Surgery for right-sided colonic diverticulitis: results of a 10-year-observation period

INTRODUCTION: In contrast to sigmoid diverticular disease, right colonic diverticulitis is a rare disease in Western countries. The clinical presentation is often similar to acute appendicitis. OBJECTIVE: The aim of this study was to analyze surgical challenge in right-sided diverticulitis. MATERIALS AND METHODS: All patients who underwent resection for both right-sided and sigmoid diverticular disease were registered prospectively in a database (observation period, 1996-2005). A retrospective analysis of all patients who underwent resection for right-sided colonic diverticulitis (ileocolic resection, right colectomy) was performed. Special focus was set on incidence, clinical symptoms, indication, procedure, clinical outcome, and histopathologic findings including immunohistochemistry. RESULTS: From a total of 593 patients treated surgically for recurring or acute complicated diverticular disease, the majority (97.8%) suffered from sigmoid diverticulitis (n = 580), whereas 2.2% (n = 16) underwent surgery for right-sided diverticulitis (including three patients with combined sigmoid and cecal diverticulitis). Related to the total number of appendectomies (n = 1167), this represented an incidence of 1.4%. In five of 16 patients, acute appendicitis was presumed preoperatively. Most common diagnostic was ultrasonography. In the group of patients with right-sided diverticulitis, the most common procedure was right hemicolectomy (n = 10), followed by ileocolic resection (n = 3) and combined right colonic resection with sigmoid resection (n = 3). Histopathological investigation confirmed complicated diverticulitis of the cecum with local perforation or abscess in 75% of the patients (12/16). Hypoganglionosis or aganglionosis was diagnosed in seven of the 16 resected specimens. DISCUSSION: As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis may be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis. As most cases will remain clinically unimminent, surgery is only indicated in complicated right-sided cases. Resection of the inflamed colonic segment with primary anastomosis is safe and can be performed laparoscopically. It can only be speculated whether hypoganglionosis or aganglionosis is a causative factor in the etiology of right-sided diverticulitis.     

Surgical therapy of complicated diverticular disease]

From 1975-1989 55 patients were operated on for complicated diverticular disease at our unit. Intraoperative we found the following complications: 21 walled of perforations, 22 stenosis of the sigmoid colon combined with obstruction of the small and/or large bowel, 8 free perforations with generalized, faecal peritonitis, 7 diverticular fistulae (5 colovesical, 1 colojejunal and 1 colocutaneous fistula) and diverticular bleedings. In 33 cases we performed a resection with primary anastomosis (8 times with protecting stoma). 17 times the Hartmann's procedure was carried out and 5 times a transverse colostomy and drainage was elected. Lethality was 20% and morbidity came to 25%. We consider the primary resection with primary anastomosis to be the procedure of choice for complicated diverticulitis except for free perforation with generalized and faecal peritonitis where we prefer the Hartmann's procedure.     

Surgical diverticulitis: treatment options.

Acute diverticulitis requiring surgical intervention has conventionally been treated by resection with colostomy or delayed resection with primary anastomosis at a second admission. Our objective was to determine the outcome for treatment of diverticulitis with resection and primary anastomosis during the same hospitalization. We conducted a retrospective review of patients (n = 74) undergoing surgery for diverticulitis. Groups included: 1) resection with primary anastomosis (n = 33), 2) resection with colostomy followed by a takedown colostomy (n = 32), and 3) delayed resection with primary anastomosis at a second admission (n = 9). Despite local perforation primary anastomosis was often performed unless patients were clinically unstable or had fecal contamination. The operation was urgent in five (15%) patients in Group 1 as compared with 26 patients (88%) in Group 2. Serious intra-abdominal complications occurred in two patients (6%) in Group 1 as compared with nine patients (28%) in Group 2 and one patient (11%) in Group 3. Postoperative abscesses occurred in two patients in Group 1, five patients in Group 2, and one patient in Group 3. We have shown that resection with primary anastomosis for acute diverticulitis--even in selected patients requiring urgent operation--can be safely performed during the same hospital admission with a low complication rate.     

Diagnosis and management of colovesical fistulae; six-year experience of 90 consecutive cases

INTRODUCTION: Colovesical fistulae are well-recognized but relatively uncommon presentation to colorectal surgery. As a result, few centres have sufficient experience in the investigation and surgical treatment of colovesical fistulae to develop clear protocols in its management. METHODS: This study examines the diagnostic and treatment pathways of 90 consecutive patients with colovesical fistulae presenting to a single surgeon, over a six-year period. Using the findings from this study and previously published data, the authors suggest tentative guidelines for the diagnosis and management of such patients. RESULTS: Pneumaturia and faecaluria were present in 90.1% of all cases. The diagnosis of colovesical fistula is predominately a clinical one, however, cystoscopy was the most accurate test to detect fistulae (46.2%) followed by barium enema (20.1%). Barium enema was the most sensitive test to detect stricture formation (70.6%). Colonic endoscopy was the most reliable means of excluding a colonic malignancy. The most common pathology was diverticular disease (72.2%), colonic carcinoma (15.3%) and Crohn's disease (9.7%). Left sided colonic resections were undertaken in 73.6% of patients, right hemicolectomy in 4.2% and defunctioning loop colostomies in 18.5%. Of the left sided resections, primary anastomosis was achieved in 92% of cases (n = 48) with one postoperative leak and no mortality. DISCUSSION: Resection and primary anastomosis should be the treatment of choice for colovesical fistulae, with an acceptable risk of anastomotic leak and mortality. Barium enema, colonic endoscopy and CT should be routine in the investigation of colovesical fistulae.     

Laparoscopic Management of Colonic Diverticular Disease and its Complications: an Analysis

Dense inflammatory reactions, loss of tissue planes and sepsis make surgical treatment of diverticulitis complex and difficult. Experience with laparoscopic management of this disease is scanty in our country. This study aims to assess the pattern of presentation, the site of involvement and complications of diverticulitis coli. This study also aims to audit the results of laparoscopic approach for complicated colonic diverticulitis. A retrospective analysis of all patients who had laparoscopic management of complicated diverticulitis patients from August 2007 to October 2014 was done from the database. The site of involvement, extent and presence or absence of complications of diverticular disease was noted. The surgical approach, intraoperative parameters and short-term outcome measures were analysed. There were 38 (8.8 %) patients with diverticular disease out of 427 patients who had laparoscopic colorectal surgery in the study period with a median age of 59 years. Out of 38 patients, 50 % had comorbid conditions. Internal fistulae were seen in 9 (23.6 %) patients, 6 with colovesical and 3 with colovaginal fistulae. Elective laparoscopic colectomy with primary anastomosis was done in 34 (89 %) cases of which, and 10 (26 %) patients had abscess on presentation requiring drainage. Four patients required emergency laparoscopic surgery of which primary resection and anastomosis was done in 3 (7.8 %), and Hartmann’s operation was done in 1 (2.6 %) patient. Two patients required stoma. The morbidity was seen in 15 % cases, and the mean hospital stay was 9.54 days. Laparoscopic approach for diverticular disease and its complication is feasible and safe. Careful selection of patients, judicious use of diverting stoma and appropriate selection of the procedure help to achieve good results even in those with septic complications and fistulising disease.     

Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery

OBJECTIVE: Recent experience with surgery for enterocutaneous fistulae (ECF) at a specialist colorectal unit is reviewed to define factors relating to a successful surgical outcome. SUMMARY BACKGROUND DATA: ECF cause significant morbidity and mortality and need experienced surgical management. Previous publications have concentrated on mortality resulting from fistulae, while factors affecting recurrence have not previously been a focus of analysis. METHODS: Records were reviewed of patients who had ECF surgery (1994-2001). Management strategy involved early drainage of sepsis and nutritional support prior to elective ECF repair, with selective defunctioning proximal stoma formation. RESULTS: A total of 205 patients were available (89 males, 43%; median age, 51 years; range, 16-86) years). ECF were related to Crohn's disease in 95, ulcerative colitis in 18, diverticular disease in 17, carcinoma in 25 (16 after radiotherapy), mesh ventral hernia repair in 21, and other causes in 29. Forty-one (20%) had undergone attempted fistula repair at other institutions. Initial management included CT-guided drainage of an intra-abdominal abscess in 23 patients, and total parenteral nutrition in 74 (36%). A total of 203 patients had definitive ECF repair. Forty-four had oversewing or wedge resection of the fistula, and 159 had resection and reanastomosis of the involved small bowel segment or ileocolic anastomosis. Ninety-day operative mortality was 3.5%. A total of 42 (20.5%) patients developed ECF recurrence within 3 months. Multivariate analysis demonstrated that recurrence was more likely after oversewing (36%) than resection (16%, P = 0.006). CONCLUSIONS: A strategy of drainage of acute sepsis, maintenance of nutritional support prior to surgery, and selective use of PS allows for primary closure in 80% of complicated ECF. Resection should be performed when feasible.     

Incidence, diagnosis, and treatment of enteric and colorectal fistulae in patients with Crohn's disease.

OBJECTIVE: The authors review their experience, evaluating the incidence and examining the various modalities employed in the diagnosis and treatment of patients with Crohn's disease complicated by fistulae. SUMMARY BACKGROUND DATA: Although common, internal and external fistulae in Crohn's disease may pose challenging problems to the surgeon. METHODS: Of 639 patients who underwent surgical treatment at the University of Chicago between 1970 and 1988 for complications of Crohn's disease, 222 patients (34.7%) were found to have 290 intra-abdominal fistulae. RESULTS: A fistula was diagnosed preoperatively in 154 patients (69.4%), intraoperatively in 60 (27%), and only after examination of the specimen in 8 (3.6%). The fistula represented the primary or single indication for surgical treatment in 14 patients (6.3%) and one of several indications in the remaining patients. Of 165 patients with an abdominal mass or abscess, 69 (41.8%) had a fistula. All patients underwent resection of the diseased intestinal segment; 160 (73.1%) with primary anastomosis and the remaining 62 with a temporary or permanent stoma. The fistula was directly responsible for a stoma in only 16 patients (7.2%) and was never responsible for a permanent stoma. Resection of the diseased bowel achieved en bloc removal of the fistula in 145 cases. Removal of 93 additional fistulae required resection of the diseased bowel segment along with closure of a fistulous opening on the stomach or duodenum (n = 14), bladder (n = 35), or rectosigmoid (n = 44). When the fistula drained through a vaginal cuff (n = 4), the opening was left to close by secondary intention; when the fistula opened through the abdominal wall (n = 46), the fistulous tract was debrided. In the remaining two entero-salpingeal fistulae, en bloc resection of the involved salpinx accomplished complete removal of the fistula. There was a dehiscence of one duodenal and one bladder repair; 14 patients (6%) experienced postoperative septic complications and one patient died. CONCLUSIONS: Fistulae are diagnosed preoperatively in 69% of cases and can be suspected in as many as 42% of patients with an abdominal mass. Fistulae are the primary or single indication for surgical treatment and are directly responsible for a stoma only in a few patients. Treatment, based on resection of the diseased bowel and extirpation of the fistula, can be accomplished with minimal morbidity and mortality.     

原发女性生殖道恶性黑色素瘤21例临床分析

目的探讨原发性女性生殖道恶性黑色素瘤的临床特点、治疗及预后。方法回顾分析本院1986年1月至2006年3月收治的原发性女性生殖道恶性黑色素瘤患者21例。其中外阴8例、阴道10例、阴道及宫颈1例、外阴及阴道1例、盆腔1例。结果患者中位年龄50(21~71)岁。临床表现主要为阴道流血、流液及发现外阴或阴道肿物。本资料阴道恶性黑色素瘤发病率高于外阴恶性黑色素瘤。按照国际妇产科联盟(FIGO)分期,期别和预后呈负相关。治疗以手术为主,手术方式由根治性切除逐渐衍变为扩大局部切除。随访:21例患者中随访率为67%(14/21),随访时间6~96个月,死亡7例,随访期间的死亡率为50%。结论女性生殖道恶性黑色素瘤发病率低,预后差。肿瘤厚度和淋巴结转移是其主要的危险因素。应采用手术基础上的综合治疗,治疗方案个体化。     

Laparoscopic surgery for diverticular disease complicated by fistulae.

OBJECTIVES: Elective laparoscopic surgery for recurrent, uncomplicated diverticular disease is considered safe and effective; however, little data exist on complicated cases. We investigated laparoscopic sigmoid resection for diverticulitis complicated by fistulae. METHODS: We conducted a retrospective review of patients who underwent laparoscopic treatment of enteric fistulae complicating diverticular disease performed by 4 surgeons at the Mount Sinai Medical Center. RESULTS: From 1994 to 2004, 14 patients underwent elective laparoscopic sigmoid resections for diverticular disease complicated by enteric fistulae. Patients' mean age was 62 and 4 were female. Multiple fistulae were present in 21%. Types of fistulae included 8 colovesical, 5 enterocolic, 2 colovaginal, 1 colosalpingal, and 1 colocutaneous. All patients successfully underwent sigmoidectomy, and 14% required additional bowel resections. No cases were proximally diverted. Conversion to open was necessary in 36% of cases, all due to dense adhesions and severe inflammation. The mean operative time was 209 minutes, and the mean blood loss was 326 mL. Two (14%) postoperative complications occurred, including one anastomotic bleed and one prolonged ileus. No anastomotic leaks or mortalities occurred. The mean postoperative stay was 6 days. CONCLUSION: Laparoscopic management of diverticular disease complicated by fistulae can be performed effectively and safely. The conversion rate is higher than traditionally accepted rates of uncomplicated cases of diverticulitis and is associated with severe adhesions and inflammation.     

Primary Anastomosis and Diverting Colostomy in Diffuse Diverticular Peritonitis

Background: Despite the well documented morbidity associated with its reversal, Hartmann’s procedure remains the favoured option in patients with complicated diverticular disease in the presence of diffuse peritonitis. A prospective study was conducted to determine whether primary anastomosis with diverting colostomy constitutes a valid alternative to the Hartmann procedure.

Methods: Between 1994 and 1998, all patients with diffuse peritonitis due to perforated diverticulitis of sigmoid origin underwent resection and primary anastomosis with diverting colostomy. Restoration of colonic continuity was programmed six weeks later, after verification of the anastomose by gastrograffin enema. The group included 5 men and 15 women with a mean age of 72 years (32-97 years). The ASA classification of the patients was as follows: ASA II (n = 2), ASA III (n = 12), ASA IV (n = 3), ASA V (n = 3). The mean delay between onset of symptoms and surgery was 74 hours (8–215 hours).

Results: Operative mortality and morbidity was 15% (n = 3) and 50% respectively. No patients showed signs of suture disruption and this was confirmed by routine radiological controls of the anastomoses. Mean length of hospitalization was 20 ± 10 days (SD; median: 18 days). Closure of the colostomy using a small peristomal incision was performed in all surviving patients after a mean delay of 45 ±9 days (range 28-67 days). Mean length of hospitalization for colostomy closure was 7 ±3 days (range 3-18 days) without mortality.

Conclusions: Applied systematically to all patients with diffuse peritonitis due to perforated diverticular disease, primary anastomosis was found to be as safe as the Hartmann procedure but appears to be superior in terms of total length of hospital stay, interval to stoma closure and rates of stoma closure. Primary anastomosis with diverting colostomy could constitute a valid alternative to the Hartmann procedure in selected patients with complicated diverticular disease, even in the presence of diffuse peritonitis.     

Operative treatment of acute complications of diverticular disease: primary or secondary anastomosis after sigmoid resection.

OBJECTIVE: To assess the comparative effects of two surgical regimens on the outcome of acute complicated diverticular disease. DESIGN: Retrospective study. SETTING: Teaching hospital, The Netherlands. SUBJECTS: 60 patients who presented with acute complicated diverticular disease. INTERVENTIONS: 28 patient were treated by sigmoid resection and a Hartmann operation, and 32 by resection with primary anastomosis and defunctioning stoma. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The severity of peritonitis and the amount of faecal contamination were similar in the 2 groups. 12 patients died (7 in the Hartmann group and 5 in the primary anastomosis group). There were 3 radiological leaks with no clinical implications in the primary anastomosis group. 6 patients in the Hartmann group and 5 in the primary anastomosis group required reoperations for intra-abdominal abscess or infection. 7 and 3 patients, respectively, developed dysfunction of their stomas, and 9/21 and 3/27, respectively, required a permanent stoma (p = 0.02, 95% confidence interval of difference 0.07 to 0.56). 3 patients in the Hartmann group developed anastomotic leaks after closure of their stomas, 1 of whom required reoperation but died. No patient developed an anastomotic leak after closure of the stoma in the primary anastomosis group. CONCLUSION: Both regimens are accepted treatments for patients with acute complicated diverticular disease, but because of the higher morbidity after the Hartmann procedure we prefer primary anastomosis with covering stoma.     

Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease

BACKGROUND: A primary anastomosis after resection of the sigmoid colon for suspected acute complicated diverticular disease has the advantage of saving the patient a secondary operation for restoring bowel continuity. Fear of anastomotic leakage often deters surgeons from making a primary anastomosis. METHODS: A series of 45 patients who underwent primary anastomosis was studied prospectively to evaluate the feasibility of a primary anastomosis following acute sigmoid resection. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Mannheim Peritonitis Index (MPI) and Hughes' peritonitis classification were used to classify patients and to detect factors predictive of postoperative outcome. Death, anastomotic leakage and septic complications were main outcome measures. RESULTS: Neither anastomotic leakage (four of 45 patients) nor death (three of 45) was related to a higher MPI, APACHE II or Hughes' score. More postoperative septic complications were seen in patients with a MPI over 16. Death, anastomotic leakage, reintervention and wound infection were observed more frequently in patients who presented with colonic obstruction than in those with abscess or perforation. CONCLUSION: Primary anastomosis is safe and effective in non-obstructed cases of complicated diverticular disease. Colonic obstruction seems to be a risk factor for the development of postoperative complications.     

Laparoscopic resection of diverticular fistulae: a 10-year experience

OBJECTIVE: Until recently the laparoscopic approach was reserved for uncomplicated diverticular disease. We show that fistulating diverticular disease can be resected safely, with good clinical outcome via a laparoscopic approach. METHOD: Between April 1994 and May 2005, 31 consecutive patients [17 male, median age of 63 years (range 40-85)], underwent attempted laparoscopic resection for diverticular fistulae. Patient data were prospectively recorded. RESULTS: There were 22 colovesical and nine colovaginal fistulae. The median operative time was 150 min (range 60-310) and the median postoperative stay was 7 days (range 3-21). Conversion to an open procedure was required in nine of 31 patients (29%). This rate fell to 10% in cases performed after April 2000. There were two nonsurgically related postoperative deaths. Both occurred in the converted group. At 3 months follow-up, two patients complained of frequency of stools, which settled by 6 months. To date there has been no recurrence of symptomatic diverticulosis or fistulation. CONCLUSION: Totally laparoscopic resection for diverticular fistulae is safe and feasible. Fistulae should not be considered as a contraindication to laparoscopic resection for an experienced laparoscopic surgeon.     

Current practices in left-sided colonic emergencies: a survey of US gastrointestinal surgeons.

BACKGROUND: The paradigms in the surgical management of obstruction and perforation of the left colon - once considered absolute contraindications to primary resection and anastomosis - are changing. The aim of this survey was to poll American Gastrointestinal surgeons on their current approach to left colonic emergencies. METHODS: A questionnaire was sent to 500 US-based surgeons, randomly selected members from the membership list of the Society for Surgery of the Alimentary Tract. It surveyed the surgeons on how they would approach 'good-risk' and 'poor-risk' patients with left colonic obstruction or perforation. RESULTS: 215 (43%) surgeons responded to the questionnaire; 180 fully completed questionnaires (36%) were analyzed. Sigmoid obstruction: 96 responders (53%) selected a one-stage procedure in 'good-risk' patients; 78 preferred sigmoid resection with (n = 46) or without (n = 32) 'on-table' colonic lavage and 18 opted for a subtotal colectomy and ileo-rectal anastomosis. Most (94%) responders preferred a staged procedure in 'high-risk' patients: a Hartmann resection (n = 120) or a transverse colostomy (n = 46). Sigmoid diverticular perforation: only one third of the responders recommended a one-stage procedure in 'good-risk' patients: 58 would perform a sigmoidectomy with (n = 19) or without (n = 39) 'on-table' colonic lavage; only two opted for subtotal colectomy with ileo-rectal anastomosis. In 'high-risk' patients most surgeons opted for a Hartmann's (88%) procedure or a diverting colostomy (7%). CONCLUSIONS: This survey suggests that a half and one-third of the responders would perform a one-stage resection and anastomosis in 'good-risk' patients with left colonic obstruction and perforation, respectively. In 'poor-risk' patients most responders would still opt for a staged procedure.     

Acute diverticulitis: safety and value of contrast studies in predicting need for operation

Results of treatment of 70 patients hospitalized with acute diverticulitis were analysed to determine the value of early contrast enema in management. A water-soluble enema done during the first week of hospitalization in 48 patients showed diverticulosis with spasm (30), a leak or peridiverticulitis (16) and a normal study (two). No complications were caused by the study. Forty patients improved on medical therapy, but four relapsed after discharge. Thirty-four (49%) patients had urgent operation during hospitalization for the acute episode of diverticulitis. Findings on contrast enema correlated with the need for surgery during the acute phase: 13 of 16 with peridiverticulitis or a leak compared with three of 30 with diverticulosis/spasm (P less than 0.001). Operations performed were: sigmoid resection and primary anastomosis (17) with covering colostomy (five). Hartmann's operation (eight), colostomy and/or drainage (seven), right hemicolectomy (two). Findings at surgery were: abscess (15), phlegmon (12), peritonitis (five) and colovesical fistula (two). It is concluded that early contrast enemas of the distal colon done with appropriate precautions are useful in confirming the diagnosis of diverticular disease: only two of 48 studies were falsely negative. A pericolic extravasation (as opposed to a small sinus tract) or abscess usually indicates need for operation, whereas the finding of diverticulosis/spasm suggests a favourable outcome of conservative management.     

克罗恩病并发肠瘘的诊断与治疗

目的探讨克罗恩病(CD)并发肠瘘的诊断与治疗方法。方法对1978至2004年收治的62例CD并发肠瘘患者的临床资料进行分析。结果本组肠外瘘68例次,其中多发瘘6例次;肠内瘘8例次。肠瘘以末端回肠瘘(27例次)和回结肠吻合口瘘(21例次)为主。手术方式主要为回结肠吻合口拆除重建(26例次)和回盲部切除回结肠吻合(14例次)。首次肠瘘、术后服用免疫药物者复发率15.4%,明显低于未服药患者(34.8%);复发时间为(40±17)个月,明显长于不服药组的(8±3)个月;两组比较,P<0.01。结论CD合并的肠瘘以肠外瘘为主。主要手术方法为瘘口切除与肠吻合术。术后应用免疫抑制药物可降低CD合并肠瘘的复发率。     

Safety of primary anastomosis in emergency colo-rectal surgery

Background The surgical management of left‐sided large bowel emergency patients remains controversial. There has been an increasing trend towards primary reconstructive surgery. The main dilemma remains appropriate patient selection for primary anastomosis. Methods The records of 323 patients who presented as acute emergencies and underwent surgery between January 1990 and December 2000 for left‐sided colorectal cancer and diverticular disease were reviewed, to compare the outcome of resection and primary anastomosis with Hartmann's procedure. Patients were stratified into 3 groups according to whether the presentation was with localized or generalized peritonitis, or with obstruction. Results Resection and anastomosis was carried out in 176 (55.7%) patients with a 30‐day mortality of 5.7%. Anastomotic dehiscence occurred in 9 (5.1%) patients, with no difference between the three groups. Wound sepsis occurred in 8 (4.5%) patients, and the median hospital stay was 13 days. Hartmann's resection was associated with a higher incidence of systemic and surgical morbidity (39.5% and 24.3%, respectively). The mortality rates in those selected for primary anastomosis (5.7%) compared favourably with those undergoing Hartmann's resections (20.4%) (P < 0.001). Conclusion Emergency primary anastomosis in left‐sided disease can be performed with a low morbidity and mortality in selected patients, even in the presence of a free perforation with diffuse peritonitis. Patients selected for staged resection, were those with major comorbid disease.     

Diverticular fistulation is associated with nicorandil usage

INTRODUCTION

We observed that a number of patients presenting to our clinic with diverticular fistulation were taking nicorandil for angna. Recognised side effects of nicorandil include gastrointestinal and genital ulceration. The aim of our study was to determine whether nicorandil is an aetiological agent in diverticular fistulation.

PATIENTS AND METHODS

We conducted a case-control study of patients with diverticular disease related enteric fistulae. Two patient groups were identified: a study group of patients with diverticular fistulae, and a control group with uncomplicated diverticular disease. The proportion of patients who had ever used nicorandil was compared between the two groups.

RESULTS

A total of 153 case notes were analysed, 69 patients with fistulae and 84 control patients with uncomplicated diverticular disease. Female to male ratio in both groups was 2:1. The mean age was 71 years in the fistula group and 69 years in the control diverticular disease group (P = ns). Of those with colonic fistulae, 16% were taking nicorandil compared with 2% of the control group (odds ratio 7.8; 95% confidence interval 1.5–39.1; P = 0.008). There was no significant difference in rates of ischaemic heart disease between fistula and control groups.

CONCLUSIONS

Nicorandil is associated with fistula formation in diverticular disease.     

Diverticular disease complicated by peritonitis: role of conservative surgical therapy

Peritonitis complicating diverticular disease may be treated by sigmoid resection (with or without primary anastomosis) or by a conservative surgical approach, either laparoscopically or by open surgery. The choice depends on the severity of the peritonitis (Hinchey), the patient's conditions (ASA) and the surgeon's experience. Sigmoid resection with primary anastomosis has a lower morbidity and mortality vs Hartmann's procedure. After the introduction of laparoscopy in colorectal surgery, exploratory laparoscopy combined with drainage has been proposed to treat acute episodes, followed by laparoscopic resection. Since 1982, over 1000 patients have been operated on for colorectal disease: 119 for complicated diverticulitis, 55 of which complicated by peritonitis. In the latter, we performed conservative surgery (25 patients) and resection (30 patients) laparoscopically or by open surgery. Our results show a higher morbidity and mortality for the Hartmann procedure vs sigmoid resection with primary anastomosis and a lower specific morbidity in patients undergoing laparoscopic exploration and drainage. Moreover, there was a low percentage (52%) of re-canalisations with the Hartmann procedure, with a morbidity of 32% associated with this procedure. In conclusion, we believe that a conservative laparoscopic surgical approach may be advocated in selected cases (Hinchey II and III without clear perforation), followed by laparoscopic sigmoidectomy, resection with primary anastomosis in Hinchey I or in cases of evident perforation with purulent or faecal peritonitis (possibly combined with a stoma), reserving the Hartmann procedure for compromised patients.     

Sutureless compression anastomosis of the distal colon and rectum. An expanded report of experiences with a total of 140 patients

Based on animal experiments with a sutureless anastomosis, the sutureless compression anastomotic technique (AKA) was introduced to colorectal surgery. The procedure was applied to 140 patients following resections of the distal colon and rectum. The outcome was controlled prospectively. Anastomosis fistulae occurred in 8 out of 140 patients (5.7%). Excluding the 16 patients with a primary protective colostomy the leakage rate was 6.4%. Out of 67 patients with an anastomosis height of 10 cm or less, 6 developed fistulae (8.9%). Excluding the 11 patients with primary colostomy the leakage rate was 10.7%. 3 patients showed clinically inapparent fistulae in the routinely performed gastrografin enema. The clinical application of the compression-anastomotic technique revealed no disadvantage. The technique seems to have advantages due to more areactive anastomosis healing.