Interpretation of the World Society of Emergency Surgery Guidelines for Diagnosis and Treatment of Acute Left Colonic Diverticulitis in the Elderly (2022 edition) / 中华外科杂志

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. Acute left colonic diverticulitis in the elderly presents with unique epidemiological features when compared with younger patients. Elderly patients have a lower risk of recurrent episodes, higher in-hospital and postoperative mortality. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) formulated the guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly (2022 edition). This article aims to interpret the guidelines statements on the following topics: diagnosis, management, non-surgical therapy and surgical technique.

Impacto de la subespecialización en los resultados de la sigmoidectomía laparoscópica por diverticulitis perforada Hinchey III / Outcomes of emergent laparoscopic sigmoid resection for Hinchey III diverticulitis: Does specialization matter?

Introducción: La sigmoidectomía por diverticulitis perforada es una cirugía de urgencia comúnmente realizada por cirujanos generales. Está descripta la correlación positiva entre el volumen del cirujano y los mejores resultados postoperatorios. Sin embargo, existe escasa evidencia de la influencia de la especialización en cirugía colorrectal sobre los resultados de la sigmoidectomía laparoscópica por diverticulitis perforada. Objetivo: Evaluar el impacto de la especialización en cirugía colorrectal en los resultados postoperatorios de la sigmoidectomía laparoscópica por diverticulitis Hinchey III. Diseño: Estudio retrospectivo sobre una base de datos cargada de forma prospectiva. Material y métodos: Se incluyeron pacientes sometidos a sigmoidectomía laparoscópica por diverticulitis perforada Hinchey III. La muestra fue dividida en dos grupos: pacientes operados por un cirujano colorrectal (CC) y aquellos operados por un cirujano general (CG). Las variables demográficas, operatorias y postoperatorias fueron comparadas entre los grupos. El objetivo primario fue determinar si existían diferencias en la proporción de anastomosis primaria, morbilidad y mortalidad a 30 días entre los grupos. Resultados: Se incluyeron 101 pacientes en el análisis; 58 operados por CC y 43 por CG. Los pacientes operados por CC presentaron una mayor proporción de anastomosis primaria (CC: 98,3% vs. CG: 67,4%, p<0,001). Los CG realizaron más estomas (CC: 13,8% vs. CG: 46,5%, p<0,001), presentaron un mayor índice de conversión (CC: 20,6% vs. CG: 39,5%, p=0,03) y una mayor estadía hospitalaria (CC: 6,2 vs. CG: 10,8 días, p<0,001). La morbilidad global (CC: 34,4% vs. CG: 46,5%, p=0.22), dehiscencia anastomótica (CC: 3,5% vs. CG: 6,8%, p=0.48) y la mortalidad (CC: 1,7% vs. CG: 9,3 %, p=0,08) fueron similares entre ambos grupos. Conclusión: La sigmoidectomía laparoscópica de urgencia realizada por CG presenta similar morbilidad y mortalidad postoperatoria que la realizada por CC. Sin embargo, la participación del especialista se asoció a una mayor frecuencia de anastomosis primarias, menos estomas y una estadía hospitalaria más corta.

Background: Sigmoid resection for perforated diverticulitis is one of the most common emergency surgeries and often performed by general surgeons. Relationship between high-volume surgeons and improved postoperative outcomes is well established. However, the influence of colorectal specialization on outcomes after emergency laparoscopic sigmoidectomy for perforated diverticulitis is not well described. Aim: Evaluate the impact of colorectal surgery training on the outcomes after emergency laparoscopic sigmoid resection for Hinchey III diverticulitis. Design: Retrospective analysis of prospectively collected database.Method: Patients undergoing emergent laparoscopic sigmoid resection for perforated (Hinchey III) diverticulitis were identified and stratified by involvement of colorectal or general surgeon. This study was conducted from 2000 to 2018 at a teaching hospital. Primary outcome measures were primary anastomosis, postoperative morbidity and mortality.Results: A total of 101 patients were identified; 58 by colorectal and 43 by general surgeons. Patients in the colorectal surgeon group had higher rates of primary anastomosis (CS: 98, 2% vs. GS: 67, 4%, p<0.001). General surgeons performed more ostomies (CS: 13, 8% vs. GS: 46, 5%, p<0.001), had a higher conversion rate (CS: 20, 6% vs. GS: 39, 5%, p=0.03) and longer mean length of hospital stay (CS: 6, 2 vs. GS: 10, 8 days, p<0.001). Overall morbidity (CS: 34, 4% vs. GS: 46, 5%, p=0.22), anastomotic leak rate (CC: 3,5% vs. CG: 6,8%, p=0.48) and mortality (CS: 1, 7% vs. GS: 9,3 %, p=0.08) were similar between groups. Conclusion: Emergency laparoscopic sigmoid resection by general surgeons wasn ́t associated with higher rates of postoperative morbidity, anastomotic leakage or mortality. However, patients operated by colorectal surgeons had higher rates of primary anastomosis, lower rates of ostomy, conversion and shorter length of hospital stay.

Peritonitis diverticular: ¿Qué nos enseñó Ladies Trial? Análisis metodológico de su diseño, aplicación y resultados / Diverticular peritonitis: What did LADIES Trial teach us? Analysis of design, application and results

Contexto y Antecedentes: LADIES TRIAL es uno de los ensayos más importantes referidos a peritonitis diverticular. A pesar de este y otros ensayos publicados, aún se debate cuáles son los procedimientos adecuados para cada escenario de peritonitis diverticular, haciendo necesaria una revisión profunda de la metodología empleada en los ensayos para validar u objetar sus conclusiones. Objetivos: Analizar la metodología empleada en el diseño, aplicación, análisis de resultados y conclusiones de sus publicaciones. Secundariamente, colaborar en el mejoramiento de la investigación de la peritonitis diverticular y facilitar el análisis del tema por parte de los lectores. Métodos: Se analizaron las partes centrales de toda investigación, desde la pregunta de investigación, elaboración de hipótesis, operacionalización de variables y diseño del ensayo, análisis estadístico de resultados y conclusiones. Se buscaron errores, sesgos y debilidades que pudiesen objetar los hallazgos del estudio. Resultados: LADIES se trató de un estudio randomizado, abierto con análisis de superioridad según intención de tratar modificada en aquellos casos de incumplimiento de los criterios de inclusión y exclusión. Su diseño fue en general correcto, aunque en su aplicación se detectaron errores, debilidades y sesgos. En cuanto a resultados LOLA mostró que en Hinchey III el lavado laparoscópico tiene mayor morbimortalidad temprana que la sigmoidectomía, con un tiempo operatorio menor. Por su parte, DIVA mostró que en Hinchey III y IV la anastomosis primaria tiene mayor sobrevida libre de ostomía con menor morbilidad, combinando la cirugía inicial y cierre ostomía, respecto de la operación de Hartmann. Conclusiones: El no haber llegado al tamaño de muestra calculado hizo que solo grandes diferencias consiguieran significancia estadística. Las bajas frecuencias de eventos adversos acentuaron este problema metodológico. La especialización de los centros y cirujanos intervinientes, como la exclusión de pacientes hemodinámicamente inestables o bajo corticoterapia comprometieron su validación externa.

Background: LADIES TRIAL is considered one of the most important trials related to diverticular peritonitis. Its protocol and results were published in 2010, 2015, 2017, and 2019. Despite this one and other published trials, the proper procedures for each diverticular peritonitis scenario are still being debated, a thorough review of the methodology used in this trial is necessary to validate or reject their conclusions. Aim: To analyze the methodology used in the design, application, analysis of results, and conclusions of all LADIES TRIAL publications. Secondly, to collaborate in the improvement of the research about diverticular peritonitis and to facilitate its analysis by the readers. Methods: The central parts of a research trial were analyzed, from the research question, hypothesis development, operationalization of variables and trial design, statistical analysis of results, to conclusions. Errors, biases and weaknesses were searched for to try and challenge the trial's findings. Results: LADIES was a randomized, open-label, superiority trial analyzed according to intention to treat modified in cases of non-compliance with the inclusion-exclusion criteria. Its design was generally correct, although errors, weaknesses, and biases were detected in its application. Regarding results, LOLA showed that, in Hinchey 3, laparoscopic lavage has a higher rate in early morbidity and mortality than sigmoidectomy, but with a shorter operative time. For its part, DIVA showed that, in Hinchey 3 and 4, the primary anastomosis has higher ostomy-free survival with less morbidity, combining the initial surgery and ostomy closure, compared to the Hartmann procedure. Conclusions: Not having reached the sample size calculated in its design implies that only large effect differences achieved statistical significance. The low frequencies of adverse events accentuated this methodological problem. The specialization of the intervening centers and surgeons, the exclusion of hemodynamically unstable patients or patients undergoing steroid therapy, compromised the external validation of their findings.

Fístula colovesical de origen diverticular. Resolución laparoscópica con nuevo recurso técnico / Diverticular colovesical fistulae. Laparoscopic tip

Introducción: La enfermedad diverticular de colon es una patología de alta prevalencia en nuestro medio. Su presentación inicial como fístulas no complicadas no es frecuente sin antecedentes de episodios de diverticulitis previa. Objetivos: Presentar detalles técnicos de la cirugía de resección y tratamiento laparoscópico de una fistula colovesical de origen diverticular. Materiales y métodos: Se presenta el caso de un paciente varón de 63 años con dolor en hipogastrio sin alteraciones evacuatorias ni cirugías previas. Sin antecedentes de diverticulitis. Se realizó ecografía abdominal y tomografía computada donde se constata aire en vejiga. El urocultivo es positivo para escherichia coli y el colon por enema detecta pequeño trayecto fistuloso entre colon sigmoides y vejiga. Se decide resección laparoscópica. Resultados: Se realizó una colectomía sigmoidea laparoscópica con identificación de trayecto fistuloso a la vejiga que se aisló y seccionó entre clips de polímero. Se completó con anastomosis primara colorrectal y sondaje vesical prolongado que se retiró a los 15 días. Los parámetros postoperatorios fueron favorables con egreso a las 72 hs. Conclusión: La fístula colovesical es una complicación de la enfermedad diverticular de colon aunque es rara su debut como forma de presentación sin episodios de diverticulitis previa. Se destaca su identificación como trayecto único y no hemos encontrado mención al respecto en la bibliografía. Su resolución de ligadura entre clips es una opción terapéutica efectiva y rápida para su resolución definitiva. El abordaje laparoscópico electivo es de elección y su tratamiento mediante el procedimiento propuesto resultó efectivo y seguro.

Background: Diverticular disease is a high prevalent colonic pathology. Initial presentation as complicated disease includes fistulas, perforation and bleeding. Objetive: To present technical surgical aspects of surgical treatment of laporoscopic resection of colovesical fistula after diverticular disease. Methods: A 63 years old patient presented with low abdominal pain and no transit symptoms. There was no previous surgery and diverticulitis episode. Abdominal ultrasound and CT scan showed air in the bladder. Urine culture was positive to Escherichia coli. Colonic barium x-rays showed a colovesical fistula. Laparoscopic resection was decided as treatment of choice. Results: Laparoscopic sigmoid colectomy, aisolation of fistula tract and posterior clips ligation and section. Primary mecanic anastomosis and 15 days vesical catheter completed the treatment. Postoperative evolution was satisfactory. Conclusions: Colovesical fistula is a frequent complication of complicated diverticular disease, however its debut without previous episodes is rare. The colonic fistula presented as unique tract is unfrequent. Resolution by polimer clips and section associated with colonic resection by laparoscopic is a good option to avoid bladder sutures. This procedure resulted safe and effective.

Laparotomía abreviada y terapia de presión negativa para el cierre temporal del abdomen como tratamiento de la peritonitis diverticular Hinchey III/IV / Abbreviated laparotomy and negative pressure therapy for temporary closure of the abdomen as treatment of diverticular peritonitis Hinchey III/IV

Introducción: Los pacientes que se presentan con cuadros de peritonitis de origen diverticular (estadios Hinchey III o IV) en un contexto de sepsis severa con inestabilidad hemodinámica (shock séptico) la realización de anastomosis primaria presenta una alta tasa de dehiscencia anastomótica y mortalidad operatoria, aconsejándose la realización de una resección y abocamiento a la manera de Hartmann. Sin embargo, la alta tasa de complicaciones relacionadas a la confección del ostoma, la complejidad de la cirugía de restauración del tránsito intestinal, asociado a que entre el 40 % y el 60 % de los Hartmann no se reconstruyen, ha estimulado a que se intenten otras variables de resolución para esta compleja y grave patología. Diversas publicaciones en los últimos años han propuesto la táctica de "cirugía del control del daño" con el objeto de disminuir la morbimortalidad de estos gravísimos cuadros sépticos y a su vez reducir la tasa de ostomías. El objetivo de este trabajo es presentar nuestra experiencia inicial con esta modalidad de manejo de la peritonitis diverticular Hinchey III/IV sepsis severa e inestabilidad hemodinámica (shock séptico) y realizar una revisión bibliográfica del tema. Material y método: Estudio observacional, descriptivo, de series de casos. Entre noviembre de 2015 y diciembre de 2016. Servicio de coloproctología del complejo médico hospitalario Churruca-Visca de la ciudad de Buenos Aires y práctica privada de los autores. Se utilizó la técnica de laparotomía abreviada y cierre temporal del abdomen mediante un sistema de presión negativa. Resultados: En el periodo descripto se operaron 17 pacientes con peritonitis generalizada purulenta o fecal de origen diverticular. Catorce casos fueron Hinchey III (82,36%) y 3 casos Hinchey IV (17,64%). En 3 casos se observó inestabilidad hemodinámica en el preoperatorio o intraoperatorio. Todos ellos correspondientes al estadio IV de Hinchey. Se describen los 3 casos tratados mediante esta táctica quirúrgica. Discusión: La alta tasa de morbimortalidad de este subgrupo de pacientes incentivó a diversos grupos quirúrgicos a implementar la técnica de control del daño, permitiendo de esta manera estabilizar a los pacientes hemodinámicamente y en un segundo tiempo evaluar la reconstrucción del tránsito intestinal. En concordancia con estas publicaciones, dos de nuestros pacientes operados con esta estrategia, pudieron ser anastomosados luego del segundo lavado abdominal. Conclusión: En pacientes con peritonitis diverticular severa asociado a shock séptico el concepto de laparotomía abreviada con control inicial del foco séptico, cierre temporal del abdomen con sistema de presión negativa y posterior evaluación de la reconstrucción del tránsito intestinal, es muy alentador. Permitiendo una disminución de la morbimortalidad como así también del número de ostomías. (AU)

Introduction: Patients presenting with diverticular peritonitis (Hinchey III or IV stages) in a context of severe sepsis with hemodynamic instability (septic shock), performing primary anastomosis has a high rate of dehiscence anastomotic and operative mortality, advising the realization of a resection and ostoma in the manner of Hartmann. However, the high rate of complications related to performing of ostoma, the complexity of intestinal transit restoration surgery, associated with the 40% to 60% of Hartmann reversal not performed, has encouraged other variables to be attempted resolution for this complex and serious pathology. Several publications in recent years have proposed the tactic of "damage control surgery" in order to reduce the morbidity of these serious septic charts while reducing the rate of ostomies. The objective of this study is to present our initial experience with this modality of management of the diverticular peritonitis Hinchey III/IV severe sepsis and hemodynamic instability (septic shock) and to carry out a bibliographic review of the subject. Material and method: Observational, descriptive study of case series. Between November 2015 and December 2016. Coloproctology service of the Churruca-Visca hospital medical complex in the city of Buenos Aires and private practice of the authors. The technique of abbreviated laparotomy and temporary closure of the abdomen was used by a negative pressure system. Results: In the period described, 17 patients with generalized purulent or fecal peritonitis of diverticular origin were operated. Fourteen cases were Hinchey III (82.36%) and 3 cases Hinchey IV (17.64%).In 3 cases, hemodynamic instability was observed in the preoperative or intraoperative period. all of them corresponding to Hinchey's Stage IV. The 3 cases treated using this surgical tactic are described. Discussion: The high morbidity rate of this subgroup of patients encouraged various surgical groups to implement the damage control technique, thus allowing patients to stabilize hemodynamically and in a second time evaluate reconstruction intestinal transit. In line with these publications, two of our patients operated on with this strategy could be anastomosated after the second abdominal wash. Conclusion: In patients with severe diverticular peritonitis associated with septic shock, the concept of abbreviated laparotomy with initial control of the septic focus, temporary closure of the abdomen with negative pressure system and subsequent evaluation of transit reconstruction intestinal, it's encouraging. Allowing a decrease in morbidity as well as the number of ostomies. (AU)

Evaluación de opciones terapéuticas para la enfermedad diverticular del colon / Evaluation of therapeutic options for diverticular disease of the colon

Introducción: La enfermedad diverticular del colon es una entidad de reciente aparición, con un aumento manifiesto en el siglo XX. El manejo quirúrgico más apropiado ha sido siempre controvertido con respecto a su estado más grave: la diverticulitis. Existen principalmente dos opciones terapéuticas: la cirugía de Hartmann y la resección con anastomosis primaria. Objetivo: Evaluar las opciones terapéuticas para la peritonitis diverticular de colon izquierdo Grado III de Hinchey. Métodos: Se realizó un estudio descriptivo, de serie de casos, a partir de la discusión e implementación de un método de tratamiento estándar aplicado a esa patología en el Hospital Clínico Quirúrgico de Holguín desde 2014 hasta 2016. El universo y la muestra coinciden con 78 pacientes intervenidos. Resultados: El proceder quirúrgico más utilizado fue la resección con anastomosis primaria. La mayor parte de las intervenciones tuvo una duración de más de 2 horas. El proceder de Hartmann fue el que más complicaciones y mortalidad posoperatorias presentó. Conclusiones: Se determinó que entre las técnicas quirúrgicas actuales para el tratamiento de la diverticulitis Grado III de Hinchey. El proceder de RAP constituye la terapéutica más adecuada(AU)

Introduction: The diverticular disease of the colon is a recent ailment having remarkable increase in the 20th century. The most appropriate surgical management of this disease has always been a topic of controversy about its most severe condition, that is, diverticulitis. There are two main therapeutic options: Hartmann's surgery and primary anastomosis resection. Objective: To evaluate the therapeutic options for Hinchey III left-sided colon diverticular peritonitis. Methods: A descriptive case-series study was conducted on the basis of discussion and implementation of a standard method of treatment used for this pathology in the Clinical and Surgical Hospital of Holguin from 2014 to 2016. The universe and the sample were the same, with 78 surgical patients. Results: The most used surgical procedure was primary anastomosis resection. Most of the interventions lasted more than 2 hours. Hartmann's procedure was the one with more complications and high postoperative mortality. Conclusions: Among the current surgical techniques for the treatment of Hinchey III diverticulitis, it was established that the primary anastomosis resection is the most adequate therapy(AU)

A double row epiploicoplasty for primary closure of free perforated sigmoid diverticulitis / Epiploicoplastia de duas fileiras para fechamento primário de diverticulite perfurada livre de sigmoide

ABSTRACT Acute free perforation of the sigmoid diverticulitis is an emergency surgical intervention required condition. Although the sigmoid resection and temporary end colostomy or abdominal lavage and drainage are the most commonly used surgical methods for its treatment, the most effective surgical method has not been established yet. We applied a different surgical method for the surgical treatment of free perforation of acute sigmoid diverticulitis outside of these surgical procedures. A double row epiploicoplasty was performed for surgical treatment of free perforated sigmoid diverticulitis with surgical success in a patient who had concominant serious diseases.

RESUMO A perfuração livre aguda da diverticulite de sigmoide é um problema que exige intervenção cirúrgica de emergência. Embora a ressecção de sigmoide e a colostomia de extremidade temporária ou a lavagem e drenagem abdominal sejam os métodos cirúrgicos mais comumente utilizados para o seu tratamento, o método cirúrgico mais eficaz ainda não foi estabelecido. Aplicamos um método cirúrgico diferente para o tratamento cirúrgico de perfuração livre de diverticulite de sigmoide aguda fora desses procedimentos cirúrgicos. Uma epiploicoplastia de duas fileiras foi realizada para o tratamento cirúrgico de diverticulite perfurada livre de sigmoide com sucesso cirúrgico em um paciente com doenças graves concomitantes.

Results of videolaparoscopic surgical treatment of diverticular disease of the colon / Resultados do tratamento cirúrgico videolaparoscópico da doença diverticular do cólon

ABSTRACT Introduction: Diverticular disease of the colon (DDC) is the fifth most common gastrointestinal disease in developed Western countries, with mortality rates of 2.5 per 100,000 inhabitants per year. Objective: The objective of this study is to compare the occurrence of complications, conversion rate, use of stoma, deaths and time of hospitalization among patients undergoing rectosigmoidectomy for DDC and patients undergoing the same surgery for other reasons. Method: This was an observational retrospective comparative study. This study was approved by the ethics committee of the Hospital Felicio Rocho - Minas Gerais, Brazil - and the data were obtained from the same hospital database. Results: The groups were classified according to age, gender, presence of comorbidities, and ASA classification. There was no evidence indicating a significant difference between groups. In this analysis, no perioperative complications were observed and there was no need for a stoma, and no deaths or fistulas occurred. Conclusion: Elective laparoscopic surgical treatment of DDC in the analyzed group showed no difference in complications, duration of surgery and hospitalization time versus control group. Therefore, the laparoscopic surgical treatment of diverticular disease translates into an excellent tool for both the surgeon and the patient.

RESUMO Introdução: A Doença Diverticular do Cólon (DDC) é a quinta doença gastrointestinal mais frequente nos países desenvolvidos do ocidente com índices de mortalidade de 2,5 por 100.000 habitantes por ano. Objetivo: O objetivo desse estudo é comparar a ocorrência de complicações, taxa de conversão, utilização de estoma, óbito e tempo de internação entre pacientes submetidos a retossigmoidectomia por DDC e pacientes submetidos ao mesmo procedimento cirúrgico por outras causas. Método: Trata-se de um estudo comparativo, retrospectivo observacional. Este estudo foi aprovado pelo comitê de ética do Hospital Felício Rocho - Minas Gerais, Brasil - e os dados foram obtidos no banco de dados do mesmo hospital. Resultados: Os grupos foram classificados em relação à idade, sexo, presença ou não de comorbidades e classificação ASA. Observou-se que não existem evidências indicando diferença significativa entre os grupos. Não houveram complicações per-operatórias, necessidade de estoma, bem como óbitos ou fístulas nesta análise. Conclusão: O tratamento cirúrgico eletivo videolaparoscópico da DDC no grupo analisado não apresentou diferença quanto às complicações, o tempo de cirurgia e o tempo de internação em relação ao grupo controle. Portanto, o tratamento cirúrgico laparoscópico da doença diverticular traduz-se em excelente ferramenta tanto para o cirurgião quanto para o paciente.

Diverticulite aguda / Acute diverticulitis

Objetivos: O objetivo deste estudo foi aprimorar o cuidado ao paciente com diverticulite aguda através de uma revisão da literatura relevante no tema, com foco em diagnóstico e manejo da condição. Métodos: Revisão de literatura, com consulta de artigos científicos no banco de dados PubMed e escolha de bibliografia por tempo de publicação inferior a 5 anos, estrutura em formato de guidelines e foco em diagnóstico e manejo. Resultados: A revisão apontou que a diverticulite possui maior prevalência a partir da 5ª década de vida e acomete mais comumente cólon sigmoide. A manifestação de dor em cólica na fossa ilíaca esquerda está presente em 70% dos pacientes, sendo que na agudização do quadro surgem sinais inflamatórios e irritação peritoneal. Outros sintomas frequentes são febre baixa e constipação. O diagnóstico normalmente é clínico, com exames complementares utilizados principalmente em quadros duvidosos e investigação de complicações da condição. O tratamento depende diretamente da presença de complicações, sendo este o fator determinante da escolha entre manejo conservador com analgesia e antibioticoterapia ou tratamento cirúrgico. Conclusões: Apesar do aprimoramento expressivo das diretrizes na última década, ainda é imperativa a busca de evidências mais robustas para o planejamento de tratamentos com o devido embasamento científico.

Aims: This study's objective was to improvethe healthcare of patients with acute diverticulitis, through a literature review of relevant scientific knowledge about this condition. Methods: A literature review was performed, with scientific articles searched in the PubMed Databases and bibliography chose according to publication date of 5 years or less, article structured in guideline format and with focus on diagnosis and available treatments. Results: The review indicated that diverticulitis has a higher prevalence at the fifth decade of life and affects more commonly the sigmoid colon. The manifestation of pain in left lower abdominal quadrant is present in 70% of the patients, with signs of peritoneal irritation. Other common symptoms are a low fever and constipation. The diagnosis is usually based on clinical signs, with complementary exams used mainly in doubtful cases and investigation of complications. Treatment depends directly on the presence of complications, which is the main factor for the choice between conservative treatment with analgesia and antibiotic therapy or surgery. Conclusions: Despite the improvement in guidelines during the last decade, it is important to continue the search for more evidence in order to plan clinical care with more robust scientific basis.

Retroneumoperitoneo y celulitis retroperitoneal: complicaciones inusuales de la enfermedad diverticular del colon / Pneumoretroperitoneum and retroperitoneal cellulitis: unusual complications of colonic diverticular disease

Se reporta dos casos de retroneumoperitoneo con neumo-mediastino, consecuencias de perforaciones diverticulares en el espacio retroperitoneal, en pacientes portadores de diverticulitis aguda y septicemia. En ambos casos no se comprobó contaminación peritoneal alguna, siendo sometidos a Colectomia parcial tipo Hartmann con buena evolución; al momento del reporte ambos han sido sometidos al restablecimiento del tránsito colo-rectal. Se discuten los problemas diagnósticos y los posibles mecanis-mos del paso del aire - y gérmenes bacterianos - al mediastino.

We report two cases of retropneumoperitoneum with pneumomediastinum, as a result of diverticular perforations in the retroperitoneal space, in patients with acute diverticulitis and septicemia. In both cases the patients underwent partial colectomy (Hartmann procedure) with good evolution, and no sign of peritoneal contamination was found. Currently both patients have undergone colorectal transit restoration. We discuss problems with the diagnosis and possible mechanism of the air and bacterial germ passage to the mediastinum.

Comparative study of collagen deposition in the colon wall of patients operated for sigmoid diverticular disease

PURPOSE: To investigate the deposition of collagen in the colon wall of patients with sigmoid diverticulitis.METHODS: Samples of sigmoid tissue from 15 patients (disease group), seven men and eight women aged 37-77 years who underwent surgery for the treatment of diverticulitis, were selected. For the control group, specimens from five patients, three men and two women aged 19-58 years undergoing emergency surgery for sigmoid trauma were selected. These subjects had no associated diseases. The histological study of the surgical specimens was performed by staining with hematoxylin-eosin and picrosirius and using a histochemical method for collagen quantification.RESULTS: Collagen deposition in the colon wall in terms of area (F), glandular epithelium (E) and total area was significantly higher in the disease group compared to control (p=0.003, p=0.026 and p=0.010, respectively). The collagen volume fraction (F fraction) and muscle tissue (M fraction) were also significantly higher compared to control (p=0.044 and p=0.026, respectively). The muscle (M area) and volume fraction of glandular epithelium (E fraction) did not differ significantly between the two groups, (p=0.074 and p=1.000, respectively).CONCLUSION: In this study, collagen deposition in the colon wall of the patients operated for sigmoid diverticulitis was higher compared to patients without the disease.

Divertículo sigmoideo gigante complicado en un paciente diabético / Complicated sigmoid giant diverticulum seen in a diabetic patient

La divertículosis colónica es una entidad frecuente en los países occidentales y representa una de las primeras enfermedades gastrointestinales con mayor repercusión en cuanto a costos de salud. La prevalencia de esta dolencia aumenta con la edad, aproximadamente hasta un 50 porciento de los adultos mayores de 60 años la padecen. Se señala que una de las razones de este incremento es el bajo consumo de fibras en la dieta y una interacción compleja entre la fibra dietética, la estructura de la pared colónica y la motilidad intestinal. El divertículo gigante de colon (mayor de 4 cm) es una entidad rara, hemos encontrado 156 publicados en la literatura. El presente caso es un paciente masculino de 47 años de edad con múltiples comorbilidades que hicieron su forma de presentación inusual y difícil su diagnóstico(AU)

Colonic diverticulosis is a frequent pathology in Western countries and represents one of the major gastrointestinal diseases with higher impact on health costs. Its prevalence increases with the age and is present in almost 50 percent of adults over 60 years old living in these countries. It has been said that among the reasons for this rise is the low dietary fiber consumption, and the complex interaction among the dietary fiber, the colon wall structure and the intestinal motility. Giant colonic diverticulum (over 4 cm long) is a rare entity; we have found just 156 cases reported in literature. This is the case of a 47 years-old male patient, who presented with multiple comorbidities that cause the unusual presentation of the diverticulum and create difficulties in diagnosing it(AU)

Procedimiento de Hartmann vs resección y anastomosis primaria en peritonitis diverticular de colon izquierdo por cirugía abierta: revisión sistemática de la literatura / Hartmann’s procedure and resection with primary anastomosis in diverticular peritonitis

Introduction: colonic diverticulosis, as diverticulitis, is a frequent disease in different stages of evolution. There is uncertainty about treatment options that are used in secondary peritonitis. The aim of this study is to determine the best treatment option for patients with peritonitis secondary to diverticulitis of the left colon in terms of postoperative morbidity (POM) and mortality, comparing Hartmann's procedure (HP) and resection with primary anastomosis (RPA). Material and Methods: systematic review. Studies in adults with peritonitis secondary to diverticulitis of the left colon treated with HP and RPA published between 1990 and 2011 were analyzed. TRIPDATABSE, IWO, MEDLINE, SciELO and LILACS databases were consulted and search strategies were applied using MeSH and free terms. Selected studies were analyzed using a score of methodological quality (MQ). The following variables were considered: mortality, POM, hospital stay, percentage of bowel transit reconstitution in patients undergoing HP and MQ of primary studies. Results: 26 primary studies were analyzed (47 series). There were no significant differences in the variable mortality (p = 0.0805), but significant difference was observed in POM (incompletely reported) (p = 0.0187). The median of MQ of the studies was 11 points for HP series and 10 for RPA series. Conclusion: the available evidence to determine the best treatment option in terms of mortality and POM in this kind of patients is insufficient. Studies with better level evidence and MQ are needed to clarify the uncertain.

Introducción: la enfermedad diverticular del colon es una entidad frecuente, como también la diverticulitis en sus diferentes estadios de evolución. Existe incertidumbre respecto de las opciones terapéuticas que se utilizan en el tratamiento de la peritonitis diverticular de colon izquierdo (PDCI). El objetivo de este estudio es determinar la mejor opción de tratamiento para pacientes con PDCI entre procedimiento de Hart-mann (PH) y resección con anastomosis primaria (RAP), en términos de mortalidad y morbilidad postoperatoria (MPO). Material y Método: revisión sistemática de la literatura. Se analizaron estudios realizados en adultos con PDCI tratados con PH y RAP, publicados entre 1990 y 2011. Se consultó en las bases de datos TRIPDATABSE, IWO, MEDLINE, SciELO y LILACS, utilizando estrategias de búsqueda con términos MeSH, palabras libres y operadores booleanos. Los estudios seleccionados fueron analizados mediante un escore de calidad metodológica (CM). Se consideraron las variables mortalidad, MPO, estadía hospitalaria, porcentaje de reconstitución de tránsito en pacientes sometidos a PH y CM de los estudios primarios. Resultados: se analizaron 26 estudios primarios (47 series de pacientes). No se encontraron diferencias significativas respecto de la variable mortalidad (p = 0,0805); pero sí en la variable MPO, reportada de forma incompleta (p = 0,0187). La mediana de la CM de los estudios primarios fue de 11 puntos para las series de PH y de 10 para las de RAP. Conclusión: la evidencia disponible no permite determinar la mejor alternativa terapéutica en términos de mortalidad y MPO en este tipo de pacientes. Se requieren estudios de mejor nivel de evidencia y CM para aclarar esta incertidumbre.

Diverticulitis exclusiva de ciego / Unique diverticulitis of the cecum

La diverticulitis cecal es una rara entidad de difícil diagnóstico que con frecuencia se confunde con un proceso apendicular agudo. Los divertículos primarios o de origen congénito, generalmente son únicos, suelen presentarse en una edad más temprana que la enfermedad diverticular cólica (divertículos secundarios). La presencia de estos en el colon derecho se reporta con menor frecuencia, su diagnóstico es en muchas ocasiones indistinguible de la apendicitis aguda y se realiza en la mayoría de los casos durante la laparotomía, el tratamiento es variable, según la literatura abarca desde la resección del divertículo hasta la hemicolectomía derecha. El objetivo de esta presentación es referir la dificultad diagnostica y la alta frecuencia de error diagnóstico que presenta esta entidad

The cecal diverticulitis is a strange disease, difficult to be diagnosed, frequently confused with acute appendicular process. The primary diverticula or those of congenital origin are generally unique; they usually appear at younger age than the colic diverticular disease (secondary diverticula). Their presence in the right colon is less frequently reported, the diagnosis is often confused with that of acute appendicitis and most of cases undergo laparatomy. According to the scientific literature, the treatment is variable, ranging from diverticular resection to right hemi-cholectomy. The objective of this paper was to present the difficulties and the high frequency of errors in diagnosing this disease

Diverticulitis perforada: alternativas de manejo quirúrgico. Caso clínico y revisión de literatura / Perforated diverticulitis: alternatives of surgical management. Case report and literature review

Sigmoid diverticular disease is common in the occidental world and it is responsible for a great number of hospitalizations. The prevalence of diverticular disease increases with age and only in few cases it is manifest as diverticulitis. Diverticulitis produces variable clinical manifestations, ranging from simple inflammation that only requires medical management, to a life threatening condition, due to a free perforation that requires urgent surgical management. Surgical management is recommended after the first attack of complicated diverticulitis, due to the elevated rate of recurrence after successful medical treatment. In this article we present a clinical case of complicated diverticulitis with free perforation treated with laparoscopic peritoneal lavage, and we make a review of the different surgical alternatives, such as Hartmann's operation, resection with primary anastomosis and laparoscopic peritoneal lavage (AU)

Colectomia eletiva laparoscópica esquerda para a doença diverticular: estudo monocêntrico sobre 205 pacientes consecutivos / Elective laparoscopic left colectomy for diverticular disease: a monocentric study on 205 consecutive patients

RACIONAL: O aumento da prevalência de doença diverticular tornou o seu manuseio mais adequado uma questão de debate constante. Especialmente para os casos de diverticulite, progresso considerável tem sido feito em termos de diagnóstico e tratamento. A ressecção cirúrgica do cólon envolvido é a única maneira de erradicar definitivamente essa condição e, portanto, a colectomia laparoscópica eletiva surgiu como uma opção segura e interessante entre as várias formas de tratamento. OBJETIVO: Analisar os resultados das colectomias laparoscópicas esquerdas para a doença diverticular realizadas durante um período de 17 anos em uma única instituição. MÉTODOS: Entre abril de 1990 e maio de 2007, um total de 205 colectomias consecutivas esquerdas laparoscópicas foram revistas retrospectivamente. Os dados obtidos incluíram o pré-operatório, indicações para a operação, os dados cirúrgicos, complicações e seguimento. Análises estatísticas univariada e multivariada foram realizadas em um esforço para identificar os fatores de risco e efeitos adversos na série. RESULTADOS: As indicações foram diverticulite aguda (80 por cento) não-complicada, diverticulite aguda ou crônica complicada (18,05 por cento) e sangramento na doença diverticular (1,95 por cento). A taxa de conversão foi de 5,85 por cento (12 casos). A mediana do tempo operatório foi de 180 minutos (100-420), com internação hospitalar de 7 (5-44) dias. O comprimento médio do espécime ressecado foi 29,12 centímetros. A maioria dos casos (88,3 por cento) teve curso pós-operatório normal, mas complicações ocorreram em 24 (11,7 por cento) pacientes. Em ordem de frequência foram: íleo paralítico (n = 6), coleções pélvica (n = 4), obstruções intestinais (n = 4) e fístulas (n = 2), entre outros. Re-operação foi necessária em oito casos e houve um óbito (0,48 por cento). O seguimento mediano foi de 26,5 (1-156) meses, com resultado satisfatório em 179 (87,32 por cento) dos pacientes. Em 18 (8,78 por cento) casos...

BACKGROUND: The increased prevalence of diverticular disease has made its most appropriate management a matter of constant debate. Especially for the cases of diverticulitis, considerable progress has been made in terms of diagnosis and management. The surgical resection of the involved colon is the only means of definitely eradicate this condition and so, the elective laparoscopic colectomy has emerged as a safe and interesting choice among the options of treatment. AIM: To analyze the outcomes of the laparoscopic left colectomy for diverticular disease performed over a 17-year period at a single institution. METHODS: Between April 1990 and May 2007, a total of 205 consecutive left laparoscopic colectomies were retrospectively reviewed. Data obtained included the pre-operative work-up, indications for surgery, operative results, complications and follow-up. Univariate and multivariate statistical analyzes were performed in an effort to identity risk factors for adverse outcomes in the series. RESULTS: Indications were for non-complicated acute diverticulitis (80 percent), acute or chronic complicated diverticulitis (18.05 percent) and bleeding diverticular disease (1.95 percent). The conversion rate was 5.85 percent (12 cases). The median operative time was 180 (100-420) min with a hospital stay of 7 (5-44) days. The mean length of the resected specimen was 29.12 (+8.2) cm. Most cases (88.3 percent) had an unremarkable postoperative course but complications occurred in 24 (11.7 percent) patients. In order of frequency, these were: paralytic ileus (n=6), pelvic collections (n=4), bowel obstructions (n=4) and fistulas (n=2), among others. A re-operation was necessary in eight cases and there was one death (0.48 percent). Median follow-up was 26.5 (1-156) months with a satisfying result seen in 179 (87.32 percent) of the patients. In 18 (8.78 percent) cases, persistent symptoms of functional colonic disorders were noted. There were 7 (3.41 percent)...

Divertículo de Meckel necrosado / Necrotic Meckel's diverticulum

Se presenta el caso de un paciente que acudió al cuerpo de guardia del CIMEQ en marzo del 2007. Presentaba un cuadro clínico de abdomen agudo quirúrgico y fue intervenido con el diagnóstico de apendicitis aguda complicada. En el transoperatorio se constató la presencia de un gran divertículo de Meckel, que inicialmente se inflamó (diverticulitis aguda) y posteriormente evolucionó hasta la necrosis, por lo que afectó la irrigación de un segmento intestinal en el íleon terminal, el ciego y el tercio inferior del colon ascendente. El apéndice no tenía ninguna alteración, por lo que se realizó una hemicolectomía derecha. El paciente evolucionó favorablemente y fue dado de alta a los 10 días, con una evolución favorable(AU)

This is the case presentation of a patient treated in Emergency Department in March 2007 presenting with a clinical picture of surgical acute abdomen and operated on due to complicated acute appendicitis. At transoperative period presence of a Meckel's diverticulum was verified that initially becomes inflamed (acute diverticulitis) and later process evolved until necrosis affecting the blood stream of an intestinal segment in terminal ileum, cecum ant the lower third of ascending colon. Appendix was not altered and a hemicholectomy was performed. Patient had a favorable course and was discharged at 10 days(AU)