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Diverticulitis of the Sigmoid Colon with Perforation: Report of Three Cases
T DIVERTICULITIS OF THE SIGMOID COLON WITH PERFORATION
Report of Three Cases JOHN
W. STEWART, M.D., F.A.C.S.*
THREE cases will be presented to illustrate what may occur when diverticulitis of the lower colon perforates. A detailed description of the cases and their treatment will be given.
CASE I
Mrs. E. 0., a, white woman, aged 63 years, was admitted on November 2, 1949, with the chief complaint of irregular vaginal discharge of pus and blood. Present Illness: In January 1949 the patient suffered an attack of pelvic pain, with inflammation in the lower abdomen. She was treated with sulfa drugs and penicillin. An abscess formed and drained through the vagina. Vaginal examination immediately prior to her admittance revealed a sinus opening in the left vaginal fornix. A probe passed upward and to the left to a mass in the sigmoid just above the rectum and palpable through the rectum. The probe reached but did not pass into the mass. Physical Examination: Pupils are equal and react normally. Ears, nose and throat are normal. The heart is strong, regular; a presystolic murmur is heard at the apex. The first sound is indistinct. The lungs are resonant throughout. Abdomen: A suprapubic scar and old striations of pregnancy are seen. The patient is quite fat. No masses are palpable but there is tenderness in the lower left quadrant. Reflexes are normal. Laboratory Examinations: X-ray with barium enema reveals many diverticula of the descending colon and sigmoid. There is no evidence of obstruction. Urinalysis is negative. Red blood cells 4.6 million; hemoglobin 16 per cent; white blood cells 8000; bleeding time 2 miilutes; clotting time 4i minutes; Kahn negative; nonprotein nitrogen 30 mg. per 100 ce.; blood sugar 110 mg. per 100 ec.
Diagnosis: Pelvic abscess draining through vagina (Fig. 432, A). Origin, ruptured sigmoid diverticulitis. Immediate Treatment: Sulfaguanidine 4 gm. (60 grains) daily by mouth in three divided doses. From the St. Mary 's Group of Hospitals and Bethesda Hospital, St. Louis. * Chairman of Department of Surgery, St. Louis University School of Medicine; Surgeon, St. Mary's Group of Hospitals and Bethesda Hospital.
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Operation-Stage 1 Preoperative Preparation: Liquid diet and a cleansing enema were given the night before operation, with no breakfast in the morning.
A -
--Fistula
c Fig. 432. A (Case I) Vaginosigmoid fistula; B (Case II), vesicosigmoid fistula; C (Case III), ileosigmoid fistula.
Morphine 16 mg. (1 grain); atropine 0.3 mg. (~~o grain) one hour before operation. Nitrous oxide anesthesia. Operation (11/19/49): Diversional Transverse Colostomy. What Was Found: Rounded, smooth, inflammatory mass in middle
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sigmoid. Many diverticula in descending and sigmoid colon. Adhesions in left side of pelvis. No diverticula in transverse or ascending colon. The mass in the sigmoid is not firmly fixed and is resectable. What Was Done: A left upper rectus incision was followed by exploration by palpation of the colon. A loop of transverse colon was brought through the wound and its peritoneal coats approximated by a row of running Dulox catgut sutures for a distance of 8 em. Two Payr clamps were applied close together at the apex of the loop and partial closure of the abdominal incision was made in layers with No. 1 chromic catgut; interrupted silkworm gut suture used for partial skin closure. The colon was divided between clamps with a cautery knife, 2 em. of each end of the divided colon extending above the skin surface. Progress Notes: 11/10/49: Payr clamp removed from proximal end of colostomy loop. 11/11/49: Payr clamp removed from distal end of colostomy. Colon tube passed down this loop and 0.25 gm. (4 grains) of sulfaguanidine suspension instilled-to be repeated once daily. 11/12/49: Patient placed on regular diet. 11/15/49: Colostomy draining well.
Operation-Stage 2 Preoperative Preparation: No breakfast; morphine 16 mg. (! grain) one hour before operation. Spinal anesthesia, using 200 mg. of procaine. Diagnosis: Diverticulitis of sigmoid, old; vaginocolic fistula, old; di.. versional transverse colostomy, old. Operation (11/25/49): Resection and End-to-End Anastomosis of the Rectosigmoid. What Was Found: Extensive adhesions between the small bowel and peritoneum of the anterior abdominal wall, and between the small bowel and the sigmoid colon. A loop of midsigmoid firmly adhered to the uterus and bladder wall in the left adnexal region. This adherent loop of sigmoid was indurated for a distance of 10 em. The lower end of the indurated mass was 8 em. above the floor of the cul-de-sac of Douglas. No tubes or ovaries were present. Many diverticula were present in the sigmoid and lower descending colon. There was evidence of old abscess formation in the left pelvis. What Was Done: The old suprapubic scar was excised. The left anterior rectus sheath was incised and the left rectus retracted laterally. The posterior sheath and peritoneum were opened. Many adhesions were freed. The loop of lower colon and involved sigmoid was mobilized by slitting its mesenteric peritoneum, 2 em. from attachment to bowel, clamping and ligating the vessels. This involved loop was divided and
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resected between rubber-covered clamps. Cultures were taken from the lumen of the cut ends of the sigmoid and rectum. End-to-end anastomosis ., was accomplished with two rows of No. 1 iodized catgut swedged on a curved needle. In the first layer a continuous Connell suture through all coats was utilized. The outer suture took in only the peritoneal and muscular layers. After the anastomosis was accomplished by bringing down the descending colon and bringing up the rectum, any raw surface remaining was covered by bringing together the split edges of the perineum with interrupted plain No. 0 catgut sutures to cover all raw surfaces. No effort was made to close the fistula into the vagina since it had adequate drainage from below. The abdominal wound was closed with No.2 chromic continuous suture. Two figure-of-8 silkworm gut sutures were placed through the skin and the anterior rectus sheath. Michel clips were used for the skin. Pathological Report: The section of colon is 16 inches in length, with thickened wall and narrowed lumen. Numerous diverticula are present. Microscopic sections show chronic inflammation but no evidence of malignancy. Pathological diagnosis: "Diverticulitis of the Colon." Progress Notes: 11/24/49: Streptomycin 250 mg. every four hours; liquids by mouth; morphine 16 mg. (1 grain) for pain. Glucose 10 per cent intravenously if vomiting. 11/29/49: Condition very satisfactory. Culture from colon reported as hemolytic streptococci. NoB. coli present. 12/2/49: Wound clips removed. Wound clean. 12/3/49: Stay sutures removed. 12/6/49: Passing gas and feces by rectum. Streptomycin discontinued.
Operation-Stage 3 Preoperative Preparation: No breakfast. Morphine 10 mg. (1 grain); nitrous oxide anesthesia. Preoperative Diagnosis: Diverticulitis of sigmoid, old; vaginal sigmoid fistula, old; resection of sigmoid, old; colostomy, transverse, diversional. Operation: Closure of Colostomy. What Was Found: Double-barrelled colostomy. Ends protruded 2 em. above skin level. Spur had been clamped. The lumen was adequate for closure. What Was Done: A longitudinal elliptical incision was made about the colostomy. The ends of the colon were freed from the skin and the anterior and posterior rectus sheaths but not from the peritoneum. The redundant ends of the colon were excised. Transverse sutures were used to close the ends of the bowel, the first layer continuous iodized catgut
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No. 1 through all coats, the second layer through the perit oneal coat. The sheaths of the rectus muscle were closed in layers with interrupted chromic No. 1 sutures. Three interrupted silkworm gut sutures closed the skin. No drains were employed. Progress Note: The patient was discharged, healed, with bowel function normal and no vaginal drainage or sign of fistula. CASE II
L. W. W., a man aged 44 years, was admitted on July 17,1946, complaining of passing fecal material and gas through his urethra for the past year, and of dysuria. Nine years earlier he was operated upon for what was said to have been an appendiceal abscess. The appendix was removed and the abscess drained. A fecal fistula persisted off and on for, seven years. Two years ago the fistulous tract was excised. One year later a second pelvic abscess developed which apparently broke into the urinary bladder. Since then he has been passing gas and fecal material through the urethra and suffers frequent attacks of cystitis. He has mild attacks of asthma. X-ray of Colon: Barium enemas show no obstruction of lower bowel but a few diverticula are present in the sigmoid. Cystoscopic examination reveals a fistulous opening in the dome of the bladder. Methylene blue, injected into the bladder, was not recovered through the rectum. Laboratory Tests on Admission: The urine is cloudy with debris; there is a trace of albumin; 50 to 60 white blood cells and 5 to 10 red blood cells in the high powered field. Many bacteria are present and a culture of urine shows a heavy growth of E. coli. General Physical Examination: Generally negative except for musical rales on inspiration and expiration. The blood pressure is 150/86-. An old suprapubic scar is present.
On admission the patient was placed on sulfasuxidine 1 gm. (15 grains) four times per day by mouth and penicillin 25,000 units every four hours, intramuscularly.
Operation-Stage 1 Preoperative Preparation: Morphine 10 mg. (l grain); atropine 0.4 mg. (rio grain); spinal anesthesia with procaine 100 mg. and cyclopropane inhalation. Preoperative Diagnosis: Vesico-intestinal fistula. Postoperative Diagnosis: Vesicosigmoid fistula (Fig. 432, B). Operation (7/22/46): Resection of Ileum; Diversional Colostomy. What Was Found: Firm omental, ileum, sigmoid and bladder mass. The rectosigmoid juncture was firmly adherent to the bladder. This was
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the site of the fistula between the bladder and sigmoid colon. No nodules were present in the liver and there was no marked lymphadenopathy. There was about 18 inches of badly adherent ileum. No communication existed between the ileum and the large bowel. What Was Done: The old suprapubic scar was excised. The ileum was freed, resected and anastomosed end-to.. .end. The cut ends were closed with two layers of iodized catgut sutures. Raw edges of mesentery were approximated with plain interrupted catgut sutures. Through a MeBurney type incision in the right hyperchondrium a loop of transverse colon was brought out and the peritoneum of the borders of the loop were approximated for a distance of 4 em. Payr clamps were applied to . the middle of the loop and the skin edges partially closed. The lower abdominal wound was now closed with Michel clips. The colostomy loop was now divided between the Payr clamps with a cautery knife. Approximately 2 cm. of each barrel of the colostomy extended above the skin surface. Pathological Report: Marked kinking of the ileum by adhesions. Some round cell infiltration in the wall of the bowel. Progress Notes: The patient was continued on penicillin and sulfasuxidine. He received 500 cc. of fresh blood by transfusion. On July 26 the colostomy was functioning well.
Operation-Stage 2 Continuous spinal anesthesia. Preoperative Diagnosis: Vesicosigmoidal fistula; colostomy, old; resection of ileum, old. Postoperative Diagnosis: Same. Operation (7/31/46): Excision of the Fistula; Resection of Sigmoid. What Was Found: A loop of sigmoid was adherent to the dome of the bladder. The induration was much reduced since the first operation. The bowel wall was thickened and a few noninflamed diverticula were seen above this area. The bladder wall was less indurated. There was a narrow fistulous tract connecting t.he bladder and sigmoid. What Was Done: The previous laparotomy wound was reopened. The involved loop of sigmoid was separated from the bladder and mobilized. The fistula in the bladder wall was excised and the bladder closed with two purse-string sutures. The first suture of No. 1 iodized catgut closed the muscular coat but did not dip into the bladder mucosa. The second layer closed the bladder peritoneum. An 8 cm. loop of sigmoid was now resected and an end-to-end anastomosis was made with two layers of No. 1 Dulox catgut. The first suture closed all coats. The second layer closed the peritoneal coat; the perineum of mesentery was closed with No. 1 plain catgut sutures. The abdomen was closed in layers with No.
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2 chromic catgut, and clips were used for the skin. Two silkworm gut stay sutures were employed. A retention catheter was placed through the urethra into the bladder to remain eight days. Fluids were given by mouth and intravenously. A light diet was given on the third postoperative day. Pathological Report: Same as in Case III. Progress Notes: 8/7/46: No gas passing with urination. 8/15/46: Cystoscopic examination by Dr. Burford showed the urine to be still cloudy. There was a puckered fold of mucosa observed in the superior aspect of the dome of the bladder practically in the midline. The old fistulous opening site was covered by mucosa and well healed. 8/17/46: Spur clamps were placed in the colostomy. 9/2/46: A second clamping of the colostomy spur was done because of inadequate lumen for closure. Third clamp remained in place forty-eight hours.
Operation-s-Stage 3 Preoperative Diagnosis: Vesicosigmoid fistula, old; resection of sigmoid, old; repair of bladder wall, old; diversional colostomy, old. Postoperative Diagnosis: Same. Operation (9/9/46): Closure of Colostomy. What Was Found: Double-barrelled colostomy in right upper quadrant of abdomen. The loop consisted of transverse colon. What Was Done: The ends of the colon were freed from the skin, muscle and fascia but not from the peritoneum. A cuff of the colon ends was excised and closed with two layers of No.1 iodized catgut. All coats were included in the first layer, the peritoneum in the second. The two layers of fascia were approximated over the bowel with No. 2 chromic catgut interrupted sutures. Partial closure of the skin was obtained with interrupted silkworm gut sutures. Postoperative Care: Codeine 65 mg. (1 grain) was given by hypodermic for pain. Liquid diet for two days was followed by heavier feeding. Progress Notes: The patient was discharged from the hospital on September 12, 1946, with the wounds healed, normal bowel function and urination, and the urine clean and free from debris. He is well and working as of this date. CASE III
E. M., a man aged 44 years, was admitted on December 16, 1946, with a history of a laparotomy after an acute attack of pain in the left lower quadrant of the abdomen three years earlier. He was told by his
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surgeon that "a mass was found plastered to everything in the pelvis; that the condition was probably malignant but there was a lot of inflammation present." The exploratory wound was closed and a doublebarrelled colostomy established at the hepatic flexure of the colon. After the operation the patient gained weight. He feels well except for arthritis of the spine, but he gets moody and depressed because of almost constant liquid drainage from the colostomy. Occasionally there is drainage of bloody mucus and pus from the rectum. This usually follows cramplike pains in the left lower abdomen. Laboratory Findings: Urinalysis negative; white blood cell count 14,400; stab cells 3; segmental cells 69; leukocytes 23; monocytes 5; red blood cells 5,770,000; hemoglobin 13 gm.; Kahn negative. X -ray Examination: Barium enema reveals a definite area of partial obstruction in the rectosigmoid juncture with narrowing of the lumen of the descending colon. There is a considerable spasm and numerous diverticula. Subsequent x-ray by passing barium suspension down the efferent loop of the colostomy also showed the bowel patent down to partial obstruction at the rectosigmoid junction. Proctoscopic examination reveals a mass filling the pelvis above the prostatic level of the rectum, with almost complete blockage of the lumen. No ulceration is seen.
In view of the patient's gain of 30 pounds in weight, the absence of a palpable abdominal mass, the leukocytosis and x-ray findings, a diagnosis of "diverticulosis of the sigmoid" was made. It was thought that resection of the sigmoid should be undertaken. The patient was given 4 gm. (60 grains) of sulfaguanidine suspension per colon tube through the distal colostomy loop daily for ten days. His blood was typed and cross matched and transfusion of 500 cc. of whole blood was given.
First Operation Cyclopropane, curare anesthesia. Preoperative Diagnosis: Diverticulitis of sigmoid colon; colostomy, old. Postoperative Diagnosis: Diverticulitis of the sigmoid colon; ileosigmoid fistula (Fig. 432, C); colostomy, old. Operation (1/2/47): Resection of Sigmoid; Closure of Opening in Ileum. What Was Found: A large mass was seen to involve the rectosigmoid juncture and adhere to the bladder. The mass narrowed the lumen of the sigmoid. There was a false anastomosis between the sigmoid and a . loop of lower ileum. The appearance of the mass and absence of regional lymphadenopathy and liver nodules indicate a previously ruptured diverticulitis, a localized peritonitis with abscess rupturing into the small bowel.
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What Was Done: Through a lower left rectus incision the rectosigmoid mass was freed from the bladder where no fistula existed and from the loop of ileum where a fistulous opening was found. The edges of the opening into the ileum were freshened and closed transversely by two layers of Dulox iodized catgut. The first layer included all coats. The outer layer approximated the peritoneal coat only. A temporary closure of the fistulous opening in the sigmoid was made with a purse-string suture of catgut and 11 em. of the thickened sigmoid was resected. The peritoneum was incised longitudinally adjacent to the sigmoid mesentery. Vessels were clamped and ligated. The mobilized sigmoid loop was cut between rubber-covered clamps well above and below the involved area. Cultures were taken from the open lumen of the sigmoid and rectum. An end-to-end anastomosis was accomplished by means of two continuous rows of No. 1 iodized gut swedged on a fine curved needle. The first row approximated all coats, the outer row only peritoneum and muscle. Raw surface was peritonealized. The abdomen was closed in layers with No.2 chromic catgut. Two figure-of-8 silkworm gut stay sutures were inserted through skin and external rectus sheath. Skin closure was with Michel clips. No drainage was employed. One unit of bank blood was given during the operation. Postoperative Treatment: Penicillin 30,000 units every four hours; morphine 16 mg. (1 grain) for pain; liquid diet for forty-eight hours. Pathological Report: Gross: The specimen consists of a segment of colon 11 em. in length. At one area near the center a purse-string suture is seen invaginating the bowel wall. This is said to be the site of an ileocecal anastomosis from a diverticulum. The wall is thin near here. The remainder of the wall is thickened and feels indurated. The mucosa is redundant; there are four other small diverticula in the specimen. Microscopic: Multiple sections taken from various areas of the gross specimen and also the area of perforation reveal the microscopic picture. There is marked thickening of the entire wall with an overgrowth of collagenous connective tissue and fibroblasts and a diffuse infiltration by chronic inflammatory cells. A reasonable number of acute inflammatory cells are also present. In the submucosa and between the mucosal crypts there is a diffuse infiltration of many chronic and a few acute inflammatory cells and eosinophils. No evidence of malignancy is seen at the site of perforation or any other area. Diagnosis: Diverticulitis with scar tissues in sigmoid. (H. Pinkerton, M.D.) Progress Notes: 1/2/47: Culture from the cut ends of the sigmoid taken at operation showed no growth. The patient was allowed to go home on Janu-
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ary 18, 1947 and readmitted on February 3. Proctoscopic examination showed the end-to-end anastomosis of the sigmoid and rectum to be patent. The mucosa was smooth. There was some narrowing and resultant edema. The patient was passing gas throuth the anastomosis. A clamp was applied- to the colostomy spur. This loosened and was removed after three days. 2/9/47: Some blood from the colostomy. 2/20/47: Considerable hemorrhage from the colostomy.
The patient was taken to the operating room and the colostomy edges were retracted and a bleeder clamped in the edge of the spur site. The loops of the colostomy had apparently not been approximated with sutures at the original colostomy and a loop of omentum with vessel had evidently been caught in the clamp and later sloughed, causing the hemorrhage. A unit of bank blood was given.
Final Operation Nitrous oxide anesthesia. Diagnosis: Diverticulitis, rupture, old; ileosigmoid fistula, old; resection of sigmoid, old; colostomy, old. Operation (2/22/47): Closure of Colostomy (Fifth Stage of Mikulicz) What Was Found: Colostomy, double-barrelled, in right hyperchondrium. Adequate spur had been removed by clamping. The tissues were very vascular and bled easily. What Was Done: The walls of the colon were freed from the skin, fascia and muscles, but not from the peritoneal attachment. The edges of the opening in the colon were freshened and closed transversely with two rows of No. 1 Dulox catgut swedged on a fine curved needle. The first row closed all coats after the manner of Connell. The second suture line approximated the perineum. The fascial layers were approximated with continuous No. 2 chromic catgut above the sutured bowel. The skin was approximated with interrupted silkworm gut sutures. No drainage was employed. Postoperative Care: The patient passed a moderate amount of soft formed stool on the evening of the third day after the closure of the colostomy. He was given a light diet on the next day. Skin sutures were removed on the seventh postoperative day. Bowel action was normal until his discharge on the tenth postoperative day and to date he has had no further abdominal symptoms and has gained much weight. His mental attitude is very good. COMMENTS
Diverticulosis of the colon is not an unusual disease. It exists in approximately 20 per cent of middle aged and older people. Approximately
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95 per cent of persons in which this condition exists are asymptomatic. Those cases in which it exists are discovered by: a so-called medical check-up. This condition is noted and if asymptomatic it is usually ignored. Infection occurs in about 5 per cent of the cases of diverticulosis, resulting in the condition known as diverticulitis. In a few cases these infected diverticula perforate. Abscesses or peritonitis result, and the prognosis becomes very unfavorable unless prompt drainage is instituted and diversional colostomy is established. Another small group, perhaps 0.5 per cent, become involved with cancer, which is about the same proportion as cancer develops in thyroid disease. Professor LeRoy Sante' reports from one of our university hospitals that in 1948 695 x-ray examinations of the colon, using barium enemas, were made. Diverticula were noted in 110 examinations or 15.8 per cent. During 1949 there were 631 similar examinations and 103 cases of diverticulosis were noted in the first eleven months (16.3 per cent). The presence of diverticula was noted in the course of many abdominal operations, particularly pelvic cases, bringing the total of incidence in one hospital to 20 per cent in people past middle age. It is possible that even a higher percentage really exists. Etiology. Constipation is not the sole cause of this condition. We have observed constipation with impaction in youthful mental patients who presented the syndrome of obstruction of the colon. Operation was not done in these cases and after the condition had cleared, x-ray examinations with barium enemas did not show evidence of diverticula. Again, in cases of congenital cloaca wherein the child dreads bowel movement and develops an acquired megacolon, there is no evidence of diverticula in subsequent x-ray examination with barium enema. Thus one cannot explain the development of diverticulosis upon the theory of constipation alone. Looking elsewhere for a cause one may note that at the menopause and afterwards there is a definite relaxation in muscular tone and tissue elasticity-observe -the crinkled necks, flabby arms and sagging bellies of many of these persons. Really active people rarely suffer this syndrome. Inactivity plays a role and perhaps explains part of the constipation factor. It is probable that the relaxed or thinned muscular coat with resultant herniation of the mucosa may be influenced by one or all of the above mentioned variables. In diverticulum of the small bowel, stomach and esophagus all coats are present in the wall of the protrusion, and in the small bowel pancreatic tissue is sometimes found, obviously indicating a congenital origin. In the lower colon, however, the muscular coat is missing in the wall of the sacculation and the mucosa protrudes through a weakened area of the muscular coat, thus definitely supporting the theory of acquirement.
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Signs and Symptoms. The usual early symptoms are tympanitis and an uneasy feeling in the intestinal tract. Left-sided pain is a constant complaint. A certain number of these patients will have occasional melena, which is one of the early symptoms of diverticulitis and adds credence to the theory that the mucosa protrudes along the entrance or exit of the sigmoid vessels. Subsequent inflammation may involve the vessel wall, with resultant bleeding. If the patient suddenly develops leukocytosis, rapid pulse, and rigidity of the abdomen with localized and rebound tenderness, perforation has probably occurred. Many cases show evidence of localized peritoneal. irritation with subsidence of symptoms in \ a short time. Treatment. With cancer of the colon, without obstruction, one can administer antibiotics for a week and proceed with a primary resection and anastomosis with relative safety to the patient. In perforations of acute diverticulitis of the colon or sigmoid another element is added, however-that of infection. Inflammation of the colon wall, peritonitis or abscess may be present. In such a case exteriorization of the loop is not feasible and is often impossible owing to fixation by the inflammatory process. The possibility of spreading the peritonitis is also present. When signs of rupture of an acute diverticulitis of the colon appear one should open the abdomen at the site of perforation. Attempts at closure of the perforation are rather futile as the sutures will not hold in the friable inflamed tissue. Only drainage is instituted. After a complete change of equipment and fresh preparation of the skin area a diversional colostomy is established (Fig. 433, A, B) and antibiotic treatment is instituted. Within a short time one can reenter the abdomen and a fairly clean resection of the affected loop of colon is now possible (Fig. 433, C, D, E). When the anastomosis is fairly healed a spur clamp is applied (Fig. 434, A). After sufficient lumen is reestablished the diversional colostomy is revised and closed in the usual manner (Fig. 434, C,D). In earlier preantibiotic days we recall two cases of perforation of an acute diverticulitis of the sigmoid in which the abdomen was drained at the site of perforation but no diversional colostomy was instituted. Both resulted fatally. In one of the cases here presented (Case II) early drainage was established and a transverse colostomy done because the condition was thought to be carcinoma. This patient survived with resultant ileosigmoid fistula. In the other two cases presented here no drainage was instituted. In one antibiotics were given and a vaginosigmoid fistula resulted. In the other an abscess developed and ruptured into the bladder. In our intern days an occasional case of diverticulosis was diagnosed.
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If it was mild the medical treatment was 0.65 gm. (10 grains) of bismuth subnitrate with 65 mg. (1 grain) of salol three times a day, the purpose
Fig. 433. A, Formation of transverse colostomy. B, After dividing loop. Antibiotics administered through colon tube in afferent colostomy stoma. C, Resection of affected sigmoid (bladder closure with two rows of sutures is not shown). D, E, Anastomosis of the transverse colon.
being to fill the diverticula with a heavy and doubtfully antibiotic drug. However one may deprecate pioneer therapeutics it is more than coincidental to discover today, in resected portions of the colon, that the
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A
Fig. 434. A, Spur clamp applied; B) Edges of stomata trimmed and freed from skin muscle and fascia; C, Closure of stomata with two rows of sutures; D, Closure of skin and fascia.
nonperforated diverticula are literally packed with sulfa crystals after preoperative medication with the nonabsorbable sulfa drugs. Relation to Carcinoma. The theory that carcinoma may be superimposed upon chronic diverticulitis or fibromatosis of the colon is parti-
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cularly intriguing. Ewing? says, "Thus however closely the processes are analyzed the conclusion remains that inflammatory hyperplasia passes into neoplastic." In a small number of cases chronic diverticulitis is associated with carcinoma. It is hard to prove that the carcinoma is superimposed because when found the carcinoma has destroyed all evidence of preexisting diverticula at that site. Four patients with known diverticulosis who also had carcinoma have been personally observed. One, observed for thirty years, had frequent attacks of lower left side abdominal pain and occasional melena and x-ray evidence of diverticulosis of the sigmoid colon. She was treated conservatively by a medical colleague and at the age of 80 developed a lower left-side abdominal mass with liver nodules and died of carcinomatosis. Another patient with x-ray evidence of diverticulosis, with only narrowing of the descending colon, suffered a lateral perforation and developed an abscess which was opened just above the left iliac crest. Diversional colostomy was established and later the descending colon and sigmoid were resected and end-to-end anastomosis effected. The perforation had occurred through the malignant area in the upper portion of a tubular thickening of the descending colon. Diverticula were found above, opposite and below the malignant growth which was not the constricting signet ring type and could very well have been superimposed upon a preexisting diverticulum. On the other hand, we can recall resections in two other patients with annular constricting type carcinoma with impending complete obstruction of the sigmoid colon, yet with numerous diverticula above and below the site of malignancy. At some time in the future an early carcinoma may be found growing in a chronically inflamed diverticula, but until such a time resection of the left colon because of the mere presence of diverticula and the possibility of subsequent perforation or new growth will have to be deferred. REFERENCES 1. LeRoy Sante: Personal communication. 2. Ewing, James: Neoplastic Diseases. 4th Ed. Philadelphia, W. B. Saunders Co., 1940, p. 27.
Report of Three Cases JOHN
W. STEWART, M.D., F.A.C.S.*
THREE cases will be presented to illustrate what may occur when diverticulitis of the lower colon perforates. A detailed description of the cases and their treatment will be given.
CASE I
Mrs. E. 0., a, white woman, aged 63 years, was admitted on November 2, 1949, with the chief complaint of irregular vaginal discharge of pus and blood. Present Illness: In January 1949 the patient suffered an attack of pelvic pain, with inflammation in the lower abdomen. She was treated with sulfa drugs and penicillin. An abscess formed and drained through the vagina. Vaginal examination immediately prior to her admittance revealed a sinus opening in the left vaginal fornix. A probe passed upward and to the left to a mass in the sigmoid just above the rectum and palpable through the rectum. The probe reached but did not pass into the mass. Physical Examination: Pupils are equal and react normally. Ears, nose and throat are normal. The heart is strong, regular; a presystolic murmur is heard at the apex. The first sound is indistinct. The lungs are resonant throughout. Abdomen: A suprapubic scar and old striations of pregnancy are seen. The patient is quite fat. No masses are palpable but there is tenderness in the lower left quadrant. Reflexes are normal. Laboratory Examinations: X-ray with barium enema reveals many diverticula of the descending colon and sigmoid. There is no evidence of obstruction. Urinalysis is negative. Red blood cells 4.6 million; hemoglobin 16 per cent; white blood cells 8000; bleeding time 2 miilutes; clotting time 4i minutes; Kahn negative; nonprotein nitrogen 30 mg. per 100 ce.; blood sugar 110 mg. per 100 ec.
Diagnosis: Pelvic abscess draining through vagina (Fig. 432, A). Origin, ruptured sigmoid diverticulitis. Immediate Treatment: Sulfaguanidine 4 gm. (60 grains) daily by mouth in three divided doses. From the St. Mary 's Group of Hospitals and Bethesda Hospital, St. Louis. * Chairman of Department of Surgery, St. Louis University School of Medicine; Surgeon, St. Mary's Group of Hospitals and Bethesda Hospital.
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Operation-Stage 1 Preoperative Preparation: Liquid diet and a cleansing enema were given the night before operation, with no breakfast in the morning.
A -
--Fistula
c Fig. 432. A (Case I) Vaginosigmoid fistula; B (Case II), vesicosigmoid fistula; C (Case III), ileosigmoid fistula.
Morphine 16 mg. (1 grain); atropine 0.3 mg. (~~o grain) one hour before operation. Nitrous oxide anesthesia. Operation (11/19/49): Diversional Transverse Colostomy. What Was Found: Rounded, smooth, inflammatory mass in middle
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sigmoid. Many diverticula in descending and sigmoid colon. Adhesions in left side of pelvis. No diverticula in transverse or ascending colon. The mass in the sigmoid is not firmly fixed and is resectable. What Was Done: A left upper rectus incision was followed by exploration by palpation of the colon. A loop of transverse colon was brought through the wound and its peritoneal coats approximated by a row of running Dulox catgut sutures for a distance of 8 em. Two Payr clamps were applied close together at the apex of the loop and partial closure of the abdominal incision was made in layers with No. 1 chromic catgut; interrupted silkworm gut suture used for partial skin closure. The colon was divided between clamps with a cautery knife, 2 em. of each end of the divided colon extending above the skin surface. Progress Notes: 11/10/49: Payr clamp removed from proximal end of colostomy loop. 11/11/49: Payr clamp removed from distal end of colostomy. Colon tube passed down this loop and 0.25 gm. (4 grains) of sulfaguanidine suspension instilled-to be repeated once daily. 11/12/49: Patient placed on regular diet. 11/15/49: Colostomy draining well.
Operation-Stage 2 Preoperative Preparation: No breakfast; morphine 16 mg. (! grain) one hour before operation. Spinal anesthesia, using 200 mg. of procaine. Diagnosis: Diverticulitis of sigmoid, old; vaginocolic fistula, old; di.. versional transverse colostomy, old. Operation (11/25/49): Resection and End-to-End Anastomosis of the Rectosigmoid. What Was Found: Extensive adhesions between the small bowel and peritoneum of the anterior abdominal wall, and between the small bowel and the sigmoid colon. A loop of midsigmoid firmly adhered to the uterus and bladder wall in the left adnexal region. This adherent loop of sigmoid was indurated for a distance of 10 em. The lower end of the indurated mass was 8 em. above the floor of the cul-de-sac of Douglas. No tubes or ovaries were present. Many diverticula were present in the sigmoid and lower descending colon. There was evidence of old abscess formation in the left pelvis. What Was Done: The old suprapubic scar was excised. The left anterior rectus sheath was incised and the left rectus retracted laterally. The posterior sheath and peritoneum were opened. Many adhesions were freed. The loop of lower colon and involved sigmoid was mobilized by slitting its mesenteric peritoneum, 2 em. from attachment to bowel, clamping and ligating the vessels. This involved loop was divided and
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resected between rubber-covered clamps. Cultures were taken from the lumen of the cut ends of the sigmoid and rectum. End-to-end anastomosis ., was accomplished with two rows of No. 1 iodized catgut swedged on a curved needle. In the first layer a continuous Connell suture through all coats was utilized. The outer suture took in only the peritoneal and muscular layers. After the anastomosis was accomplished by bringing down the descending colon and bringing up the rectum, any raw surface remaining was covered by bringing together the split edges of the perineum with interrupted plain No. 0 catgut sutures to cover all raw surfaces. No effort was made to close the fistula into the vagina since it had adequate drainage from below. The abdominal wound was closed with No.2 chromic continuous suture. Two figure-of-8 silkworm gut sutures were placed through the skin and the anterior rectus sheath. Michel clips were used for the skin. Pathological Report: The section of colon is 16 inches in length, with thickened wall and narrowed lumen. Numerous diverticula are present. Microscopic sections show chronic inflammation but no evidence of malignancy. Pathological diagnosis: "Diverticulitis of the Colon." Progress Notes: 11/24/49: Streptomycin 250 mg. every four hours; liquids by mouth; morphine 16 mg. (1 grain) for pain. Glucose 10 per cent intravenously if vomiting. 11/29/49: Condition very satisfactory. Culture from colon reported as hemolytic streptococci. NoB. coli present. 12/2/49: Wound clips removed. Wound clean. 12/3/49: Stay sutures removed. 12/6/49: Passing gas and feces by rectum. Streptomycin discontinued.
Operation-Stage 3 Preoperative Preparation: No breakfast. Morphine 10 mg. (1 grain); nitrous oxide anesthesia. Preoperative Diagnosis: Diverticulitis of sigmoid, old; vaginal sigmoid fistula, old; resection of sigmoid, old; colostomy, transverse, diversional. Operation: Closure of Colostomy. What Was Found: Double-barrelled colostomy. Ends protruded 2 em. above skin level. Spur had been clamped. The lumen was adequate for closure. What Was Done: A longitudinal elliptical incision was made about the colostomy. The ends of the colon were freed from the skin and the anterior and posterior rectus sheaths but not from the peritoneum. The redundant ends of the colon were excised. Transverse sutures were used to close the ends of the bowel, the first layer continuous iodized catgut
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No. 1 through all coats, the second layer through the perit oneal coat. The sheaths of the rectus muscle were closed in layers with interrupted chromic No. 1 sutures. Three interrupted silkworm gut sutures closed the skin. No drains were employed. Progress Note: The patient was discharged, healed, with bowel function normal and no vaginal drainage or sign of fistula. CASE II
L. W. W., a man aged 44 years, was admitted on July 17,1946, complaining of passing fecal material and gas through his urethra for the past year, and of dysuria. Nine years earlier he was operated upon for what was said to have been an appendiceal abscess. The appendix was removed and the abscess drained. A fecal fistula persisted off and on for, seven years. Two years ago the fistulous tract was excised. One year later a second pelvic abscess developed which apparently broke into the urinary bladder. Since then he has been passing gas and fecal material through the urethra and suffers frequent attacks of cystitis. He has mild attacks of asthma. X-ray of Colon: Barium enemas show no obstruction of lower bowel but a few diverticula are present in the sigmoid. Cystoscopic examination reveals a fistulous opening in the dome of the bladder. Methylene blue, injected into the bladder, was not recovered through the rectum. Laboratory Tests on Admission: The urine is cloudy with debris; there is a trace of albumin; 50 to 60 white blood cells and 5 to 10 red blood cells in the high powered field. Many bacteria are present and a culture of urine shows a heavy growth of E. coli. General Physical Examination: Generally negative except for musical rales on inspiration and expiration. The blood pressure is 150/86-. An old suprapubic scar is present.
On admission the patient was placed on sulfasuxidine 1 gm. (15 grains) four times per day by mouth and penicillin 25,000 units every four hours, intramuscularly.
Operation-Stage 1 Preoperative Preparation: Morphine 10 mg. (l grain); atropine 0.4 mg. (rio grain); spinal anesthesia with procaine 100 mg. and cyclopropane inhalation. Preoperative Diagnosis: Vesico-intestinal fistula. Postoperative Diagnosis: Vesicosigmoid fistula (Fig. 432, B). Operation (7/22/46): Resection of Ileum; Diversional Colostomy. What Was Found: Firm omental, ileum, sigmoid and bladder mass. The rectosigmoid juncture was firmly adherent to the bladder. This was
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the site of the fistula between the bladder and sigmoid colon. No nodules were present in the liver and there was no marked lymphadenopathy. There was about 18 inches of badly adherent ileum. No communication existed between the ileum and the large bowel. What Was Done: The old suprapubic scar was excised. The ileum was freed, resected and anastomosed end-to.. .end. The cut ends were closed with two layers of iodized catgut sutures. Raw edges of mesentery were approximated with plain interrupted catgut sutures. Through a MeBurney type incision in the right hyperchondrium a loop of transverse colon was brought out and the peritoneum of the borders of the loop were approximated for a distance of 4 em. Payr clamps were applied to . the middle of the loop and the skin edges partially closed. The lower abdominal wound was now closed with Michel clips. The colostomy loop was now divided between the Payr clamps with a cautery knife. Approximately 2 cm. of each barrel of the colostomy extended above the skin surface. Pathological Report: Marked kinking of the ileum by adhesions. Some round cell infiltration in the wall of the bowel. Progress Notes: The patient was continued on penicillin and sulfasuxidine. He received 500 cc. of fresh blood by transfusion. On July 26 the colostomy was functioning well.
Operation-Stage 2 Continuous spinal anesthesia. Preoperative Diagnosis: Vesicosigmoidal fistula; colostomy, old; resection of ileum, old. Postoperative Diagnosis: Same. Operation (7/31/46): Excision of the Fistula; Resection of Sigmoid. What Was Found: A loop of sigmoid was adherent to the dome of the bladder. The induration was much reduced since the first operation. The bowel wall was thickened and a few noninflamed diverticula were seen above this area. The bladder wall was less indurated. There was a narrow fistulous tract connecting t.he bladder and sigmoid. What Was Done: The previous laparotomy wound was reopened. The involved loop of sigmoid was separated from the bladder and mobilized. The fistula in the bladder wall was excised and the bladder closed with two purse-string sutures. The first suture of No. 1 iodized catgut closed the muscular coat but did not dip into the bladder mucosa. The second layer closed the bladder peritoneum. An 8 cm. loop of sigmoid was now resected and an end-to-end anastomosis was made with two layers of No. 1 Dulox catgut. The first suture closed all coats. The second layer closed the peritoneal coat; the perineum of mesentery was closed with No. 1 plain catgut sutures. The abdomen was closed in layers with No.
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2 chromic catgut, and clips were used for the skin. Two silkworm gut stay sutures were employed. A retention catheter was placed through the urethra into the bladder to remain eight days. Fluids were given by mouth and intravenously. A light diet was given on the third postoperative day. Pathological Report: Same as in Case III. Progress Notes: 8/7/46: No gas passing with urination. 8/15/46: Cystoscopic examination by Dr. Burford showed the urine to be still cloudy. There was a puckered fold of mucosa observed in the superior aspect of the dome of the bladder practically in the midline. The old fistulous opening site was covered by mucosa and well healed. 8/17/46: Spur clamps were placed in the colostomy. 9/2/46: A second clamping of the colostomy spur was done because of inadequate lumen for closure. Third clamp remained in place forty-eight hours.
Operation-s-Stage 3 Preoperative Diagnosis: Vesicosigmoid fistula, old; resection of sigmoid, old; repair of bladder wall, old; diversional colostomy, old. Postoperative Diagnosis: Same. Operation (9/9/46): Closure of Colostomy. What Was Found: Double-barrelled colostomy in right upper quadrant of abdomen. The loop consisted of transverse colon. What Was Done: The ends of the colon were freed from the skin, muscle and fascia but not from the peritoneum. A cuff of the colon ends was excised and closed with two layers of No.1 iodized catgut. All coats were included in the first layer, the peritoneum in the second. The two layers of fascia were approximated over the bowel with No. 2 chromic catgut interrupted sutures. Partial closure of the skin was obtained with interrupted silkworm gut sutures. Postoperative Care: Codeine 65 mg. (1 grain) was given by hypodermic for pain. Liquid diet for two days was followed by heavier feeding. Progress Notes: The patient was discharged from the hospital on September 12, 1946, with the wounds healed, normal bowel function and urination, and the urine clean and free from debris. He is well and working as of this date. CASE III
E. M., a man aged 44 years, was admitted on December 16, 1946, with a history of a laparotomy after an acute attack of pain in the left lower quadrant of the abdomen three years earlier. He was told by his
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surgeon that "a mass was found plastered to everything in the pelvis; that the condition was probably malignant but there was a lot of inflammation present." The exploratory wound was closed and a doublebarrelled colostomy established at the hepatic flexure of the colon. After the operation the patient gained weight. He feels well except for arthritis of the spine, but he gets moody and depressed because of almost constant liquid drainage from the colostomy. Occasionally there is drainage of bloody mucus and pus from the rectum. This usually follows cramplike pains in the left lower abdomen. Laboratory Findings: Urinalysis negative; white blood cell count 14,400; stab cells 3; segmental cells 69; leukocytes 23; monocytes 5; red blood cells 5,770,000; hemoglobin 13 gm.; Kahn negative. X -ray Examination: Barium enema reveals a definite area of partial obstruction in the rectosigmoid juncture with narrowing of the lumen of the descending colon. There is a considerable spasm and numerous diverticula. Subsequent x-ray by passing barium suspension down the efferent loop of the colostomy also showed the bowel patent down to partial obstruction at the rectosigmoid junction. Proctoscopic examination reveals a mass filling the pelvis above the prostatic level of the rectum, with almost complete blockage of the lumen. No ulceration is seen.
In view of the patient's gain of 30 pounds in weight, the absence of a palpable abdominal mass, the leukocytosis and x-ray findings, a diagnosis of "diverticulosis of the sigmoid" was made. It was thought that resection of the sigmoid should be undertaken. The patient was given 4 gm. (60 grains) of sulfaguanidine suspension per colon tube through the distal colostomy loop daily for ten days. His blood was typed and cross matched and transfusion of 500 cc. of whole blood was given.
First Operation Cyclopropane, curare anesthesia. Preoperative Diagnosis: Diverticulitis of sigmoid colon; colostomy, old. Postoperative Diagnosis: Diverticulitis of the sigmoid colon; ileosigmoid fistula (Fig. 432, C); colostomy, old. Operation (1/2/47): Resection of Sigmoid; Closure of Opening in Ileum. What Was Found: A large mass was seen to involve the rectosigmoid juncture and adhere to the bladder. The mass narrowed the lumen of the sigmoid. There was a false anastomosis between the sigmoid and a . loop of lower ileum. The appearance of the mass and absence of regional lymphadenopathy and liver nodules indicate a previously ruptured diverticulitis, a localized peritonitis with abscess rupturing into the small bowel.
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What Was Done: Through a lower left rectus incision the rectosigmoid mass was freed from the bladder where no fistula existed and from the loop of ileum where a fistulous opening was found. The edges of the opening into the ileum were freshened and closed transversely by two layers of Dulox iodized catgut. The first layer included all coats. The outer layer approximated the peritoneal coat only. A temporary closure of the fistulous opening in the sigmoid was made with a purse-string suture of catgut and 11 em. of the thickened sigmoid was resected. The peritoneum was incised longitudinally adjacent to the sigmoid mesentery. Vessels were clamped and ligated. The mobilized sigmoid loop was cut between rubber-covered clamps well above and below the involved area. Cultures were taken from the open lumen of the sigmoid and rectum. An end-to-end anastomosis was accomplished by means of two continuous rows of No. 1 iodized gut swedged on a fine curved needle. The first row approximated all coats, the outer row only peritoneum and muscle. Raw surface was peritonealized. The abdomen was closed in layers with No.2 chromic catgut. Two figure-of-8 silkworm gut stay sutures were inserted through skin and external rectus sheath. Skin closure was with Michel clips. No drainage was employed. One unit of bank blood was given during the operation. Postoperative Treatment: Penicillin 30,000 units every four hours; morphine 16 mg. (1 grain) for pain; liquid diet for forty-eight hours. Pathological Report: Gross: The specimen consists of a segment of colon 11 em. in length. At one area near the center a purse-string suture is seen invaginating the bowel wall. This is said to be the site of an ileocecal anastomosis from a diverticulum. The wall is thin near here. The remainder of the wall is thickened and feels indurated. The mucosa is redundant; there are four other small diverticula in the specimen. Microscopic: Multiple sections taken from various areas of the gross specimen and also the area of perforation reveal the microscopic picture. There is marked thickening of the entire wall with an overgrowth of collagenous connective tissue and fibroblasts and a diffuse infiltration by chronic inflammatory cells. A reasonable number of acute inflammatory cells are also present. In the submucosa and between the mucosal crypts there is a diffuse infiltration of many chronic and a few acute inflammatory cells and eosinophils. No evidence of malignancy is seen at the site of perforation or any other area. Diagnosis: Diverticulitis with scar tissues in sigmoid. (H. Pinkerton, M.D.) Progress Notes: 1/2/47: Culture from the cut ends of the sigmoid taken at operation showed no growth. The patient was allowed to go home on Janu-
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JOHN W. STEWART
ary 18, 1947 and readmitted on February 3. Proctoscopic examination showed the end-to-end anastomosis of the sigmoid and rectum to be patent. The mucosa was smooth. There was some narrowing and resultant edema. The patient was passing gas throuth the anastomosis. A clamp was applied- to the colostomy spur. This loosened and was removed after three days. 2/9/47: Some blood from the colostomy. 2/20/47: Considerable hemorrhage from the colostomy.
The patient was taken to the operating room and the colostomy edges were retracted and a bleeder clamped in the edge of the spur site. The loops of the colostomy had apparently not been approximated with sutures at the original colostomy and a loop of omentum with vessel had evidently been caught in the clamp and later sloughed, causing the hemorrhage. A unit of bank blood was given.
Final Operation Nitrous oxide anesthesia. Diagnosis: Diverticulitis, rupture, old; ileosigmoid fistula, old; resection of sigmoid, old; colostomy, old. Operation (2/22/47): Closure of Colostomy (Fifth Stage of Mikulicz) What Was Found: Colostomy, double-barrelled, in right hyperchondrium. Adequate spur had been removed by clamping. The tissues were very vascular and bled easily. What Was Done: The walls of the colon were freed from the skin, fascia and muscles, but not from the peritoneal attachment. The edges of the opening in the colon were freshened and closed transversely with two rows of No. 1 Dulox catgut swedged on a fine curved needle. The first row closed all coats after the manner of Connell. The second suture line approximated the perineum. The fascial layers were approximated with continuous No. 2 chromic catgut above the sutured bowel. The skin was approximated with interrupted silkworm gut sutures. No drainage was employed. Postoperative Care: The patient passed a moderate amount of soft formed stool on the evening of the third day after the closure of the colostomy. He was given a light diet on the next day. Skin sutures were removed on the seventh postoperative day. Bowel action was normal until his discharge on the tenth postoperative day and to date he has had no further abdominal symptoms and has gained much weight. His mental attitude is very good. COMMENTS
Diverticulosis of the colon is not an unusual disease. It exists in approximately 20 per cent of middle aged and older people. Approximately
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95 per cent of persons in which this condition exists are asymptomatic. Those cases in which it exists are discovered by: a so-called medical check-up. This condition is noted and if asymptomatic it is usually ignored. Infection occurs in about 5 per cent of the cases of diverticulosis, resulting in the condition known as diverticulitis. In a few cases these infected diverticula perforate. Abscesses or peritonitis result, and the prognosis becomes very unfavorable unless prompt drainage is instituted and diversional colostomy is established. Another small group, perhaps 0.5 per cent, become involved with cancer, which is about the same proportion as cancer develops in thyroid disease. Professor LeRoy Sante' reports from one of our university hospitals that in 1948 695 x-ray examinations of the colon, using barium enemas, were made. Diverticula were noted in 110 examinations or 15.8 per cent. During 1949 there were 631 similar examinations and 103 cases of diverticulosis were noted in the first eleven months (16.3 per cent). The presence of diverticula was noted in the course of many abdominal operations, particularly pelvic cases, bringing the total of incidence in one hospital to 20 per cent in people past middle age. It is possible that even a higher percentage really exists. Etiology. Constipation is not the sole cause of this condition. We have observed constipation with impaction in youthful mental patients who presented the syndrome of obstruction of the colon. Operation was not done in these cases and after the condition had cleared, x-ray examinations with barium enemas did not show evidence of diverticula. Again, in cases of congenital cloaca wherein the child dreads bowel movement and develops an acquired megacolon, there is no evidence of diverticula in subsequent x-ray examination with barium enema. Thus one cannot explain the development of diverticulosis upon the theory of constipation alone. Looking elsewhere for a cause one may note that at the menopause and afterwards there is a definite relaxation in muscular tone and tissue elasticity-observe -the crinkled necks, flabby arms and sagging bellies of many of these persons. Really active people rarely suffer this syndrome. Inactivity plays a role and perhaps explains part of the constipation factor. It is probable that the relaxed or thinned muscular coat with resultant herniation of the mucosa may be influenced by one or all of the above mentioned variables. In diverticulum of the small bowel, stomach and esophagus all coats are present in the wall of the protrusion, and in the small bowel pancreatic tissue is sometimes found, obviously indicating a congenital origin. In the lower colon, however, the muscular coat is missing in the wall of the sacculation and the mucosa protrudes through a weakened area of the muscular coat, thus definitely supporting the theory of acquirement.
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Signs and Symptoms. The usual early symptoms are tympanitis and an uneasy feeling in the intestinal tract. Left-sided pain is a constant complaint. A certain number of these patients will have occasional melena, which is one of the early symptoms of diverticulitis and adds credence to the theory that the mucosa protrudes along the entrance or exit of the sigmoid vessels. Subsequent inflammation may involve the vessel wall, with resultant bleeding. If the patient suddenly develops leukocytosis, rapid pulse, and rigidity of the abdomen with localized and rebound tenderness, perforation has probably occurred. Many cases show evidence of localized peritoneal. irritation with subsidence of symptoms in \ a short time. Treatment. With cancer of the colon, without obstruction, one can administer antibiotics for a week and proceed with a primary resection and anastomosis with relative safety to the patient. In perforations of acute diverticulitis of the colon or sigmoid another element is added, however-that of infection. Inflammation of the colon wall, peritonitis or abscess may be present. In such a case exteriorization of the loop is not feasible and is often impossible owing to fixation by the inflammatory process. The possibility of spreading the peritonitis is also present. When signs of rupture of an acute diverticulitis of the colon appear one should open the abdomen at the site of perforation. Attempts at closure of the perforation are rather futile as the sutures will not hold in the friable inflamed tissue. Only drainage is instituted. After a complete change of equipment and fresh preparation of the skin area a diversional colostomy is established (Fig. 433, A, B) and antibiotic treatment is instituted. Within a short time one can reenter the abdomen and a fairly clean resection of the affected loop of colon is now possible (Fig. 433, C, D, E). When the anastomosis is fairly healed a spur clamp is applied (Fig. 434, A). After sufficient lumen is reestablished the diversional colostomy is revised and closed in the usual manner (Fig. 434, C,D). In earlier preantibiotic days we recall two cases of perforation of an acute diverticulitis of the sigmoid in which the abdomen was drained at the site of perforation but no diversional colostomy was instituted. Both resulted fatally. In one of the cases here presented (Case II) early drainage was established and a transverse colostomy done because the condition was thought to be carcinoma. This patient survived with resultant ileosigmoid fistula. In the other two cases presented here no drainage was instituted. In one antibiotics were given and a vaginosigmoid fistula resulted. In the other an abscess developed and ruptured into the bladder. In our intern days an occasional case of diverticulosis was diagnosed.
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If it was mild the medical treatment was 0.65 gm. (10 grains) of bismuth subnitrate with 65 mg. (1 grain) of salol three times a day, the purpose
Fig. 433. A, Formation of transverse colostomy. B, After dividing loop. Antibiotics administered through colon tube in afferent colostomy stoma. C, Resection of affected sigmoid (bladder closure with two rows of sutures is not shown). D, E, Anastomosis of the transverse colon.
being to fill the diverticula with a heavy and doubtfully antibiotic drug. However one may deprecate pioneer therapeutics it is more than coincidental to discover today, in resected portions of the colon, that the
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A
Fig. 434. A, Spur clamp applied; B) Edges of stomata trimmed and freed from skin muscle and fascia; C, Closure of stomata with two rows of sutures; D, Closure of skin and fascia.
nonperforated diverticula are literally packed with sulfa crystals after preoperative medication with the nonabsorbable sulfa drugs. Relation to Carcinoma. The theory that carcinoma may be superimposed upon chronic diverticulitis or fibromatosis of the colon is parti-
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cularly intriguing. Ewing? says, "Thus however closely the processes are analyzed the conclusion remains that inflammatory hyperplasia passes into neoplastic." In a small number of cases chronic diverticulitis is associated with carcinoma. It is hard to prove that the carcinoma is superimposed because when found the carcinoma has destroyed all evidence of preexisting diverticula at that site. Four patients with known diverticulosis who also had carcinoma have been personally observed. One, observed for thirty years, had frequent attacks of lower left side abdominal pain and occasional melena and x-ray evidence of diverticulosis of the sigmoid colon. She was treated conservatively by a medical colleague and at the age of 80 developed a lower left-side abdominal mass with liver nodules and died of carcinomatosis. Another patient with x-ray evidence of diverticulosis, with only narrowing of the descending colon, suffered a lateral perforation and developed an abscess which was opened just above the left iliac crest. Diversional colostomy was established and later the descending colon and sigmoid were resected and end-to-end anastomosis effected. The perforation had occurred through the malignant area in the upper portion of a tubular thickening of the descending colon. Diverticula were found above, opposite and below the malignant growth which was not the constricting signet ring type and could very well have been superimposed upon a preexisting diverticulum. On the other hand, we can recall resections in two other patients with annular constricting type carcinoma with impending complete obstruction of the sigmoid colon, yet with numerous diverticula above and below the site of malignancy. At some time in the future an early carcinoma may be found growing in a chronically inflamed diverticula, but until such a time resection of the left colon because of the mere presence of diverticula and the possibility of subsequent perforation or new growth will have to be deferred. REFERENCES 1. LeRoy Sante: Personal communication. 2. Ewing, James: Neoplastic Diseases. 4th Ed. Philadelphia, W. B. Saunders Co., 1940, p. 27.