Diverticular disease of the colon

Diseases o f the Volume Number

C o t oN R t crvM 42 6 JUNE 1999

CENTENNIAL ARTICLES IN COLON AND RECTAL SURGERY

Diverticular Disease of the Colon A Century-Old Problem

David J. Schoetz, Jr., M.D.

From the Department of Colon and Rectal Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts

Schoetz DJ Jr. Diverticular disease of the colon: a century- old problem. Dis Colon Rectum 1999;42:703-709.

A s The American Society of Colon and Rectal Surgeons celebrates its 100th anniversary, it is

only fitting that one of the topics chosen for review should be diverticular disease of the colon. "Illis disease is often characterized as a 20th-century development, which is not strictly correct, but reinforces the fact that the advances in diagnosis and treatment of this now-common condition have been predomi- nantly in the past century. Although the primary aim of this discussion is to trace the development of surgical treatment of diverticnlosis and its various complications, some background history of the understanding of the disease permits perspective in understanding the current recommendations for treatment and even predicting future trends.

H I S T O R Y , P A T H O G E N E S I S , A N D

N A T U R A L H I S T O R Y

Acquired diverticular disease of the colon was first described in 1700 by Littre ~ as saccular outpouchings of the colon; these outpouchings were thought to be an anatomic oddity. Cmveilhier, 2 in 1849, is credited with the first in-depth description of the disease process of inflammation of diverticula with resultant be- ,nign fistulas to the bladder. In 1899 Graser 3 intro- duced the term "peridiverticulitis," suggesting that herniation of the mucosa through areas of penetration of the vasa recta was the pathogenesis of the devel-

No reprints are available.

opment of diverticula; this is now a well-established

concept. In 1904 Beer 4 proposed that the mechanism

of the development of diverticulitis was impaction of

feces in the neck of the diverticulum, causing inflam-

mation and subsequent abscess with possible fistula

formation. Telling, 5 in 1908, reported 80 cases of di-

verticulitis of the sigmoid and suggested that the dis-

ease may be more prevalent than previously suspected. Nine years later, Telling and Gruner 6

published their classic description of complicated di-

verticular disease. Thus, although the disease had

been virtually unknown until the late 19th century, by

1920 the basic understanding of the cause and man-

ifestations of diverticulosis had been established, and

the observation of an increasing prevalence of the

disease had been made. Complications of diverticular

disease were also well characterized, including acute

diverticulitis, abscess, fistula, perforation, and ob-

struction.

Establishment of lower gastrointestinal contrast ra-

diography, with increasing application for diagnosis

of intestinal disorders after World War I, confirmed by

radiographic findings that diverticula were indeed

more common than had been suspected. Autopsy

studies tend to underestimate the frequency of dis-

ease, because small diverticula may escape detection. On the other hand, radiographic estimates of fre-

quency tend to overestimate the prevalence, because

patients undergoing the studies have gastrointestinal

symptoms that warranted the radiographic study in

the first place. It is clear that acquired di_verticulosis is

unusual in patients younger than 40 years of age, but

703

704 SCHOETZ Dis Colon Rectum, June 1999

the incidence increases linearly thereafter. Parks 7 es- timated a 5 percent incidence in patients in the fifth decade, increasing to 50 percent in the ninth decade of life. With the increasing age of the population of western countries, the frequency of diverticular disease and its complications will only increase, making the disease an even greater health care problem in

terms of morbidity, mortality, and cost. Diverticula in western countries are seen predom-

inantly in the sigmoid colon and the distal descending colon, in contradistinction to the almost exclusively right-sided disease seen in the Asian population. As the migration of Asian to westernized countries has become more common, with assumption of western

dietary habits, it is generally accepted that the prevalence of left-sided diverticula has significantly increased in the migrating Asian population. Not sur-

prisingly, the frequency of complications of diverticulosis has increased in these populations as

well. Painter and Burkitt s have been pivotal in the pro-

mulgation of the fiber-deficiency theory of the pathogenesis of acquired diverticulosis. They have traced the evolution of the diet in industrialized nations, citing the development of roller milling of flour in

1880 as a primary cause of decreased fiber consump- tion. This, combined with the increasing availability of refined sugars and meat and the decreased consump-

tion of whole grain breads and cereals, resulted in a drastic reduction in the ingestion of crude fiber and led to the predicted observed increase in complicated diverticular disease some 40 years later.

The relationship between decreased fiber intake and an increased prevalence of diverticula hinges on the observation that intraluminal pressures within the colon are of critical importance in the origin of the condition. Painter and associates, 9 using open-t ipped perfusion catheters, demonstrated that the intraluminal pressures within the sigmoid colon of persons with diverticula during periods of peak contraction resulted in pressures of up to 90 mmHg, a value nine times higher than a colon not affected by diverticulosis. They theorized that these high pressures resulted in segmentation of the colon, the high pressures within the segments herniating the mucosa through the muscle in areas of weakness. This would result in the previously observed gross and microscopic changes in diverticulosis. In this widely accepted theory of pathogenesis, fiber deficiency would aggravate the intraluminal pressures by not providing a "pressure damper" to diffuse and prevent the segmenting

contractions, It also forms the basis for the recently often-recommended high-fiber diet suggested to indi- viduals with symptomatic diverticular disease.

The natural history of diverticular disease has been characterized by Parks, 7 who observed that the disease tends to be more aggressive in patients younger than 40 years of age. Of all patients with diverticular disease, the most common complication of divertic-

ula, acute diverticulitis, develops in 10 to 25 percent of patients at some time during their life. More than one-half have a short prodrome of abdominal pain, lasting less than one month before admission to the hospital. 10 Nearly one-quarter were readmitted with a

second attack after successful medical treatment, with a higher incidence in patients whose bowel function did not return to normal after the first attack. Further-

more, medical treatment was less likely to be successful with each subsequent attack. In a Lahey Clinic study, Boles and Jordan n observed 294 patients for more than ten years and found that only 40 percent of patients had a single attack and that complications, such as obstruction, free perforation, abscess, and fistula, were more common in patients with recurrent episodes. These and similar observations resulted in the current recommendation to consider elective resection after the second attack of uncomplicated diverticulitis, after the first attack in patients with com-

plicated diverticulitis, and in "young" patients because of the aggressive nature of the disease---a recommendation that has recently been challenged.

The most common complication of diverticulosis is acute diverticulitis. Complicated forms of diverticulitis include free intraperitoneal perforation, abscess, fistula, and obstruction. Lower gastrointestinal tract bleeding from diverticula is not associated with underlying acute inflammation; rather, the presumed cause of this problem is erosion of a submucosal blood vessel by impacted stool at the neck of a dive> ticulum. Discussion of diverticular bleeding is beyond the scope of this review, which focuses on the historical developments of surgery for inflammatory complications of diverticulosis.

D I A G N O S I S A N D MEDICAL T R E A T M E N T

Accurate diagnosis of the presence of acute dive> ticulitis continues to undergo an evolution, diagnosis at the beginning of the 20th century being clinical, perhaps with pathologic confirmation from surgical or autopsy material. In the 1930s lower gastrointestinal tract radiog- raphy had become the diagnostic method of choice, lz

Vol. 42, No. 6 CENTENNIAL ARTICLE 705

Proctoscopy was rarely indicated, because the disease

affected the sigmoid and spared the rectum. With the

development of water-soluble contrast agents, the potentia/risk of barium peritonitis became avoidable

in the acute setting, relying on low-pressure studies confined to the left colon in an unprepared colon.

The advent of colonoscopy in the late 1960s and the

subsequent development of the flexible sigmoido-

scope permitted direct visualization of the mucosa of

the involved colon but was rarely of value in an acute

attack, with a risk of perforation that did not justify its

routine use in the acutely inflamed colon. Acute di-

verticulitis is still considered a relative contraindica-

tion to flexible endoscopy. Colonoscopy is reserved

for evaluation of strictures and exclusion of cancer

after resolution of the acute episode. In the older

literature the inability to differentiate diverticulitis

from cancer as a cause of colonic obstruction was a

much more common indication for surgical resection than it is today.

The advent and refinement of cross-sectional imag-

ing since the 1980s has resulted in the current enthu-

siasm for the use of computed tomography (CT) as the diagnostic method of choice for patients sus-

pected of having acute diverticulitis or one of its

complications. ~3 Interventional techniques have ex-

tended the role of the radiologist beyond diagnosis to treatment of diverticular abscesses, often simplifying operative management. ~4

In the preantibiotic era, treatment of diverticulitis consisted of bed rest, no residue diet, ice packs to the abdomen, and enemas of warm saline solution. ~2

With clinical improvement, a low residue diet combined with mineral oil by mouth was instituted, as

was tincture of belladonna to relieve intestinal spasm.

With this regimen, the success rate in the short term

was surprisingly high. With the advent of systemic antibiotics in the late

1930s, all conditions in which bacteria were thought to play a significant role were treated with every

single drug and combination imaginable. Treatment of diverticulitis today is primarily with any broad-

spectrum antibiotic directed at colonic microflora, particularly Eschericbia coli and Bacteroides fragilis. This has become the standard of care despite a lack of randomized placebo-controlled trials documenting the necessity of antibiotic treatment and the previously proven resolution of acute diverticulitis in a high percentage of patients not treated w'ith antimi- crobial agents,

SURGICAL T H E R A P Y

William Mayo, 15 in 1907, presented his experience with five cases of diverticulitis to the American Surgi-

cal Association. He advised drainage of localized abscesses, with proximal colostomy reserved for pa-

tients with colonic obstruction. If medical treatment was not successful, he recommended elective sig-

moid resection to prevent complications of diverticu-

litis. Despite the advances in anesthetic and periop- erative care that have revolutionized all aspects of

abdominal surgery, these observations are as true today as when first written.

Proximal transverse colostomy, with external drain-

age of abscess but without resection of the diseased bowel, was a common method of treatment in the

early 1900s because of the morbidity associated -with sigmoid resection. If proximal fecal diversion were

successful in alleviating the inflammatory process,

patients would often undergo closure of the cotostomy without resection of the diseased bowel. In 1942

Smithwick 16 published his observations that simple proximal colostomy without resection did not resolve

the inflammatory process in a significant proportion of patients and strongly urged the traditional three-

stage approach as follows: 1) proximal colostomy with drainage of abscess, 2) sigmoid resection with maintenance of the proximal colostomy to protect the

anastomosis, and 3) closure of the cotostomy. With this approach, he was able to achieve a 6 percent operative mortality rate and a good clinical outcome in 82 percent of patients. Based on this article and others, the three-stage approach became the standard

of care for surgery of complicated diverticulitis. Application of this treatment plan resulted in the

observation that proximal fecal diversion did not resolve the acute episode in a substantial number of

patients. It was presumed that the infection persisted because a column of stool occupied the colon distal to the colostomy, with continual fecal soiling. Welch and associates iv reported an incidence of failure to

resolve the acute condition in 8.2 percent of patients treated with proximal colostomy without resection. Although they continued to advocate multistaged pro- cedures for the most severe complications, they suggested that aggressive single-stage resection could be performed safely in patients with persistent or recurrent attacks in the majority of instances. Colcock ~8 presented the Lahey Clinic experience with 294 patients with diverticulitis and demonstrated the safety of single-stage resection in 61.2 percent of patients


treated. Less than 20 percent had three-stage proce- dures, and the remainder were treated with a variety of two-stage approaches, with increasing emphasis on resection of the diseased segment at the initial

operation. In tracing the evolution of" surgery for diverticular disease, Rodkey and Welch ~9 found that resection of the perforated segment at the first operation resulted in a significantly reduced mortality.

Based on these and other reports, sigmoid resection with primary anastomosis was increasingly used as the preferred approach in patients with recurrent attacks and fistulas; however, the three-stage approach continued to be the recommended treatment for abscess and perforation despite the demonstra- tion, in one study, 2° of a 39 percent mortality rate associated with abscess and a 26 percent mortality rate associated with perforation. It was thought that the general condition of the patient precluded safe resection, despite the fact that Madden and Tan 2~ had applied immediate resection with anastomosis for abscess and perforation in a series of 29 patients, with a mortality rate of 10 percent associated with one-stage resection compared with a cumulative mortality rate of 47.3 percent in patients treated with multiple operations.

Two-stage options that evolved to permit removal of the diseased colon at the initial operation included resection with anastomosis and proximal diversion and the modified Hartmann operation, with end sigmoid colostomy and closure of the rectal stump be- low the inflammatory process. Although there is an advantage to the performance of a mucous fistula rather than a Hartmann operation, it is unusual to be able to reach the distal segment to the anterior abdominal wall, because of the presence of a phlegmon in the sigmoid colon in most instances. Similarly, Mikulicz exteriorization of the inflamed bowel is more often written about than performed for the same reason.

By the early 1980s the trend toward single-stage resection was evident. In a series of 140 patients treated for histologically verified complicated diverticulitis, primary resection with anastomosis was performed in 61 percent, with a 1 percent mortality rate. Three-stage operations were associated with a cumulative mortality rate of 14 percent, whereas resection and proximal colostomy in carefully selected circumstances resulted in no mortality, and the Hartmann operation, applied to patients with more advanced disease, was associated with a 16 percent mortality rate, with a lower overall period of hospitalization

and recuperation. = It is likely that the availability of the circular end-to-end stapler, which facilitated reanastomosis of the Hartmann procedure, was a moti- vating factor in the more widespread application of this operation to diverticulitis.

Review of the literature reinforces the difficulty in comparing studies because of a lack of unanimity regarding the stage of the dive1~icular process at the time of operation. Hinchey and associates 23 are to be credited with suggesting a disease severity classifica- tion, which has generally gained wide acceptance:

Stage I--Pericolic abscess or phlegmon Stage II--Pelvic, intra-abdominal, or retroperito-

neal abscess Stage III--Generalized purulent peritonitis Stage IV--Generalized fecal peritonitis.

Primary anastomosis after resection is safe in Stages I and II disease, whereas two-stage resection is safer in Stages III and IV disease. 24

At one time the operation of sigmoid myotomy was applied to patients with symptomatic divet*icular disease in the absence of acute inflammation. 25 Based on

the observation of thickened sigmoid smooth muscle, the same principle of the pyloromyotomy was applied to the colon, with division of the antimesenteric mus- culature from the rectosigmoid back to the point at which the muscle becomes pliant. Although demon- strably safe, with a leak rate similar to an anastomosis and excellent relief of symptoms, the tedium of the procedure and the theoretical concern for leaving unprotected submucosa, with the possibility of rup- ture, prevented widespread application. This procedure has been abandoned.

Regarding extent of resection, over the years debate has centered around two issues. The first is whether all diverticula in the colon need be resected, despite the fact that more than 95 percent of patients with diverticular complications have the sigmoid colon as the primary focus of disease. After seemingly adequate resection, recurrent diverticulitis was noted to occur in 7.7 percent of 65 patients known to have residual diverticula in an early study, 26 resulting in recommendation for resection of all of the affected colon. Wolff and associates 27 demonstrated progression of diverticulosis. Recurrent diverticulitis was not dependent on the number of diverticula and did not support the application of subtotal colectomy to patients with pandivel~icular disease. 27 The other con- troversy has been the distal line of resection; division of the proximal rectum may be thought to be techni- cally difficult at the time of initial operation. In a stud3,"


from the Mayo Clinic, zs when an anastomosis was

performed to the anatomic rectum, as demonstrated

by the loss of taenia at the line of transection, the

recurrent diverticulitis rate was significantly lower

than if there was sigmoid colon distal to the anasto-

mosis. At present, then, the recommendation for ex-

tent of resection is from the rectum proximally to

above the most proximally inflamed area. Total sig-

moidectomy will suffice in most instances.

SPECIAL C I R C U M S T A N C E S

It has long been believed that diverticulitis in young

patients, variably defined as younger than 40 to 45

years of age, is a more aggressive and morbid disease

and merits resection more often than in the older age

groups. 7 In a study by Hannan and associates 29 in

1961, patients younger than 45 years required surgery

nearly twice as often as the rest of the group. Cer-

tainty, there is a cumulatively greater risk of recurrent

disease in younger patients, with their longer lifespan.

For many years the standard recommendation was to

offer elective sigmoid resection to patients with one

documented attack of diverticulitis before the age of

50 years. Although this precept was based on re-

peated observations, few data were available regard-

ing the natural history" of successfully medically

treated patients in this age group. Recently, Vignati

and associates 3° examined 40 patients aged 50 or

younger with acute diverticulitis; 25 percent required

operation at the initial attack, and of the remainder, 68

percent did not require surgery during a minimum

five-year follow-up. Patients who required operation

underwent elective sigmoid resection; none required

colostomy. Perhaps the traditional aggressive surgical

approach in the younger age group is not justified.

Immunocompromised patients have been demon-

strated to have a more virulent course, often with few

clinical signs but overwhelming sepsis and a poor

clinical outcome in terms of morbidity and mortality

after operative intervention. 3~ This has resulted in a

more aggressive operative approach, with earlier sur-

gical intervention advised for patients taking steroids,

chemotherapeutic agents, and transplant immuno-

suppression drugs who present with acute diverticu-

litis. Patients being considered for transplantation

who have had even one prior attack of diverticulitis

should strongly be considered for elective resection

before the transplant if medically feasible.

N E W D E V E L O P M E N T S

Failure to achieve preoperative mechanical cleans-

ing of the colon is associated with a higher frequency

of multistaged resections. In patients who do not

respond to intensive medical therapy, operation may

be required in the presence of an unprepared bowel.

Intraoperative colonic lavage has been demonstrated

to be safe in patients with colonic obstruction, en-

abling resection with primary anastomosis after thor-

oughly irrigating the colon of stool at the time of the

initial operation. In a series of 62 patients undergoing

nonelective surgery for diverticular disease at the La-

hey Clinic 32 from 1987 to 1996, 33 underwent intra-

operative lavage and primary anastomosis with one

anastomotic leak. Thirteen of these patients had early

peritonitis, and 6 had free perforation. The extension

of the technique of on-table iavage to indications

other than obstruction was proven to be safe in this

study. Furthermore, if a proximal covering stoma is

believed to be indicated, the surgeon may choose

between colostomy and loop ileostomy. The absence

of stool distal to the stoma mitigates the previously

observed problems of persistent sepsis. This ap-

proach is not applicable to patients with fecal perito-

nitis or well-established fibrinous peritonitis.

Because the techniques of invasive radiology have

improved, the ability of interventionists to provide

satisfactory percutaneous drainage of diverticular ab-

scesses has resulted in a significant percentage of patients being converted from what previously would

have been a multistaged operation to an elective sin-

gle-stage resection. 14 In a series of 19 patients under-

going percutaneous drainage of diverticular abscess-

es, 33 disease was controlled in 74 percent. Although

sinography demonstrated communication with the

colon in nearly one-half of the patients, colocutane-

ous fistulas were surprisingly unusual. 33 The current

management of a patient not responding to antibiotics

is to perform CT, seeking a drainable collection. It

must be remembered, however, that resolution of the abscess is only the first step in the appropriate treat-

ment of the underlying disease process. Closing a

proximal colostomy is associated with an unaccept- ably high incidence of recurrent diverticulitis.

Laparoscopic surgery has been applied with vari- able success to diverticulitis. 34 Because it is a benign

disease, the objections to performing resection in can-

cer are obviated. Debate continues on the ability of the laparoscope to provide the theoretical benefits of "minimally invasive" surgery.35 Laparoscopic-assisted


sigmoid resection, in which a portion of the procedure is accomplished in a more open fashion after mobilization of the colon, may be preferable to com-

pletely intracorporeal dissection because of the diffi-

culty in resecting the inflamed or adherent colon through the laparoscope. There is some sentiment that the use of "handoscopy" will greatly facilitate the

dissection and result in decreased operating time, shorter length of stay, and less postoperative morbid-

ity. This remains to be proven.

C U R R E N T R E C O M M E N D A T I O N S

Based on the historical developments in the diagnosis and treatment of patients with acquired diverticular disease of the colon during the past century,

the current recommendations for treatment are sum-

marized as follows:

1. Diverticulosis of the colon is a common condi-

tion in industrialized nations, increasing in incidence with increasing age. Symptomatic dive>

ticular disease, in the absence of objective evidence of acute inflammation, is rarely an in-

dication for surgical intervention. Rather, control of symptoms with fiber supplement and anti-

spasmodic medication should suffice. 2. The most common complication of diverticulo-

sis is acute diverticulitis, which is diagnosed most often on clinical grounds and confirmed by either CT or water-soluble enema in the acute setting. Treatment of the acute episode is with

broad-spectrum antibiotics, with the need for hospitalization based on the severity of the at-

tack. 3. After one documented attack, successfully

treated, there is no reason to consider elective resection unless unusual circumstances are present, such as immunosuppression or perhaps age younger than 45 years.

4. After two documented attacks, successfully treated, a recommendation should be made for elective colon resection unless other comorbid conditions constitute inordinate risk for elective operation.

5. Complicated diverticulitis includes free intraperitoneal perforation, abscess, fistula, and obstruction. Operative intervention is generally required in these circumstances. The timing is determined by the specific clinical situation, with immediate surgery required for patients with free perforation with peritonitis. Whether a

multistaged resection is necessary depends on

the degree of peritoneal contamination and the

overall condition of the patient. Fecal peritonitis and advanced generalized fibrinous peritonitis

will most often be treated by resection, end

colostomy, and Hartmann closure of the rectum; reanastomosis is performed at a later date. Early

peritonitis may be treated safely with single- stage resection with on-table lavage and primary

anastomosis.

6. Nonresolution of an acute attack should prompt

a search for a pericolonic abscess that may per-

mit percutaneous drainage by CT or ultrasound

guidance. Successful drainage will permit later elective resection in the majority of instances.

Failure to obtain satisfactory drainage is an indication for surgery. Whether this can be accom-

plished in a single stage is dependent on the individual situation.

7. Fistulas, most often to the bladder in a male

patient and to the vagina in a female patient, require exclusion of an underlying carcinoma

before performance of an elective resection in a single stage.

8. Obstruction that does not resolve with antibiotic treatment requires operation. Single-stage resec-

tion with intraoperative colonic washout is the

procedure of choice if preoperative mechanical cleansing cannot be accomplished. Again, all efforts should be made to exclude carcinoma

preoperatively, because the extent of mesenteric resection is dependent on this information.

9. Regardless of the indications for operation, the distal line of transection should be the proximal

rectum, not leaving diseased sigmoid colon dis-

tal to the anastomosis. Total sigmoidectomy, with anastomosis of pliable descending colon to the rectum, is the desired result. If the diverticulitis involves the more proximal bowel, the

proximal line of colon transection should be above the previous area of inflammation. Exci- sion of all of the colon involved by diverticulosis is not necessary.

REFERENCES

1. Littre A. 1700. Cited by: FinneyJM Diverticulitis and its surgical treatment. Proc Interstate Post-Grad Med As- sembly North Am 1928;55:57,65.

2. CruveilhierJ. Trait4 d'Anatomie Pathologique Gendral4. Vol. 1. Paris: Bailliere, 1849.


3. Graser E. Das falsche Darmdivertikel. Arch klin Chir

1899;59:63~7. 4. Beer E. Some pathological and clinical aspects of ac-

quired (false) diverticula of the intestine. Am J Med Sci 1904;128:135-45.

5. Telling WH. Acquired diverticula of the sigmoid flexure, considered especially in relation to secondary pathological processes and their clinical symptoms. Lancet 1908;1:843-50,928-31.

6. Telling WH, Gruner OC. Acquired diverticula, diverticulitis, and peridiverticulitis of the large intestine. Br J Surg 1917;4:468-530.

7, Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol 1975;4:53-69.

8. Painter NS, Burkitt DP. Diverticular disease of the colon, a 20th century problem. Clin Gastroenterol 1975;4:3-21.

9. Painter NS, Truelove SC, Arclran GM, et aI. Segmenta- tion and the localization of intraluminal pressures in tile human colon, with special reference to the pathogenesis of colonic diverticula. Gastroenterology 1965;49: 169-77.

10. Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. BMJ 1969;4:639-45.

11. Boles RS Jr, Jordan SM. The clinical significance of diverticulosis, Gastroenterology 1958;35:579-82.

12. Rankin FW, Brown PW. Diverticulitis of the colon. Surg Gynecol Obstet 1930;50:836-47.

13. Hulnick DH, Megibow AJ, Balthazar EJ, Naidich DP, Bosniak MA. Computed tomography in the evaluation of diverticulitis. Radiology 1984;152:491-5.

14. Saini S, Mueller PR, Wittenberg J, Butch RJ, Rodkey GV, Welch CE. Percutaneous drainage of diverticular abscess. An adjunct to surgical therapy. Arch Surg 1986; 121:475-8.

15. Mayo WJ, Wilson LB, Gfffin HZ. Acquired diverticulitis of the large intestine. Surg Gynecol Obstet 1907;5:8-15.

16. Smithwick RH. Experiences with the surgical management of diverticulitis of the sigmoid. Ann Surg 1942;115:

969-85. 17. Welch CE, Alien AW, Donaldson GA, An appraisal of

resection of the colon for diverticulitis of the sigmoid. Ann Surg 1953;138:332-43.

18. Colcock BP. Surgical treatment of diverticulitis. Twenty years' experience. Am J Surg 1968;115:264-70.

19. Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular disease. Ann Surg; 1984;200: 466-78.

20. Byrne JJ, Garick EI. Surgical treatment of diverticulitis. Am J Surg 1971;121:379-84.

21. Madden JL, Tan PY. Primary resection and anastomosis

in the treatment of perforated lesions of the colon, with

abscess or diffusing peritonitis. Surg Gynecol Obstet 1961;113:646-50.

22, Hackford AW, Schoetz DJ Jr, Coller JA, Veidenheimer MC. Surgical management of complicated diverticulitis. The Lahey Clinic experience, 1967 to 1982. Dis Colon Rectum 1985;28:317-21.

23. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv" Surg 1978;

12:85-109. 24. Auguste LJ, Wise L. Surgical management of perforated

diverticulitis. Am J Surg 1981;141:122-27. 25. Reiily M. Sigmoid myotomy. Clin Gastroenterol 1975;4:

121-45. 26. Leigh JE, Judd ES, Waugh JM. Diverticulitis of the colon.

Recurrence after apparently adequate segmental resection. Am J Surg 1962;103:51-4.

27. Wolff BG, Ready RL, MacCarty RL, Dozois RR, Beart RW

Jr. Influence of sigmoid resection on progression of diverticular disease of the colon. Dis Colon Rectum

1984;27:645-7. 28. Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis

and recurrent colonic diverticulitis. Am. J Surg 1986; 151:

269-71. 29. Hannan CE, Knightly JJ, Coffey RJ. Diverticular disease

of the colon in the younger age group. Dis Colon

Rectum 1961;4:419-23. 30. Vignati PV, Welch JP, Cohen JL. Long-term manage-

merit of diverticulitis in young patients. Dis Colon Rec-

tum 1995;38:627-9. 31. Perkins JD, Shield CF, Chang FC, Farha GJ. Acute di-

verticulitis. Comparison of treatment in immunocom-

promised and nonimmunocompromised patients. Am J Surg 1984;148:745-8.

32, Lee EC, Mm-ray JJ, Coller JA, Roberts PL, Schoetz DJ Jr. Intraoperative colonic lavage in nonelective surgery for

diverticular disease. Dis Colon Rectum 1997;40:669-74. 33, Stabile BE, Puccio E, vanSonnenberg E, Neff' CC. Pre-

operative percutaneous drainage of diverticular ab-

scesses. Am J Surg 1990;159:99-105. 34. Franklin ME Jr, Dorman JP, Jacobs M, Plasencia G. Is

lapamscopic surgery applicable to complicated diver-

ticular disease? Surg Endosc 1997;11:1021-5. 35. Bruce CJ, CollerJA, MurrayJJ, Schoetz DJJr, Roberts PL,

Rusin LC. Laparoscopic resection for diverticular disease. Dis Colon Rectum 1996;39:$1-$6.

Documents

Diverticular disease of the colon