende vaatjes van
buiten naar de mucosa toe, dus
bekleding= alleen serosa+mucosa
(geen muscularis)
Diverticulitis
(diagnostiek)
 Bloed: infectieparameters: leucocytose+verhoogd CRP/BSE
 echo: verdikt colon+infiltratie vet/mesenterium; soms abces in geval
van gedekte perforatie
 Gouden standaard= CT

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.
-----

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.
-----

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.
Correlatie tussen distale colorectale neoplasie en distale
ernstige diverticulose bij vrouwen

1: Am J Gastroenterol. 2004 Oct;99(10):2007-11. Links
- Is diverticulosis associated with colorectal neoplasia? A cross-sectional colonoscopic study.
- Kieff BJ, Eckert GJ, Imperiale TF.
- Divisions of Gastroenterology, General Internal Medicine, and Biostatistics, Department of Medicine, School of
Medicine, Indiana University, Indianapolis, IN 46202, USA.
- OBJECTIVE: To determine the relationship between distal diverticulosis and risk for colorectal neoplasia.
METHODS: Patients undergoing first-time colonoscopy for any indication were eligible if they had no prior
polypectomy, colonic resection, or inflammatory bowel disease. Patients completed a survey about risk factors
for colorectal cancer (CRC) prior to colonoscopy. Endoscopists, blinded to study objective and survey results,
recorded the size, extent (none, few, or many), and location of diverticuli and polyps. RESULTS: The 502
participants were 67% male with a mean age of 58.6 yr. Twenty-three percent had extensive distal diverticulosis
(EDD), 36% had > or =1 adenoma, and 14% had advanced neoplasia. Overall comparison of those with EDD
versus few or no diverticuli revealed no differences in the risks of any neoplasia or advanced neoplasia, either
distally (26.7%vs 25.4%; 12.9%vs 8.8%, respectively) or proximally (25%vs 18.4%; 6.0%vs 4.9%). Compared to
women with few or no distal diverticuli, however, women with EDD were more likely to have any neoplasia and
advanced neoplasia, both distally (34.6%vs 16.3%; p= 0.03, and 23.1%vs 5.7%; p= 0.003) and proximally
(30.8%vs 14.9%; p= 0.049, and 11.5%vs 4.3%, p= 0.13). Adjustment for age did not affect results for advanced
distal neoplasia (OR = 3.92; CI: 1.18-13); however, adjustment for the presence of a distal neoplasm eliminated
the increased risk of proximal neoplasia associated with EDD (OR = 1.31; CI: 0.43-4.02). CONCLUSION: In this
study, women with EDD were more likely to have advanced distal neoplasia. The presence of distal neoplasia in
women with EDD accounted for their increased risk of proximal neoplasia. Distal diverticulosis was not
independently associated with proximal neoplasia in men or women.

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.
-----

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,
[email protected].
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 leftsided 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.

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.
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


----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.
 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.
[email protected].
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



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. [email protected]
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.
------

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. [email protected]
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.
-----



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.
-----


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. [email protected]
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.

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. [email protected]
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.
-----

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.
-----

1: Drugs Aging. 2004;21(4):211-28. Links
- 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.

1: Am Fam Physician. 2005 Oct 1;72(7):1229-34. Links
- Comment in:
 Am Fam Physician. 2006 Jun 15;73(12):2123; author reply 2123.
- 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. [email protected]
- 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 gramnegative 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.
- PMID: 16225025 [PubMed - indexed for MEDLINE]

1: Schweiz Rundsch Med Prax. 2007 Jan 31;96(5):153-7. Links
- [Diverticulosis--diverticulitis]
- [Article in German]
- Maier KP.
- Akademisches Lehrkrankenhaus der Universität Tübingen, Städtische Kliniken Esslingen.
[email protected]
- Diverticular disease is a common disorder in the western world. The course of the illness is
benign: At least 75% of all patients with diverticular disease remain asymptomatic life long. 1020% develop clinical symptoms, usually painful diverticulitis. Diverticular disease is diagnosed
clinically in most cases. Computed tomography (CT) has replaced contrast enema as the
diagnostic procedure of choice for acute diverticulitis. Most patients with uncomplicated
diverticulitis can be treated as outpatients Bowel rest, intravenous fluid therapy, broad spectrum
antibiotics are treatment modelities if a patient has been hospitalized. Close follow-up is
mandatory, especially in patients treated as outpatients. Failure to improve with conservative
medical therapy warrants a diligent search for complications and surgical consultation. Surgery
may be nessasary in a few of hospitalized patients. Commonly, the operation is performed in a
single-stage procedure. Once the acute setting has passed, a colonoscopy should be electively
performed to exclude competing diagnoses particularly colonic cancer.
Diverticulitis van het coecum: andere ziekte en vaker
operatie
 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.
 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.
Diverticulitis <50jr geen agressiever beloop
 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.
 METHODS: retrospective study
 CONCLUSION: Diverticulitis in young patients does not have a
particularly aggressive course and the risk of recurrence is similar to
that of older patients.
 TABLE 3Consensus Antibiotic Treatment for Patients with
DiverticulitisOutpatientAmoxicillin-clavulanate
(Augmentin)Trimethoprim-sulfamethoxazole (Bactrim, Septra) and
metronidazole (Flagyl)Fluoroquinolone and
metronidazoleInpatientMetronidazole or clindamycin
(Cleocin)plusAminoglycoside (gentamicin [Garamycin] or tobramycin
[Tobrex])orMonobactam (aztreonam [Azactam])orThird-generation
cephalosporin (ceftriaxone [Rocephin], ceftazidime [Fortaz], cefotaxime
[Claforan])alternativelySecond-generation cephalosporin (cefoxitin
[Mefoxin], cefotetan [Cefotan])Beta-lactamase inhibitor combinations
(ampicillin-sulbactam [Unasyn], ticarcillin-clavulanate
[Timentin])Information from reference 6.
 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. [email protected]
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.

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 intraabdominal 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.
-----

1: Dig Dis. 2007;25(2):151-9. Links
-
Diverticular disease in the elderly.
Comparato G, Pilotto A, Franzè A, Franceschi M, Di Mario F.
University of Parma, Parma, Italy.
There are few diseases whose incidence varies as greatly worldwide as that of diverticulosis. Its prevalence is
largely age-dependent: the disease is uncommon in those under the age of 40, the prevalence of which is
estimated at approximately 5%; this increases to 65% in those > or =65 years of age. Of patients with diverticula,
80-85% remain asymptomatic, while, for unknown reasons, only three-fourths of the remaining 15-20% of
patients develop symptomatic diverticular disease. Traditional concepts regarding the causes of colonic
diverticula include alterations in colonic wall resistance, disordered colonic motility and dietary fiber deficiency.
Currently, inflammation has been proposed to play a role in diverticular disease. Goals of therapy in diverticular
disease should include improvement of symptoms and prevention of recurrent attacks in symptomatic,
uncomplicated diverticular disease, and prevention of the complications of disease such as diverticulitis.
Diverticulitis is the most usual clinical complication of diverticular disease, affecting 10-25% of patients with
diverticula. Most patients admitted with acute diverticulitis respond to conservative treatment, but 15-30% require
surgery. Predictive factors for severe diverticulitis are sex, obesity, immunodeficiency and old age. Surgery for
acute complications of diverticular disease of the sigmoid colon carries significant rates of morbidity and
mortality, the latter of which occurs predominantly in cases of severe comorbidity. Postoperative mortality and
morbidity are to a large extent driven by patient-related factors. Copyright 2007 S. Karger AG, Basel.
- PMID: 17468551 [PubMed - indexed for MEDLINE]

1: Schweiz Rundsch Med Prax. 2007 Feb 14;96(7):234-6. Links
- [Course and conservative treatment of diverticular disease]
- [Article in German]
- Hoffmann R.
- Innere Abteilung, Hohenloher Krankenhaus, Ohringen.
- Diverticular disease is one of the most gastrointestinal disorders especially in developed
countries. Prevalence rises with age, about two-thirds of patients in the age of 80 years are
affected. In western countries diverticulosis is predominantly located in the distal colon. Only a
minority of patients with diverticulosis develops symptoms. Ultrasound studies and CT scan are
most important in diagnosing diverticulitis and its complications. Patients with the first attack of
uncomplicated diverticulitis are treated with broad-spectrum antibiotics and in more severe case
with bowel rest. Mesalazin is another choice of treatment. Recurrence of the disease is of
increased risk to develop complications such as abscess formation, fistula and obstruction.
These complications should be treated by operative resection. Lower gastrointestinal bleeding
from divertikular sources should be treated by interventional endoscopy.
- PMID: 17361908 [PubMed - indexed for MEDLINE]

1: Dig Surg. 2007;24(5):361-6. Epub 2007 Aug 30. Links
- Outcome after emergency surgery for acute perforated diverticulitis in 200 cases.
- Vermeulen J, Akkersdijk GP, Gosselink MP, Hop WC, Mannaerts GH, van der Harst E, Coene PP,
Weidema WF, Lange JF.
- Department of Surgery, MCRZ St. Clara Hospital and Zuider Hospital, Rotterdam, The Netherlands.
[email protected]
- BACKGROUND: Mortality and morbidity rates of acute perforated diverticulitis remain high. The ideal treatment
is still controversial. The object of this study was to compare patients with perforated diverticulitis treated either
by resection with primary anastomosis (PA) or Hartmann's procedure (HP). METHODS: A multicenter study was
carried out on 200 consecutive patients with acute perforated diverticulitis who were presented in the surgical
units of four affiliated teaching hospitals in Rotterdam, The Netherlands, between 1995 and 2005. Mortality and
morbidity were compared in relation to type of surgery, ASA classification, age, gender, Mannheim Peritonitis
Index (MPI), Hinchey score, surgeon's experience, and the time of operation. RESULTS: There was a tendency
for more severely affected patients (Hinchey, MPI, ASA and age) to undergo HP. Multivariate logistic regression
analysis showed no significant difference in mortality between HP and PA. After HP, more patients needed one or
more reinterventions to treat postoperative complications compared to PA. Besides, HP resulted in a longer total
hospital and intensive care unit stay. Specialist colorectal surgeons performed significantly more frequently a PA
instead of a HP and had fewer postoperative complications than general surgeons. The time of operation did not
influence the choice of surgical procedure. CONCLUSION: Selected patients with perforated diverticulitis can be
managed well by PA, as it does not seem to be inferior to HP in terms of severe postoperative complications that
need surgical or radiological reintervention and mortality. This decision should be made while taking into account
the patient's concomitant diseases, response on preoperative resuscitation and the availability of a surgeon
experienced in colorectal surgery.
- PMID: 17785981 [PubMed - in process]

The title, it was reported, was thought up
because John needed one for New Zealand
producer Adrian Bohm, who asked him to
come. It proved prophetic as Cleese promptly
to have 17 cm
of his sigmoid colon removed due to
diverticulitis. Cleese wanted to sell
his ex-intestine on eBay, except the
rules of the auction site forbid it.
fell ill shortly after and had
Oorzaken diverticulosis
 Westerse landen: vezelarm dieet:
laag residu-faeces+persen: hoge
drukken
 Genetische predispositie
Rudolf II (Giuseppe Arcimboldo 1527-1593)
Diverticulitis
(gradaties van perforatie: Hinchey classificatie)
 Hinchey I: ongecompliceerde diverticulitis
 Hinchey II: afgedekte (dunne darm/omentum) perforatie: abces
 Hinchey III: vrije (mini-)perforatie: fibrineuze peritonitis (vrije i.p.
pus+fibrine beslagen peritoneum)
 Hinchey IV: vrije perforatie: faecale peritonitis
Diverticulitis
(complicaties)
 Perforatie
 Stenose/ileus
 Bloeding (zelden)
Diverticulitis
(therapie)
 1e aanval: conservatief: vloeibaar dieet, rust, AB niet evidence-based;
zorgvuldige controle om eventuele vrije perforatie (CT: vrij lucht), die
nog kan ontstaan, niet te missen
 Tzt (als CRP/BSE zijn genormaliseerd) colonoscopie doen teneinde
colonca toch nog uit t esluiten
Diverticulitis
(therapie)




Operatie iha pas bij>1 geobjectiveerde (verhoogde CRP/BSE, CT/echo) aanval
Hinchey II: resectie+primaire naad ev.+ beschermend ileostoma voor 4-12 wk; eventueel
kan men hier eerst de radioloog verzoeken percutaan te draineren (1-2 wk) om de
patient in een betere conditie te brengen (geen koorts meer)
Hinchey III: resectie+primaire naad+beschermend ileostoma
Hinchey IV: Hartmann procedure
NB Helaas wordt iha bij Hinchey II-IV toch nog als een reflex meestal een Hartmannprocedure verricht, die
in de praktijk meestal een definitief stoma betekent; ook is het opheffen van een Hartmannprocedure
(colon/rectumoperatie) meer riskant (meer naadlekkages) dan het opheffen van een beschermend
ileostoma
Diverticulitis
(normaal colon)
Operatie-indicaties bij diverticulose en diverticulitis
Johan Lange
Algemene Heelkunde, Erasmus MC, Rotterdam