Transverse taeniomyotomy for diverticular disease

Colonic diverticulosis and diverticular hemorrhage

Colonic diverticulosis predisposes individuals to lower gastrointestinal hemorrhage in up to 5% of cases. These sac-like protrusions are pseudodiverticula and arise due to a combination of anatomic, dietary, motility, and structural influences. In the setting of acute hemorrhage, patient stabilization takes priority, followed closely by maneuvers aimed at localizing and controlling blood loss. Through the use of an arsenal of tools including colonoscopy, angiography, and nuclear scintigraphy, most diverticular bleeds can be localized and subsequently controlled. When persistent and not controlled by colonoscopic or angiographic means, expeditious surgical resection serves as definitive therapy.

Elastosis in diverticular disease of the sigmoid colon

Diverticular disease of the sigmoid colon is an increasingly common clinical problem in the ageing population of western industrialised countries but the mechanism by which the disease develops remains unknown. The muscular abnormality is the most striking and consistent feature and this has been studied by light and electron microscopy in 25 surgical specimens of uncomplicated diverticular disease and in 25 controls. This is the first ultrastructural study of human colonic muscle to be published and shows that the muscle cells in diverticular disease are normal; neither hypertrophy nor hyperplasia is present. There is, however, an increase in the elastin content of the taeniae coli by greater than 200% compared with controls: elastin is laid down between the muscle cells and the normal fascicular pattern of the taeniae coli is distorted. There is no alteration in the elastin content of the circular muscle. As elastin is laid down in a contracted form, this elastosis may be responsible for the shortening or 'contracture' of the taeniae which in turn leads to the characteristic concertina-like corrugation of the circular muscle. Such a structural change could explain the altered behaviour of the colon wall in diverticular disease and its failure to change on treatment with bran.

[On the role of myotomy in the treatment of diverticular disease (author's transl)]

Spontaneous motor action of fresly prepared circular and longitudinal muscle strips were examined in two separated trials. Bowel musculature of diverticular patients were compared with those of normal subjects. Finally all explantations were examined histologically.

RESULTS

1. There was no difference in electrical activity and tension development regarding circular muscle strips of patients suffering from D.D. and those of normal subjects. 2. The longitudinal muscles show however significant differences in contrast to normal subjects; to sum up D.D. presents us a spastic and contracted taenia. 3. The histological investigations did not explain the different electromechanical results. There were however remarcable ribbons only in the longitudinal muscle of D.D.--known from myoma uteri. The results of the electrophysiological analysis have importance for our surgical concept in the treatment of peridiverticulitis. They justify the horizontal myotomy in the left, functionally disturbed colon descendens additional to the resection as an preventive procedure.

Sigmoid motility and clinical results after transverse taeniamyotomy for diverticular disease

The purpose of our investigation was to evaluate the effect of multiple transverse taeniamyotomy on sigmoid motility and on the clinical picture of 8 patients affected by symptomatic, uncomplicated diverticular disease of the sigmoid, selected for the operation after the failure of medical therapy. We recorded rectosigmoid intraluminal pressures and the manometric tracings were correlated with the corresponding photofluorograms before and after the operation for 1 year.

Motility indices were computed and a significant decrease after meals and Prostigmin was found in patients who underwent transverse taeniamyotomy. These functional changes were accompanied by a marked clinical recovery, expressed in terms of relief from lower abdominal pain and improvement in bowel movements.

Considering the functional and clinical disadvantages reported after colectomy and longitudinal myotomy, and observing our results after transverse taeniamyotomy, even though they are short term results, we conclude that the latter operation is an effective procedure for the treatment of diverticular disease with muscular hypertrophy and high intracolonic pressure which has not responded to a medical and dietetic regimen.

Combined horizontal and longitudinal colomyotomy for diverticular disease: preliminary report

The operation of horizontal and longitudinal colomyotomy for diverticular disease is described and satisfactory short-term results in six patients are presented. The indications and reasons for the use of this procedure are discussed. It is suggested that the operation is a satisfactory treatment, without the risks associated with division of all the circular muscle fibers, or with resection and anastomosis. The necessity for long-term high dietary fiber intake is stressed.