- Email: [email protected]
Giant colon diverticulum
+Model JVS-491; No. of Pages 3
ARTICLE IN PRESS
Journal of Visceral Surgery (2015) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL IMAGES
Giant colon diverticulum C. Chater ∗, A. Saudemont , P. Zerbib Service de chirurgie digestive et transplantation, université Lille Nord de France, CHU Lille, 59000 Lille, France
KEYWORDS Giant colonic diverticulum; Giant sigmoid diverticulum
Summary Giant colonic diverticulum is defined by a diverticulum whose diameter is greater than 4 cm. This is a rare entity, arising mainly in the sigmoid colon. The diagnosis is based on abdominal computed tomography that shows a gas-filled structure communicating with the adjacent colon, with a smooth, thin diverticular wall that does not enhance after injection of contrast. Surgical treatment is recommended even in asymptomatic diverticula, due to the high prevalence and severity of complications. The gold standard treatment is segmental colectomy. Some authors propose a diverticulectomy when the giant diverticulum is unique. © 2015 Elsevier Masson SAS. All rights reserved.
A 69-year-old man, treated for ischemic heart disease, sought advice for abdominal discomfort (heaviness) without pain. Clinical examination revealed a palpable smooth and mobile infra-umbilical abdominal mass. Abdomino-pelvic CT scan showed a thick but smooth-walled 8 cm diameter sigmoid diverticulum (Fig. 1). Intra-operative colonoscopy was not performed. The patient underwent laparoscopic-assisted sigmoidectomy to remove the diverticulum and the recto-sigmoid juncture (Fig. 2); postoperative recovery was uneventful. Pathology confirmed the diagnosis of giant colonic diverticulum (GCD) with no associated pathology, protruding through the muscular layer along the anti-mesenteric border of the sigmoid colon (Figs. 3 and 4). GCD was described for the first time in France by Bonvin and Bonte in 1946; it is rare, with fewer than 200 cases reported in the literature. GCD is defined as a diverticulum whose diameter exceeds 4 cm [1]; GCD has been reported up to 30 cm in size. Three distinct entities have been described [2]: • acquired inflammatory giant diverticulum (85%), located on the anti-mesenteric border, forming a mucosal hernia protruding through a defect in the muscularis on the anti-mesenteric border. Its origin can be explained by the presence of an intermittent communication with the colonic lumen; the diverticulum progressively increases in size through a ‘‘valve effect’’, which entraps air in the diverticulum. The presence of intra-diverticular gas-forming anaerobic bacteria might enhance the process [2];
∗
Corresponding author. E-mail address: [email protected] (C. Chater).
http://dx.doi.org/10.1016/j.jviscsurg.2015.06.002 1878-7886/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Chater C, et al. Giant colon diverticulum. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.06.002
+Model JVS-491; No. of Pages 3
ARTICLE IN PRESS
2
C. Chater et al.
Figure 1. Preoperative CT scan showing a thick but smoothwalled 8 cm sigmoid diverticulum containing an air-fluid level (A. Sigmoid colon. B. Giant sigmoid diverticulum).
• congenital giant diverticulum (10%), located on the mesenteric border; its wall is composed of all histologic layers of the colonic wall. This belongs to the category of digestive tract duplications; • inflammatory giant pseudo-diverticulum, secondary to mucosal perforation of an ordinary-size diverticulum, resulting in an abscess that becomes encysted. This inflammatory pseudo-diverticulum is limited by fibrotic tissues without a proper wall structure. GCD is mainly located in the sigmoid. Clinical presentation is variable, ranging from an asymptomatic abdominal
Figure 2. Operative specimen: giant sigmoid diverticulum (A. Sigmoid colon. B. Giant sigmoid diverticulum).
Figure 3. Giant sigmoid diverticulum protruding through the muscular layer on the anti-mesenteric border of the sigmoid colon, with no visible tumor (A. Sigmoid colon. B. Giant sigmoid diverticulum).
mass to an acute abdomen. Diagnosis relies on contrastenhanced abdomino-pelvic CT scan [3] showing an air-filled, thin, smooth-walled cavity along the colon, which is not enhanced by contrast material. Barium enema can be falsely negative because of intermittent communication with the colonic lumen (valve effect) in 40% of cases [3]. Like any other colonic diverticular disease, GCD can become complicated (perforation, infection, obstruction, bleeding or fistulization into neighboring organs) [2]. Volvulus is a specific complication of GCD [2]. Moreover, two cases of malignant tumor (one adenocarcinoma [4] and one case of MALT lymphoma [5]) have been reported in the literature. These two cases should be distinguished from adenocarcinomas that arise within but are unrelated to otherwise banal diverticular disease of the colon. It is difficult to establish any relation of cause and effect between GCD and the risk of malignant transformation. Moreover, the diagnosis of adenocarcinoma developing within GCD is difficult and prognosis is often worse than sporadic colonic adenocarcinoma because of the absence of any muscular layer in the diverticular wall [6]. For this reason, serosal and extra-diverticular involvement might occur more rapidly.
Figure 4. Giant sigmoid diverticulum, without any visible tumor, protruding through the muscular layer, developed on the antimesenteric border of the sigmoid colon (A. Sigmoid colon. B. Giant sigmoid diverticulum).
Please cite this article in press as: Chater C, et al. Giant colon diverticulum. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.06.002
+Model JVS-491; No. of Pages 3
ARTICLE IN PRESS
Giant colon diverticulum Mortality related to complications ranges between 10 and 40% [7]. In analogy to colonic diverticular disease, the risk of complications of GCD is estimated around 20% [2]. Moreover, some authors consider GCD as a complication in itself of diverticular disease when the latter is also present [2]. The prevalence of these complications and their potential severity impose surgical treatment, even including asymptomatic GCD discovered fortuitously [2]. This attitude can be supported by the low morbidity and mortality of elective colonic resections. When GCD develops in the setting of left colonic diverticular disease, treatment consists of sigmoid resection removing the recto-sigmoid juncture and the GCD. Effectively, the recurrence rate of diverticular disease was higher when the recto-sigmoid juncture was left in place [8]. When GCD is solitary, developing on an otherwise healthy colon and located on the anti-mesenteric border, Choong et al. have proposed simple diverticulectomy [1]; no recurrence has been reported.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
3
References [1] Choong CK, Frizelle FA. Giant colonic diverticulum: report of four cases and review of the literature. Dis Colon Rectum 1998;41:1178—85. [2] Gillion JF, Julles MC, Convard JP, et al. Giant colonic or ileo-jejunal diverticulum and infra-mesocolic abdominal pseudocysts: diagnosis, pathological and clinical analysis. J Chir (Paris) 2005;142(4):248—56. [3] Zeina AR, Nachtigal A, Matter I, et al. Giant colon diverticulum: clinical and imaging findings in 17 patients with emphasis on CT criteria. Clin Imaging 2013;37(4):704—10. [4] Kricun R, Stasik JJ, Reither RD, Dex WJ. Giant colonic diverticulum. AJR Am J Roentgenol 1980;135(3):507—12. [5] Arima N, Tanimoto A, Hamada T, et al. MALT lymphoma arising in giant diverticulum of ascending colon. Am J Gastroenterol 2000;95(12):3673—4. [6] Van Beurden A, Baeten CI, Lange CP, et al. Adenocarcinoma arising within a colonic diverticulum in a patient with recurrent diverticulitis. Clin Med Oncol 2008;2:529—31. [7] Gauzit R, Péan Y, Barth X, et al. Epidemiology, management, and prognosis of secondary non-postoperative peritonitis: a French prospective observational multicenter study. Surg Infect (Larchmt) 2009;10(2):119—27. [8] Thaler K, Baig MK, Berho M, et al. Determinants of recurrence after sigmoid resection for uncomplicated diverticulitis. Dis Colon Rectum 2003;46(3):385—8.
Please cite this article in press as: Chater C, et al. Giant colon diverticulum. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.06.002
ARTICLE IN PRESS
Journal of Visceral Surgery (2015) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL IMAGES
Giant colon diverticulum C. Chater ∗, A. Saudemont , P. Zerbib Service de chirurgie digestive et transplantation, université Lille Nord de France, CHU Lille, 59000 Lille, France
KEYWORDS Giant colonic diverticulum; Giant sigmoid diverticulum
Summary Giant colonic diverticulum is defined by a diverticulum whose diameter is greater than 4 cm. This is a rare entity, arising mainly in the sigmoid colon. The diagnosis is based on abdominal computed tomography that shows a gas-filled structure communicating with the adjacent colon, with a smooth, thin diverticular wall that does not enhance after injection of contrast. Surgical treatment is recommended even in asymptomatic diverticula, due to the high prevalence and severity of complications. The gold standard treatment is segmental colectomy. Some authors propose a diverticulectomy when the giant diverticulum is unique. © 2015 Elsevier Masson SAS. All rights reserved.
A 69-year-old man, treated for ischemic heart disease, sought advice for abdominal discomfort (heaviness) without pain. Clinical examination revealed a palpable smooth and mobile infra-umbilical abdominal mass. Abdomino-pelvic CT scan showed a thick but smooth-walled 8 cm diameter sigmoid diverticulum (Fig. 1). Intra-operative colonoscopy was not performed. The patient underwent laparoscopic-assisted sigmoidectomy to remove the diverticulum and the recto-sigmoid juncture (Fig. 2); postoperative recovery was uneventful. Pathology confirmed the diagnosis of giant colonic diverticulum (GCD) with no associated pathology, protruding through the muscular layer along the anti-mesenteric border of the sigmoid colon (Figs. 3 and 4). GCD was described for the first time in France by Bonvin and Bonte in 1946; it is rare, with fewer than 200 cases reported in the literature. GCD is defined as a diverticulum whose diameter exceeds 4 cm [1]; GCD has been reported up to 30 cm in size. Three distinct entities have been described [2]: • acquired inflammatory giant diverticulum (85%), located on the anti-mesenteric border, forming a mucosal hernia protruding through a defect in the muscularis on the anti-mesenteric border. Its origin can be explained by the presence of an intermittent communication with the colonic lumen; the diverticulum progressively increases in size through a ‘‘valve effect’’, which entraps air in the diverticulum. The presence of intra-diverticular gas-forming anaerobic bacteria might enhance the process [2];
∗
Corresponding author. E-mail address: [email protected] (C. Chater).
http://dx.doi.org/10.1016/j.jviscsurg.2015.06.002 1878-7886/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Chater C, et al. Giant colon diverticulum. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.06.002
+Model JVS-491; No. of Pages 3
ARTICLE IN PRESS
2
C. Chater et al.
Figure 1. Preoperative CT scan showing a thick but smoothwalled 8 cm sigmoid diverticulum containing an air-fluid level (A. Sigmoid colon. B. Giant sigmoid diverticulum).
• congenital giant diverticulum (10%), located on the mesenteric border; its wall is composed of all histologic layers of the colonic wall. This belongs to the category of digestive tract duplications; • inflammatory giant pseudo-diverticulum, secondary to mucosal perforation of an ordinary-size diverticulum, resulting in an abscess that becomes encysted. This inflammatory pseudo-diverticulum is limited by fibrotic tissues without a proper wall structure. GCD is mainly located in the sigmoid. Clinical presentation is variable, ranging from an asymptomatic abdominal
Figure 2. Operative specimen: giant sigmoid diverticulum (A. Sigmoid colon. B. Giant sigmoid diverticulum).
Figure 3. Giant sigmoid diverticulum protruding through the muscular layer on the anti-mesenteric border of the sigmoid colon, with no visible tumor (A. Sigmoid colon. B. Giant sigmoid diverticulum).
mass to an acute abdomen. Diagnosis relies on contrastenhanced abdomino-pelvic CT scan [3] showing an air-filled, thin, smooth-walled cavity along the colon, which is not enhanced by contrast material. Barium enema can be falsely negative because of intermittent communication with the colonic lumen (valve effect) in 40% of cases [3]. Like any other colonic diverticular disease, GCD can become complicated (perforation, infection, obstruction, bleeding or fistulization into neighboring organs) [2]. Volvulus is a specific complication of GCD [2]. Moreover, two cases of malignant tumor (one adenocarcinoma [4] and one case of MALT lymphoma [5]) have been reported in the literature. These two cases should be distinguished from adenocarcinomas that arise within but are unrelated to otherwise banal diverticular disease of the colon. It is difficult to establish any relation of cause and effect between GCD and the risk of malignant transformation. Moreover, the diagnosis of adenocarcinoma developing within GCD is difficult and prognosis is often worse than sporadic colonic adenocarcinoma because of the absence of any muscular layer in the diverticular wall [6]. For this reason, serosal and extra-diverticular involvement might occur more rapidly.
Figure 4. Giant sigmoid diverticulum, without any visible tumor, protruding through the muscular layer, developed on the antimesenteric border of the sigmoid colon (A. Sigmoid colon. B. Giant sigmoid diverticulum).
Please cite this article in press as: Chater C, et al. Giant colon diverticulum. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.06.002
+Model JVS-491; No. of Pages 3
ARTICLE IN PRESS
Giant colon diverticulum Mortality related to complications ranges between 10 and 40% [7]. In analogy to colonic diverticular disease, the risk of complications of GCD is estimated around 20% [2]. Moreover, some authors consider GCD as a complication in itself of diverticular disease when the latter is also present [2]. The prevalence of these complications and their potential severity impose surgical treatment, even including asymptomatic GCD discovered fortuitously [2]. This attitude can be supported by the low morbidity and mortality of elective colonic resections. When GCD develops in the setting of left colonic diverticular disease, treatment consists of sigmoid resection removing the recto-sigmoid juncture and the GCD. Effectively, the recurrence rate of diverticular disease was higher when the recto-sigmoid juncture was left in place [8]. When GCD is solitary, developing on an otherwise healthy colon and located on the anti-mesenteric border, Choong et al. have proposed simple diverticulectomy [1]; no recurrence has been reported.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
3
References [1] Choong CK, Frizelle FA. Giant colonic diverticulum: report of four cases and review of the literature. Dis Colon Rectum 1998;41:1178—85. [2] Gillion JF, Julles MC, Convard JP, et al. Giant colonic or ileo-jejunal diverticulum and infra-mesocolic abdominal pseudocysts: diagnosis, pathological and clinical analysis. J Chir (Paris) 2005;142(4):248—56. [3] Zeina AR, Nachtigal A, Matter I, et al. Giant colon diverticulum: clinical and imaging findings in 17 patients with emphasis on CT criteria. Clin Imaging 2013;37(4):704—10. [4] Kricun R, Stasik JJ, Reither RD, Dex WJ. Giant colonic diverticulum. AJR Am J Roentgenol 1980;135(3):507—12. [5] Arima N, Tanimoto A, Hamada T, et al. MALT lymphoma arising in giant diverticulum of ascending colon. Am J Gastroenterol 2000;95(12):3673—4. [6] Van Beurden A, Baeten CI, Lange CP, et al. Adenocarcinoma arising within a colonic diverticulum in a patient with recurrent diverticulitis. Clin Med Oncol 2008;2:529—31. [7] Gauzit R, Péan Y, Barth X, et al. Epidemiology, management, and prognosis of secondary non-postoperative peritonitis: a French prospective observational multicenter study. Surg Infect (Larchmt) 2009;10(2):119—27. [8] Thaler K, Baig MK, Berho M, et al. Determinants of recurrence after sigmoid resection for uncomplicated diverticulitis. Dis Colon Rectum 2003;46(3):385—8.
Please cite this article in press as: Chater C, et al. Giant colon diverticulum. Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.06.002