Diverticulitis of the midrectum

Changes in the Clinical Features and Long-term Outcomes of Colonic Diverticulitis in Japanese Patients

Objective The purpose of this study was to investigate whether changes occurred in the clinical features of acute colonic diverticulitis (ACD) over a period of 10 years, to estimate the long-term probability of disease recurrence and to investigate whether it could be treated in an outpatient setting. Methods Between January 1998 and January 2009, 488 ACD patients were diagnosed and treated in Saiseikai Central Hospital, Tokyo. The diagnoses were made by ultrasonography (US) and/or CT. We investigated the time-dependent changes in the characteristics of patients with ACD, and we used the Kaplan-Meier method to estimate the cumulative probability of recurrence, based on information from a questionnaire. Results The percentage of patients who were diagnosed with left-sided ACD significantly increased over time in comparison to those with right-side disease (4% in 1998, 36% in 2009). Patients with left-sided ACD were significantly older and were diagnosed at a more advanced disease stage than those with right-sided ACD. Among the 212 ACD patients who responded to the questionnaire, the cumulative probability of recurrence in 125 patients with no history of ACD at 2.9, 5.9 and 10.1 years was 16.0%, 20.1% and 26.2%, respectively. The probability of recurrence in patients with right-sided and left-sided ACD did not differ to a statistically significant extent. In addition, outpatient treatability in patients with left-sided to right-sided ACD did not differ to a statistically significant extent (66.6% vs. 70.1%). Conclusion The ratio of left-sided to right-sided ACD was found to have increased over the past decade. Left-sided ACD patients were older and their incidence of complications was higher in comparison to right-sided patients; however, the rate of recurrence and outpatient treatability in patients with left-sided and right-sided ACD did not differ to a statistically significant extent.

Recurrent Rectal Diverticulitis

Diverticular involvement of the colon is very common in the United States. Patients present with asymptomatic diverticuli and may have complications of these, spanning the spectrum of uncomplicated diverticulitis to an acute surgical abdominal as a result of feculent peritonitis. We discuss a patient requiring low anterior resection for intractable symptoms resulting from recurrent rectal diverticulitis as well as a review of the limited literature on the subject of diverticular disease of the rectum.

Isolated rectal diverticulum complicating with rectal prolapse and outlet obstruction: case report

The occurrence of rectal diverticula is very rare, with only sporadic reports in the literature since 1911. Symptomatic rectal diverticula are encountered even less frequently. Treatments of these complicated events range from conservative treatments to major surgical interventions. We present a hitherto unreported occurrence of isolated rectal diverticulum complicated with rectal prolapse and outlet obstruction. Delorme's procedure resulted in subsidence of symptoms and resolution of the diverticulum. It provides a minimal invasive surgical technique to successfully address the reported malady.

Surgery for complicated diverticulitis

The surgical treatment of acute, complicated diverticulitis remains controversial. No randomized studies have been performed to clarify which operative procedure best fits each situation. As a result, the surgeon must use accumulated knowledge and judgment to make the correct decisions for an individual patient. The morbidity and mortality of patients with complicated diverticular disease in 1993 depend, not so much on the operative procedure, but on the severity of the disease and the associated comorbid conditions, namely the presence of fecal or purulent peritonitis, past medical problems, immune status, and nutritional status. However, adherence to the several principles detailed in this report will minimize morbidity and mortality. The surgeon should always attempt to convert the patient from an emergency to an urgent or elective operative status. In the absence of free perforation, this goal usually can be achieved. Rushing into surgery in patients with a normal immune system is generally ill advised. It is far preferable to stabilize the patient, percutaneously drain abscesses if possible, prepare the bowel before exploration, and thus keep the option of primary anastomosis open. A primary anastomosis done first thing in the morning is far preferable to an end-stoma created in the middle of the night in an emergency situation. The algorithm displayed in Figure 1 provides a useful guideline for treating patients with complicated diverticulitis.

Level of anastomosis and recurrent colonic diverticulitis

About 7 percent of patients who have resections for diverticular disease later suffer from recurrent disease. In resections for sigmoid disease, the surgeon often has the choice of using either the distal sigmoid colon or the upper rectum for the distal portion of the anastomosis. We examined the courses of 501 consecutive patients who had resection and anastomosis for diverticular disease at the Mayo Clinic between 1970 and 1975. Recurrent diverticulitis developed in 12.5 percent of the patients in whom the sigmoid colon had been used for the distal margin of anastomosis and in 6.7 percent of those in whom the rectum had been used (p = 0.03). Reoperation was required in 3.4 percent of the patients in whom the sigmoid colon was used as the distal anastomotic site and in 2.2 percent of those in whom the rectum had been used (p greater than 0.05). We found no increase in anastomotic leaks or other perioperative complications in patients in whom the rectum had been mobilized. We conclude that the entire distal sigmoid colon should be removed during resection for diverticular disease and anastomosed to the upper rectum to avoid recurrent diverticulitis.