[Acute sigmoid diverticulitis: toward a more and more conservative treatment]. / Diverticulites sigmoïdiennes aiguës: vers un traitement de plus en plus conservateur.

Acute diverticulitis of the colon is a frequent pathology especially among elderly people and people of Caucasian origin. The prevalence is higher among sedentary people and in people with low-fiber diet. Its diagnosis is mainly based on computed tomography (CT) that allows guiding the therapeutic management. Over the last few years the treatment of acute diverticulitis has passably changed with in particular an evolution toward a restriction of the elective and emergency surgery indications and a reduction of the antiobiotherapy and hospitalization number. This article reviews the epidemiology, the diagnostic tools, and the management of this frequent digestive pathology.

[Colonic diverticulosis and its complications: pathogenesis, classification and clinical implications]. / Die Kolondivertikulose und ihre Komplikationen: Pathogenese, Klassifikation und Klinische Implikationen.

Current understanding of the pathogenesis of colonic diverticulosis and its complications has certain implications for current therapy concepts, which are summarised here. Colonic diverticula in the Western world are pseudodiverticula predominating in the sigmoid colon. Pathogenesis is multifactorial and includes low-fibre diet, dysmotility, increased intraluminal pressure and morphological changes. Uncomplicated diverticulitis results from microperforations, contradicting the hypothesis of the "abscessed diverticulum". Administration of antibiotics for treatment is controversial. Complicated sigmoid diverticulitis is characterised by an intensive inflammatory infiltrate with macrophages. Immunosuppression and especially steroid intake are identified as risk factors. Nowadays, elective or emergency resection is generally recommended as therapy of first choice. However, contrary concepts with merely conservative treatment or drainage--even for perforated diverticulitis--are emerging. The pathogenesis of chronically recurrent diverticulitis is poorly understood and concepts are changing. Resection after the second episode is replaced by a risk-adapted strategy. Diverticular bleeding occurs due to rupture of a vas rectum at the fundus of the diverticulum. Conservative and endoscopic management is the first line and surgical resection plays a role as salvage-strategy in case of recurrent and life-threatening bleeding. Localising the bleeding, i.e., with angiography, is crucial prior to surgery. The pathophysiology of colonic diverticulosis is complex and incompletely understood and linked with several controversial issues, regarding treatment strategies.

[Sigmoid diverticulitis]. / Les sigmoidites diverticulaires.

BACKGROUND: The sigmoid diverticulitis is the most common complication of diverticulosis of the colon. The remaining questions concern the current risk factors for recurrence after a first acute episode, radiological asking immediately upon suspicion of diverticulitis and therapeutic management including the indications of surgical treatment, what to conduct and its principles. METHODS: Literature review. RESULTS: Risk factors of recurrence are: persistent or recurrent diverticulitis, abscess, stenosis and / or fistula. Abdominal CT is recommended in all patients clinically suspected diverticulitis of the colon. Treatment of acute diverticulitis is medical. The emergency surgical treatment depends on the stage of Hinchey. Stage I: In case of failure of medical treatment, resection-anastomosis in an emergency time delay to be proposed. Stage II: a percutaneous drainage followed by resection-anastomosis in 1 time. Stage III: surgery in emergency sigmoid colectomy based on. Stage IV: Hartmann procedure is the procedure of reference. Prophylactic colectomy is proposed in the case of presence of risk factors of recurrence. CONCLUSION: Comparison with other literature review were allowed to find that ultrasound made by an experienced radiologist could replace abdominal CT, and for stage III and IV Hinchey, laparoscopic resection can be performed with an immediate restoration of digestive continuity in well selected patients.

Preoperative CT staging in sigmoid diverticulitis--does it correlate with intraoperative and histological findings?

PURPOSE: This study was designed to evaluate whether the computed tomography (CT) reflects the extent of the inflammation in sigmoid diverticulitis (SD) in order to draw conclusions for selecting the appropriate treatment. METHODS: Two hundred four patients who underwent resection for SD from January 2003 to December 2008 were included. The preoperative CT stage was compared with intraoperative and histological findings. Patients were classified into phlegmonous (Hansen-Stock IIa), abscess-forming (HS IIb), and free perforated (HS IIc) forms of SD. Patients with a recurrent type of diverticulitis were excluded. RESULTS: In the phlegmonous type (HS IIa; n = 75), we found a correlation with the preoperative stage in 52% (intraoperative) and 56% (histological), an understaging in 12% (intraoperative) and 11% (histological), and an overstaging in 36% (intraoperative) and 33% (histological). In the abscess-forming type (HS IIb, Hinchey I/II; n = 87), we found conformity in 92% (intraoperative) and 90% (histological), understaging in 3% (intraoperative) and 0% (histological), and overstaging in 5% (intraoperative) and 10% (histological). In the presence of a free perforation (HS IIc, Hinchey III/IV; n = 42), we saw conformity in 100% (intraoperative and histological). The positive predictive value for correctly diagnosing of phlegmonous type (HS IIa), abscess-forming type (HS IIb), and free perforation (HS IIc) by CT was intraoperatively (histologically) 52% (56), 92% (90), and 100% (100), respectively. CONCLUSIONS: The CT is one of the most accurate methods for staging in SD. However, in the phlegmonous type (HS IIa), it leads to an overestimation of the findings in every third patient. It must be clarified whether this pronounced low inflammation should really be regarded as a complicated form of SD. In contrast, the abscess-forming (HS IIb) and free perforated (HS IIc) type of complicated SD is very well reflected by CT.

Acute diverticulitis: old challenge, current trends, open questions.

Acute diverticulitis (AD) is an increasing issue for health systems worldwide. As accuracy of clinical symptoms and laboratory examinations is poor, a pivotal role in preoperative diagnosis and severity assessment is played by CT scan. Several new classifications trying to adapt the intraoperative Hinchey's classification to preoperative CT findings have been proposed, but none really entered clinical practice. Treatment of early AD is mostly conservative (antibiotics) and may be administered in outpatients in selected cases. Larger abscesses (exceeding 3 to 5 cm) need percutaneous drainage, while management of stages 3 (purulent peritonitis) and 4 (fecal peritonitis) is difficult to standardize, as various approaches are nowadays suggested. Three situations are identified: situation A, stage 3 in stable/healthy patients, where various options are available, including conservative management, lavage/drainage and primary resection/anastomosis w/without protective stoma; situation B, stage 3 in unstable and/or unhealthy patients, and stage 4 in stable/healthy patients, where stoma-protected primary resection/anastomosis or Hartmann procedure should be performed; situation C, stage 4 in unstable and/or unhealthy patients, where Hartmann procedure or damage control surgery (resection without any anastomosis/stoma) are suggested. Late, elective sigmoid resection is less and less performed, as a new trend towards a patient-tailored management is spreading.

[Laparoscopic resection with primary anastomosis in Hinchey stages I and II without previous abscess drainage]. / Laparoskopische Resektion mit primärer Anastomose im Hinchey-Stadium I und II ohne vorherige Abszessdrainage. Eine prospektive Untersuchung.

INTRODUCTION: Intra-abdominal abscesses in diverticulitis so far have been drained percutaneously until the acute inflammation subsides and colon resection can be carried out for restoration of continence. However this method is successful in only about half of patients and lavage lasts for 2 to 3 weeks. Therefore it has to be decided whether an early operation without prior interventional drainage can attain results similar to those of the elective operation. METHODS: We performed primary laparoscopic surgery without prior interventional drainage or colon lavage in 72 patients in Hinchey stages I and II within 12 h of hospital admission. The peri- and postoperative processes were analyzed prospectively using 115 parameters. RESULTS: There was no difference in the postoperative course of patients receiving elective surgery for recurrent diverticular disease and those undergoing surgery for acute diverticulitis (Hinchey stages I and II). The rates of surgical and general complications were identical (7.7% vs 9.6% and 9% vs 3.6%, respectively). Wound infections were noted in 7.7% and 7.2%, respectively. No case of anastomotic leakage was observed. CONSEQUENCE: Based on our prospective data (grade of evidence II), we consider laparoscopic sigmoid resection with primary anastomosis (in continuity) in Hinchey stages I and II without prior interventional drainage and colon preparation to be justified.

Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan.

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.

[Sigmoid colon diverticulitis : Treatment modalities 2011-2013]. / Sigmadivertikulitis : Behandlungsmodalitäten 2011 bis 2013.

INTRODUCTION: Diverticulosis is a relevant disease in Germany with a prevalence of over 60 % in patients aged ≥70 years. The S2k guidelines for the treatment of diverticulosis were recently published. Systematic epidemiological data on treatment modalities do not exist. METHODS: Analysis of in-hospital treatment modalities for diverticulosis based on data from the Federal Office of Statistics. RESULTS: Approximately 130,000 inpatient cases of diverticulosis are treated in Germany per year. Approximately 25 % undergo surgery and of these slightly under 50 % (12,000 procedures) are carried out by laparoscopy. The complication rates are 18 % in a best case scenario and up to 85 % in a worst case scenario. A stage-adjusted classification of treatment modalities based on data from the Federal Office of Statistics is currently practically impossible. CONCLUSION: To enable stage-adjusted epidemiological analysis of diverticulosis, a standardized and transparent documentation system enabling systematic analysis is necessary, which does not currently exist (e. g. ICD 10 coding); moreover, information on conservative and interventional treatment options are not included in the operations and procedures key (OPS) coding system.

[Sigmoid diverticulitis. Surgical indications and timing]. / Sigmadivertikulitis. Operationsindikation und -zeitpunkt.

Indication and time for surgery of diverticular disease are determined by the stage of the disease. Clinically pragmatic pretreatment staging is thus a prerequisite for stage-adapted therapy. The correct indication for surgery is also based on knowledge of the spontaneous disease course, its course after conservative and operative therapy and the individual risk factors for complicated diverticular disease. Surgery is not indicated for bland diverticulosis or uncomplicated diverticulitis. It is generally indicated, however, for acute complicated diverticulitis. Decisive in establishing the indication for surgery is therefore the precise pretherapeutic differentiation of complicated and uncomplicated diverticulitis. Depending on the type of complication and the clinical appearance, the time for surgery of acute complicated diverticulitis is fixed on an emergency or early elective basis following initial conservative and/or interventional therapy. Chronically recurrent diverticulitis is likewise an indication for surgery. In terms of timing, an elective interval operation is best after the second inflammatory episode but should already be performed after the first one in risk groups, e.g. immunosuppressed patients.

Preservation and peeling of the inferior mesenteric artery in the anterior resection for complicated diverticular disease.

The authors, on the basis of 3 cases of complicated diverticular disease, discuss the indications to surgery, considering the advantages and disadvantages of the various surgical techniques and examining in particular the rules for a correct operation with resection and primary or secondary anastomosis. As they performed a rectosigmoidectomy with primary high colorectal anastomosis, they report the reasons why they adopted the preservation and peeling of the inferior mesenteric artery (IMA).

[Sigmoid diverticulitis: indications and timing of surgery]. / Sigmadivertikulitis: Indikation und Zeitpunkt zur Operation.

BACKGROUND: Diverticular disease represents a common problem in the clinical routine. In addition to the question of who should be admitted to hospital for treatment and who can be treated as an outpatient, the questions of the indications and timing for surgery are decisive. Because the disease is internationally classified in different ways, the recommendations are also not uniform. OBJECTIVE: In this article the essential aspects of the indications for and timing of surgery are structured and oriented to the new S2K guidelines. RESULTS: The indications and timing of surgery can only be reasonably determined by evaluating all essential information on diverticular disease. A prerequisite is an exact, comprehensive and applicable classification of the disease before treatment. An adequate assessment cannot be made using morphological information obtained by imaging alone. DISCUSSION: The new classification of sigmoid diverticulitis corresponding to the German guidelines for diverticular disease classification (GGDDC) enables an appropriate strategy for evaluating the indications and selection of the time for surgery.

Uncomplicated diverticulitis, more complicated than we thought.

INTRODUCTION: The classification of complicated and uncomplicated diverticulitis has been used for many years. We note variations in the course of uncomplicated diverticulitis. We propose and describe three categories of uncomplicated diverticulitis. METHODS: A review was performed on 907 patients who underwent sigmoid resection for diverticulitis between January 1, 2005 and December 30, 2009 at Mayo Clinic, Rochester. Overall, 223 individuals were excluded as they were not uncomplicated diverticulitis. The remaining 684 patients were divided into three classifications as follows: 54 (7.9 %) atypical, 66 (9.6 %) chronic/smoldering, and 564 (82 %) acute resolving. Data elements abstracted included demographics, preoperative symptoms, imaging and endoscopy, operative and pathologic findings, postoperative complications, and resolution of symptoms. RESULTS: The 30-day complication rate of the atypical, chronic/smoldering, and acute groups was 26 %, 22 %, and 35 %, respectively. Resolution of symptoms for the atypical and chronic/smoldering groups was 93 % and 89 %, respectively. Only two patients in the acute resolving group required an operation for recurrence. CONCLUSION: A spectrum of clinical presentation for uncomplicated diverticulitis may require different approaches. A select group of patients with chronic/smoldering and atypical disease will continue to be burdened by symptoms. The success of surgical intervention was greater than 89 % in both groups with acceptable morbidity, and should remain an option.

[Standardization in sigmoid diverticulitis surgery planning: indications based on evaluation with the Hughes classification]. / Standardsicherung bei Sigmadivertikulitis-Operationsplanung: Indikationsvorgabe nach Evaluation anhand der HUGHES-Klassifikation.

Sigmoid diverticulitis accounts for the most frequent colonic disease in Western countries. We studied 145 patients with diverticulitis (elective resection in 105, emergency resection in 40 patients) using the HUGHES classifications-based indication of the resection procedure (Stage I, acute diverticulitis/colonic wall phlegmonia, continent resection; Stage II, perforated diverticulitis with local perotinitis, continent resection, Hartmann's procedure exceptionally; Stage III/IV, Hartmann's procedure, continent resection exceptionally). Stage-specific morbidity was I: 18%, II: 22%, III/IV: 60%; emergency case mortality was 15%; elective case mortality was 0%. Severe local failure was significantly higher in stage II/IV than stage II/I class diverticulitis. Early elective resection is recommended with regard to morbidity, mortality, and hospitalisation time and related costs.

Incidence and clinical significance of sigmoidoceles as determined by a new classification system.

PURPOSE: A study was undertaken to assess the incidence and clinical significance of sigmoidocele as a finding during cinedefecography. METHODS: All patients who underwent cinedefecography between July 1988 and July 1992 were prospectively evaluated. Clinical data were assessed by a standardized questionnaire. Sigmoidocele was classified based on the degree of descent of the lowest portion of the sigmoid: 1 degree = above the pubococcygeal line; 2 degrees = below the pubococcygeal line and above the ischiococcygeal line; 3 degrees = below the ischiococcygeal line. This classification was then correlated with the patient's symptoms and percentage of redundancy relative to rectal length. RESULTS: Twenty-four sigmoidoceles (5.2 percent) were noted in 463 cinedefecographic studies; 289 of these patients had constipation. These five males and 19 females were of a mean age of 57 (range, 20-77) years. Nine patients had 1 degree sigmoidocele, seven had 2 degrees, and eight had 3 degrees. Percentage of sigmoid redundancy was 51 percent, 65 percent, and 88 percent for 1 degree, 2 degrees, and 3 degrees, respectively (P = 0.0001). Impaired rectal emptying was present in 16 patients (67 percent). Five of eight patients with 3 degrees sigmoidocele underwent colonic resection with or without rectopexy. The other three patients were conservatively managed. One of seven patients with 2 degrees sigmoidocele underwent colectomy, and the other six were conservatively managed as were all nine patients with 1 degree. Posttreatment improvement was noted in 100 percent (6 of 6) of patients operated on but in only 33 percent (6 of 18) of patients conservatively treated. Thus, this proposed classification system yielded excellent correlation among the mean of level of the sigmoidocele, percentage of redundancy, and clinical symptoms. Furthermore, clinical significance of 3 degrees sigmoidocele is supported by the fact that all five of 3 degrees patients who underwent colonic resection reported symptomatic improvement at a mean follow-up of 23 (range, 15-39) months. CONCLUSION: Sigmoidocele may account for symptoms of obstructed defecation, and, therefore, it must be considered in the differential diagnosis and evaluation of constipation. Staging of sigmoidocele is useful in determining both clinical significance and optimal treatment.