Treatment of Perforated Diverticulitis with GeneralizedPeritonitis: Past, Present, and Future Jefrey Vermeulen Johan F. Lange Published online: 6 January 2010Ó The Author(s) 2010. This article is published with open access at Springerlink.com prevalence of perforated diverticulitis complicated by The supposed optimal treatment of perforated generalized peritonitis is low, its importance lies in the diverticulitis with generalized peritonitis has changed several significant postoperative mortality, ranging from 4–26% times during the last century, but at present is still unclear.
regardless of selected surgical strategy The first cases of complicated perforated Until today the optimal treatment for perforated diver- diverticulitis of the colon were reported in the beginning of ticulitis has been a matter of debate. During the last dec- the twentieth century. At that time the first therapeutic ades, the ‘‘gold standard’’ has changed several times.
guidelines were postulated in which an initial nonresec- Primary resection has become the standard practice, but tional procedure was provided to be the safest plan of fear of anastomotic leakage often deterred many surgeons management. After many years in which resection had from performing primary anastomosis. Therefore, for many become standard practice, today, one century later, again surgeons Hartmann’s procedure (HP) has remained the (laparoscopic) nonresectional surgery is presented as a safe favored option for these patients Nevertheless, and promising alternative in treatment of complicated improvements in surgical techniques, radiological inter- perforated diverticulitis. The question rises what had hap- vention techniques, anesthesia, advances in intensive care medicine, and progress in the management of peritoneal This paper includes a historic summary of sepsis have led to an increasing interest in resection with changing patterns in surgical strategies in perforated div- primary anastomosis (PA) with or without diverting stoma erticulitis complicated by generalized peritonitis.
Recently, laparoscopic lavage and drainage without resection has been successfully used for patients who have generalized peritonitis caused by perforated diverticulitis(PPD) ]. Because this nonresectional mini-invasive sur- Perforation with generalized peritonitis is the most com- gical strategy was associated with a reduction in morbidity mon life-threatening emergency requiring surgical inter- and mortality, it might be a promising alternative to the vention in diverticular disease of the colon []. Whereas standard open resectional practice ].
most people with diverticular disease remain asymptom- This paper includes an overview of the development of atic, approximately 15% develop symptoms, and of these different surgical strategies in PPD through the years, and 15% will develop significant complications, such as per- based on this overview we present our personal opinion for foration []. In most cases perforation is the first mani- the management of this surgical emergency.
festation of the disease Although the absolute J. Vermeulen (&) Á J. F. LangeDepartment of Colorectal Surgery, Erasmus Medical Center, Since the beginning of the previous century, a three-stage Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlandse-mail: [email protected] operation strategy was common practice for the treatment of diverticular disease. The first report of surgical treatment for a source of sepsis as bowel contractions continue evacu- complicated diverticulitis was by Mayo [in 1907. The ating infective material. Clinical observations and this new classic three-stage operation includes an initial diverting understanding of pathophysiology of diverticulitis led to colostomy and drainage followed by resection of the the conviction that the colonic perforation had to be involved colon and, finally, a colostomy closure as the third removed primarily , Nevertheless, controversy stage. This nonresectional surgery strategy was reaffirmed persisted because the ‘‘evidence’’ was only based on expert and advocated by the experiences at the Mayo Clinic, which opinion and some (small) noncomparative case series.
presented the results in 1924, to be the safest [ During the next two decades, indications for emergency surgery evolved toward complicated diverticulitis, such as Two-staged procedure with primary resection perforation, obstruction, and fistula formation, only. Apreliminary transverse colostomy was advised in all cases Since the 1980s and 1990s, the standard practice of PPD in which resection was contemplated, and the period of has definitively changed from nonresectional surgery delay before this resection should be from 3 to 6 months toward primary resection of the involved sigmoid. A two- []. The rationale for this strategy was that primary stage operation with the initial operation being resection of resection is too difficult in the acute stage of the disease, the diseased segment with the construction of a colostomy often causing iatrogenic complications and hence mortal- proximally and suture closure of the distal rectal stump ity. After the fecal stream was diverged by performing a became the preferred surgical strategy in these category transverse colostomy during the first surgical stage, drain- patients ]. The second stage was represented by the age of the abdomen and pelvic cavity was initiated to colostomy closure. Among surgeons this operation has diminish sigmoid inflammation. After several months the been known since as Hartmann’s procedure (HP), although second stage—resection of the involved bowel—could be Hartmann ] himself only performed such a procedure performed to treat and prevent relapse of the disease.
for rectum carcinoma and had advocated that the patient Smithwick ] advocated this procedure in favor toward should not undergo restoration of bowel continuity.
resectional operations. He reported a postoperative mor- This change in strategy was mainly based on the results tality after a three-stage procedure of nearby 12% com- of two reviews published in 1980 and 1984 by Krukowski pared with 17% if the involved colon segment was resected and Matheson ] and Greif et al. ]. Mortality after during initial surgery ]. Considering that antibiotics primary resection was reported to be lower compared with were not discovered yet, these results can be regarded as those procedures in which the perforated segment could not be removed at initial operation , ]. Unfortunately both In 1945 Florey [was responsible for the development reviews were not systematic, containing a wide range of of penicillin for use as a medicine. Since then antibiotics different surgical techniques and covering more than were more frequently used during colonic surgery. Partly, 25 years during which substantial improvements in antibi- this led toward a shift in the continuing controversy otic and other perioperative supportive therapies has taken between three- and two-staged operations in favor of pri- place. Furthermore, it is not known whether the patients of mary resection of the involved colon. Although at that time both groups were comparable for a number of essential Smithwick ], amongst others, still recommended the variables, such as age, ASA classification, and Hinchey and three-stage and initially nonresectional operation , Mannheim Peritonitis Index (MPI) scores.
more publications advocating primary resection in case of Between 1993 and 2000, two randomized controlled PPD arose –Initial improvement after colostomy trials (RCT) assessing primary versus secondary resection and drainage, without resection, often was followed by were published [These RCTs drew opposite con- severe deterioration several days later when the involved clusions. Kronborg [concluded that three-stage nonre- sectional surgery (suture and transverse colostomy) in PPD Since the 1960s, combinations of antibiotics were used was still superior to primary resection because of a lower against gram-negative bacteria and anaerobic bacteria.
postoperative mortality rate. Mortality in Hinchey IV Combination antibacterial therapy had shown better sur- patients was not different in both groups. Unfortunately, vival in septic patients ]. Unfortunately, mortality rates the study was preliminary stopped because of low in patients with PPD remained high. The basic cause of this recruitment (an average of four patients each year) and high mortality was that the source of infection remained in hence underpowered. A total of 62 patients were included the peritoneal cavity [Painter and Burkitt [docu- and operated by 27 different surgeons during a period of mented the increased intraluminal pressures and muscle abnormalities as the cause for diverticula formation in the Zeitoun et al. ] concluded that primary resection was sigmoid. When left in situ, the perforated segment remains postoperative peritonitis and fewer reoperations. Never- diverting loop ileostomy seems not to diminish postoper- theless, postoperative mortality after primary resection was ative mortality []. The use of perioperative colonic lavage higher compared with nonresectional surgery (24% vs.
appears to lower postoperative complications in case of 19%), but this difference was not significant. Although the PA, but the evidence in the present literature is limited evidence was weak, the American Society of Colon and Rectal Surgeons has published practice guidelines in which Postoperative morbidity and mortality rates of patients the three-stage operative approach strategy (nonresectional after emergency surgery for PPD are still high and mainly surgery) was no longer recommended for most patients caused by the poor general condition of the frequently aged because of high associated morbidity and mortality patients and the severity of disease –This suggests As a result of improvements in radiological intervention that further reduction in mortality will require improve- techniques, postoperative complications and ongoing ment in medical management of pre- and perioperative abdominal sepsis could be treated percutaneously, which sepsis and comorbid conditions. Type of surgery seems no made more radical resections during initial surgery possi- longer significantly related with postoperative mortality, ble [HP had become mandatory for emergency indi- although many recent studies favor PA, with or without cations in PPD. But skepticism about primary resection loop ileostomy, instead of HP in purulent of fecal PPD These statements were confirmed by a sys-tematic review by Salem and Flum in which mortalityrates after HP and PA of 19% and 10% respectively, were Improvements in surgical and radiological interventiontechniques and progress in the management of peritoneal sepsis led to an increasing interest in colonic resection withprimary anastomosis (PA) since the 1990s. Although not The role of laparoscopic resectional surgery in PPD is proven in randomized controlled trials, PA with or without limited. In acute complicated diverticulitis without perito- defunctioning loop ileostomy seemed not to be inferior to nitis, laparoscopic sigmoid resection with PA seemed to be HP in terms of severe postoperative complications and a safe procedure ]. Outcome after laparoscopic PA in mortality [, , Probably, even the presence of PPD is lacking in the present literature. Laparoscopic HP fecal peritonitis was no longer considered an absolute seems to be a technically feasible procedure with reason- contraindication to immediate bowel reconstruction able outcomes for patients in this category ]. In 1996, However, fear of anastomotic leakage often deters many Faranda et al. first described a nonresectional laparoscopic surgeons from performing a one-stage procedure (e.g., PA procedure that seemed to be a more promising alternative ]. In patients with peritonitis without gross fecal con- Although HP is considered a two-stage procedure, the tamination, laparoscopic peritoneal lavage, inspection of second stage (reversal of colostomy) will never be per- the colon, and the placement of abdominal drains appear to formed in a large number of patients , Restoration diminish morbidity and improve outcome []. In a of bowel continuity after HP is a technically challenging series of 100 patients with PPD, Myers et al. [showed operation and is associated with significant morbidity and excellent results after laparoscopic lavage and drainage of mortality [These rates can be as high as 25% and 14%, the peritoneal cavity, with morbidity and mortality respectively, after colostomy reversal in patients who had undergone HP for PPD , Together with the debilitated Laparoscopic damage control surgery seems to decrease condition of many of these patients, this is one of the main the rate of more radical procedures, including HP [ reasons that HP often results in a permanent colostomy.
In patients who were found to have fecal peritonitis or who They face the physical (leakage, parastomal hernia) and fail to improve after lavage, acute resection should still be psychological (lifestyle alterations) challenges that are performed ]. A comparative study between laparoscopic associated with having a stoma , ]. The risk of per- peritoneal lavage and open PA with diverting loop ileos- manent ileostomy is recognizably less than that of HP and tomy for the management of PPD found no differences in postoperative morbidity and mortality [Laparoscopic The performance of a diverting loop ileostomy has been peritoneal lavage reduced the length of hospital stay and a reported to decrease the rate of symptomatic anastomotic stoma could be avoided in most patients.
leakage in patients operated for rectal cancer []. The In a second elective stage definitive surgery can take same is found in case of diverticular peritonitis. However, place, e.g., laparoscopic resection and PA , although the quality of the present studies is poor. Besides, a subsequent elective resection is probably unnecessary [, Nevertheless, the number of studies are rather important [, Nevertheless, because the evidence is limited and mostly based on small groups of patients.
weak, until now primary resection remains the standard Besides, the rates of additional radiological interventions treatment for PPD, although the European Association for and conversion to an open procedure are high [Finally, Endoscopic Surgery Evidence-based Guidelines stated that for many hospitals it will not be possible to have a surgical laparoscopic nonresectional surgery may be considered in team with expertise in colorectal laparoscopic surgery present all the time. Therefore, laparoscopy is of unclear orlimited value in the emergency setting caused by PPD.
However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics [ Some authors have expressed their concerns with lapa- Until the 1990s, all stages of perforated diverticulitis were roscopic nonresectional treatment of perforated diverticu- treated by surgery. The principles of primary treatment of litis. They state that the decision to perform nonresectional abdominal infections caused by perforation, as outlined by surgery is influenced by the surgical access to the abdomen, Polk in 1979 have not changed much during the years.
i.e., laparoscopy, rather than based on evidence in the lit- These principles include alimentary tract decompression, erature [Patients should undergo primary resection, fluid resuscitation, antibiotics to cover gram-negative aer- whether the surgical access to the abdomen is conventional obes and anaerobes, and so-called ‘‘source control.’’ Source or laparoscopic, because there is ‘‘evidence’’ in the litera- control consists of all measurements to eliminate the source ture that resectional surgery leads to lower postoperative of infection, to control ongoing contamination, and to peritonitis, and mortality rates, compared with nonresec- restore premorbid anatomy and its function , tional surgery [Unfortunately, the evidence to The progress of antibiotic development and interven- which they referred []—resection favoring nonre- tional radiographic techniques has changed the manage- sectional surgery—is equivocal or to the contrary as stated ment of perforated diverticulitis. The high specificity of CT before. The major criticism of the nonresectional laparo- scan has allowed this modality to become a surrogate to the scopically lavage technique is the continued presence of perioperative assessment made by the Hinchey classifica- the perforated colon as a septic focus as well as the column tion [Furthermore, CT scan has become an important of feces remaining in the colon proximally to the perfora- therapeutic modality. It is now recognized that patients tion as a potential ongoing source of contamination. This with small, contained perforations, who are not systemi- also was the main criticism toward the three-stage proce- cally ill, can be treated initially with antibiotics alone or by dure that was used to treat PPD until the 1970s. Classen CT-guided percutaneous drainage [, Source control et al. had observed that postoperative mortality related to by percutaneous drainage has become the treatment of sepsis was lowered after addition of more effective anti- choice for most abscesses, provided that adequate drainage biotics to treat gram-negative and anaerobic bacteria since is possible and no debridement or repair of anatomical 1970 [Besides, PPD is accompanied by ileus, hence, it structures is necessary [The size of the drain used is is not likely that the fecal column is propelled toward the very important because complete evacuation of the abscess perforation. A patent communication between the colonic must be obtained. If the abscess cannot be drained suffi- lumen and the peritoneal cavity usually cannot be found ciently, source control will fail. Although mechanical during laparoscopy because the site of the original perfo- control of the source of infection remains important, sev- ration has become sealed by the inflammatory process and eral studies have found that abscesses up to 4 cm seem to omentum and seems efficient to control the source of respond better to antibiotics alone [Currently, the contamination. If the perforation site is too large to be only patients who require surgery (laparoscopically or sealed before peristalsis resumes, resection of the bowel open) for source control are those who fail conservative treatment and those who require emergency surgery, The suggestion that nonresectional surgery in combi- nation with more advanced antibiotics have never proven If nonresectional laparoscopic lavage and drainage to to be an inferior strategy could explain the excellent treat PPD is found to be a safe and better alternative for results after laparoscopic lavage in combination with resectional surgery in the future, why should this be dif- modern management of peritoneal sepsis with improved ferent from nonresectional nonsurgical, e.g., CT-guided, antibiotics and intensive care medicine. Naturally the percutaneous lavage and drainage? The present literature as latter technique has several advantages over the open yet does not report about this (hypothetical or future) three-stage procedure, of which less wound complications treatment strategy. Is it possible that this will be the next (such as infections and hernias), no stomal complications, step in the ever more conservative management of different and avoidance of a second operation are the most To answer this question, it is important to take into strategy in contained diverticular perforations, it is not account the main principles of abdominal infection treat- likely that nonresectional interventional radiographic ment when using percutaneous lavage and drainage. Fluid techniques will play a prominent role in the initial treat- resuscitation and modern antibiotic strategies will not be ment of PPD in the near future. Clearly, more (prospective different from laparoscopically lavage procedures. To gain randomized) research is warranted to confirm all of these source control in percutaneous techniques, it is important that large-size catheters will be used for adequate drainageof thick and viscous purulent contents ]. The main This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which per- problem is the inability for inspection of the abdominal mits any noncommercial use, distribution, and reproduction in any cavity to localize the site and size of the perforation. In medium, provided the original author(s) and source are credited.
laparoscopic procedures to treat PPD, careful removal ofadherent omentum or bowel is tried to locate the site ofperforation. If clearly adherent, the adhered omentum or small intestinal loops can be left in place and the abdominalcavity is irrigated with liters of warm saline At the end of 1. Vermeulen J, Gosselink MP, Hop WCJ, Lange JF, Coene PPLO, the procedure, one or more drains are inserted. Such a van der Harst E, Weidema WF, Mannaerts GHH (2009) Hospital careful adhesiolysis and inspection of the abdominal cavity, mortality after emergency surgery for perforated diverticulitis.
to look for or exclude other causes of generalized purulent 2. Parks TG (1975) Natural history of diverticular disease of the peritonitis, is not possible using today’s radiographic modalities. Furthermore, in case of a large perforation, 3. Hart A, Kennedy J, Stebbings W (2000) How frequently do large causing fecal peritonitis, source control by percutaneous bowel diverticular perforate? An incidence and cross-sectional lavage and drainage is impossible and hence surgical treat- study. Eur J Gastroenterol Hepatol 12:661–666 4. Morris CR, Harvey IM, Stebbings WS, Hart AR (2008) Incidence ment will be necessary to achieve source control and restore of perforated diverticulitis and risk factors for death in a UK premorbid anatomy and function. It is, therefore, not likely that percutaneous (nonsurgical) nonresectional lavage and 5. Salem L, Flum DR (2004) Primary anastomosis or Hartmann’s drainage will play a prominent role in the treatment of PPD procedure for patients with diverticular peritonitis? A systematicreview. Dis Colon Rectum 47:1953–1964 in the near future, because it cannot meet the principles of 6. Constantinides VA, Tekkis PP, Senapati A (2006) Association of Coloproctology of Great Britain Ireland. Prospective multicentreevaluation of adverse outcomes following treatment for compli-cated diverticular disease. Br J Surg 93:1503–1513 7. Schilling MK, Maurer CA, Kollmar O, Buchler MW (2001) Pri- mary vs. secondary anastomosis after sigmoid colon resection forperforated diverticulitis (Hinchey Stage III and IV): a prospective During the last century, mortality rates after emergency outcome and cost analysis. Dis Colon Rectum 44:699–703 surgery for PPD have remained high: nearly 20%. Progress 8. Hoemke M, Treckmann J, Schmitz R, Shah S (1999) Compli- cated diverticulitis of the sigmoid: a prospective study concerning in (antibiotic) sepsis management has led to more radical primary resection with secure primary anastomosis. Dig Surg surgical procedures, but survival did not improve signifi- cantly. The reason for this remains unclear. The question 9. Myers E, Hurley M, O’Sullivan GC, Kavanagh D, Wilson I, arises whether ‘‘old-fashioned’’ (laparoscopic) nonresec- Winter DC (2008) Laparoscopic peritoneal lavage for generalizedperitonitis due to perforated diverticulitis. Br J Surg 95:97–101 tional surgery in combination with ‘‘modern’’ sepsis man- 10. Franklin ME Jr, Portillo G, Trevin˜o JM, Gonzalez JJ, Glass JL agement is the key to success. The last reports are (2008) Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg In our personal opinion, supported by the existing lit- 11. Bretagnol F, Pautrat K, Mor C, Benchellal Z, Huten N, de Calan erature about treatment of PPD, resection with PA should L (2008) Emergency laparoscopic management of perforated be the standard procedure in the emergency surgery for sigmoid diverticulitis: a promising alternative to more radical perforated diverticulitis with generalized peritonitis. HP must seriously be considered the surgical procedure of 12. Mayo WJ, Wilson LB, Griffin HZ (1907) Acquired diverticulitis of the large intestine. Surg Gynecol Obstet 5:8–15 choice for older patients with multiple comorbidities, 13. Judd ES, Pollack LW (1924) Diverticulitis of the colon. Ann Surg realizing that restoration of bowel continuity is not an issue. Laparoscopic nonresectional surgery is regarded as a 14. Lockhart-Mummery JP (1938) Late results of diverticulitis.
good alternative in case of purulent peritonitis, provided 15. Smithwick RH (1942) Experiences with the surgical management that it is performed by a surgeon who is experienced in of diverticulitis of the sigmoid. Ann Surg 115:969–983 laparoscopic surgery. Although currently, percutaneous 16. Florey HW (1945) Use of micro-organisms for therapeutic pur- drainage of abdominal abscesses is the preferred treatment 17. Smithwick RH (1960) Surgical treatment of diverticulitis of diverticulitis. Should Hartmann’s procedure be considered a one- stage procedure? Colorectal Dis 11:619–624 18. Miller DW, Wichern WA (1971) Perforated sigmoid diverticu- 39. Banerjee S, Leather AJM, Rennie JA, Samano N, Gonzalez JG, litis. Appraisal of primary versus delayed resection. Am J Surg Papagrigoriadis S (2005) Feasibility and morbidity of reversal of 19. Classen JN, Bonardi R, O’Mara CS, Finney DC, Sterioff S (1976) 40. Nugent KP, Daniels P, Stewart B, Patankar R, Johnson CD Surgical treatment of acute diverticulitis by staged procedures.
(1999) Quality of life in stoma patients. Dis Colon Rectum 20. Smiley DF (1966) Perforated sigmoid diverticulitis with spread- 41. Gooszen AW, Geelkerken RH, Hermans J, Lagaay MB, Gooszen HG (2000) Quality of life with a temporary stoma: ileostomy vs.
21. Large JM (1964) Treatment of perforated diverticulitis. Lancet 42. Bell C, Asolati M, Hamilton E, Fleming J, Nwariaku F, Sarosi G, 22. Eng K, Ranson JCH, Localio SA (1977) Resection of the per- Anthony T (2005) A comparison of complications associated forated segment. A significant advance in treatment of divertic- with colostomy reversal versus ileostomy reversal. Am J Surg ulitis with free perforation or abscess. Am J Surg 133:67–72 23. Jacobson MA, Young LS (1986) New developments in the treat- 43. Gastinger I, Marusch F, Steinert R, Wolff S, Koeckerling F, ment of Gram-negative bacteremia. West J Med 144:185–194 Lippert H (2005) Working Group ‘‘Colon/Rectum Carcinoma’’.
24. Painter NS, Burkitt DP (1963) Intrasigmoid pressures in diver- Protective defunctioning stoma in low anterior resection for rectal 25. Auguste L, Borrero E, Wise L (1985) Surgical management of 44. Matthiessen P, Hallbo¨o¨k O, Rutega˚rd J, Simert G, Sjo¨dahl R perforated colonic diverticulitis. Arch Surg 120:450–452 (2007) Defunctioning stoma reduces symptomatic anastomotic 26. Hartmann H (1923) Note sur un proce´de´ nouveau d’extirpation leakage after low anterior resection of the rectum for cancer: a des cancers de la partie terminale due coˆlon. Bull Me´m Soc Chir randomized multicenter trial. Ann Surg 246:207–214 45. Kressner U, Antonsson J, Ejerblad S, Gerdin B, Pa˚hlman L 27. Krukowski ZH, Matheson NA (1984) Emergency surgery for (1994) Intraoperative colonic lavage and primary anastomosis— diverticular disease complicated by generalized and faecal peri- an alternative to Hartmann procedure in emergency surgery of the tonitis: a review. Br J Surg 71:921–927 28. Greif JM, Fried G, McSherry CK (1980) Surgical treatment of 46. Regenet N, Pessaux P, Hennekinne S, Lermite E, Tuech JJ, perforated diverticulitis of the sigmoid colon. Dis Colon Rectum Brehant O, Arnaud JP (2003) Primary anastomosis after intra- operative colonic lavage vs. Hartmann’s procedure in generalized 29. Kronborg O (1993) Treatment of perforated sigmoid diverticu- peritonitis complicating diverticular disease of the colon. Int J litis: a prospective randomized trial. Br J Surg 80:505–507 30. Zeitoun G, Laurent A, Rouffet F, Hay JM, Fingerhut A, Paquet 47. Makela J, Kiviniemi H, Laitinen S (2005) Prognostic factors of JC, Peillons C, Research TF (2000) Multicentre, randomized perforated sigmoid diverticulitis in the elderly. Dig Surg 22:100– clinical trial of primary versus secondary sigmoid resection in generalised peritonitis complicating sigmoid diverticulitis. Br J 48. Pisanu A, Cois A, Uccheddu A (2004) Surgical treatment of perforated diverticular disease: evaluation of factors predicting 31. Wong WD, Wexner SD, Lowry A, Vernava A III, Burnstein M, prognosis in the elderly. Int Surg 89:35–38 Denstman F, Fazio V, Kerner B, Moore R, Oliver G, Peters W, 49. Oomen JTL, Engel AF, Cuesta MA (2005) Mortality after acute Ross T, Senatore P, Simmang C (2000) Practice parameters for surgery for complications of diverticular disease of the sigmoid the treatment of sigmoid diverticulitis–supporting documentation.
colon is almost exclusively due to patient related factors. Colo- The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 43:290–297 50. Abbas S (2007) Resection and primary anastomosis in acute 32. Wilson RF (1985) Special problems in the diagnosis and treat- complicated diverticulitis, a systematic review of the literature.
ment of surgical sepsis. Surg Clin North Am 64:965–989 33. Peoples JB, Vilk D, Maguire JP, Elliott DW (1990) Reassessment 51. Zdichavsky M, Granderath FA, Blumenstock G, Kramer M, of primary resection of the perforated segment for severe colonic Ku¨per MA, Ko¨nigsrainer A (2009) Acute laparoscopic inter- vention for diverticular disease (AIDD): a feasible approach.
34. Gooszen AW, Tollenaar RA, Geelkerken RH, Smeets HJ, Bem- Langenbecks Arch Surg Surg 19:1143–1149 elman WA, Van Schaardenburgh P et al (2001) Prospective study 52. Agaba EA, Zaidi RM, Ramzy P, Aftab M, Rubach E, Gecelter G, of primary anastomosis following sigmoid resection for suspected Ravikumar TS, Denoto G (2009) Laparoscopic Hartmann’s pro- acute complicated diverticular disease. Br J Surg 88:693–697 cedure: a viable option for treatment of acutely perforated div- 35. Richter S, Lindemann W, Kollmar O, Pistorius GA, Maurer CA, Schilling MK (2006) One stage sigmoid colon resection for 53. Faranda C, Barrat C, Catheline JM, Champault GG (2000) Two- perforated diverticulitis (Hinchey stages III and IV). World J stage laparoscopic management of generalized peritonitis due to perforated sigmoid diverticula: eighteen cases. Surg Laparosc 36. Medina VA, Papanicolaou GK, Tadros RR, Fielding LP (1991) Acute perforated diverticulitis: primary resection and anastomo- 54. Taylor CJ, Layani L, Ghusn MA, White SI (2006) Perforated diverticulitis managed by laparoscopic lavage. ANZ J Surg 37. Maggard MA, Zingmond D, O’Connell JB, Ko CY (2004) What proportion of patients with an ostomy (for diverticulitis) gets 55. Karoui M, Champault A, Pautrat K, Valleur P, Cherqui D, Champault G (2009) Laparoscopic peritoneal lavage or primary 38. Vermeulen J, Coene PP, Van Hout NM, van der Harst E, anastomosis with defunctioning stoma for Hinchey 3 complicated Gosselink MP, Mannaerts GH, Weidema WF, Lange JF (2009) diverticulitis: results of a comparative study. Dis Colon Rectum Restoration of bowel continuity after surgery for acute perforated 56. Favuzza J, Friel JC, Kelly JJ, Perugini R, Counihan TC (2009) 61. Polk HC Jr (1979) Generalized peritonitis: a continuing chal- Benefits of laparoscopic peritoneal lavage for complicated sig- moid diverticulitis. Int J Colorectal Dis 24:797–801 62. Cheadle WG, David A, Spain DA (2003) The continuing chal- 57. Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski lenge of intra-abdominal infection. Am J Surg 186:15–22 A, Champault G, Fingerhut A, Isla A, Johansson M, Lundorff P, 63. Lohrmann C, Ghanem N, Pache G, Makowiec F, Kotter E, Navez B, Saad S, Neugebauer EA (2006) Laparoscopy for Langer M (2005) CT in acute perforated sigmoid diverticulitis.
abdominal emergencies: evidence-based guidelines of the Euro- pean Association for Endoscopic Surgery. Surg Endosc 20:14–29 64. Stijn Blot S, De Waele JJ (2005) Critical issues in the clinical 58. Santaniello M, Bergamaschi R (2006) Perforated diverticulitis: management of complicated intra-abdominal infections [review].
should the method of surgical access to the abdomen determine 65. Soumian S, Thomas S, Mohan PP, Khan N, Khan Z, Raju T 59. Essani R, Bergamaschi R (2009) Laparoscopic peritoneal lavage (2008) Management of Hinchey II diverticulitis. World J Gas- for generalized peritonitis due to perforated diverticulitis. Br J 66. Men S, Akhan O, Ko¨roglu M (2002) Percutaneous drainage of 60. O’Sullivan GC, Murphy D, O’Brien MG, Ireland A (1996) abdominal abscess. Eur J Radiol 43:204–218 Laparoscopic management of generalised peritonitis due to per-forated colonic diverticula. Am J Surg 171:432–434

Source: http://www.drgramatica.com.ar/cirugias/images/diverticulitis.pdf

Microsoft word - new patient clinical information form, final, 14mar03.doc

William R. Klemme, M.D. Diplomat, American Board of Orthopaedic Surgery Practice Limited to Spine Surgery Adult and Pediatric Spine Surgery Degenerative and Deformity Conditions NEW PATIENT CLINICAL INFORMATION FORM Is your problem related to: ‰ Job injury Briefly describe your main problem/complaint. Also, describe the injury that caused these symptoms, if applicable. How


Case report: Management of heterotopic ossification associated with myocutaneous flap reconstruction of a sacral pressure ulcer Colin W. McInnes1, Richard A.K. Reynolds2, Jugpal S. Arneja3 1Faculty of Medicine, University of British Columbia, Vancouver, BC2Department of Orthopedics, Children’s Hospital of Michigan, Detroit, MI3Division of Plastic Surgery, British Columbi

Copyright ©2010-2018 Medical Science