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Laparoscopic management of generalized peritonitis due to perforated colonic diverticula
Laparoscopic Management Due to Perforated
of Generalized Peritonitis Colonic Diverticula
Gerald C. O’Sullivan, MCh, FRCSI, Dermot Murphy, MB, FRCSI, Michael G. O’Brien, MB, FRCSI, Adrian Ireland, MB, FRCSI, Cork, Ireland
PURPOSE: The use of laparoscopic peritoneal lavage in conjunction with parenteral fluids and antibiotic therapy in the management of generalized peritonitis secondary to perforated diverticular disease of the colon was assessed. PATIENTS AND METHODS: This cohort comprised 8 patients with generalized peritonitis secondary to perforated diverticular disease of the left colon that was diagnosed laparoscopically. All the patients had purulent peritonitis, but no fecal contamination. They were treated with laparoscopic peritoneal lavage and intravenous fluids and antibiotics. RESULTS: All patients made a complete recovery, with resumption of normal diet within 5 to 8 days. No patient has required surgical intervention during a 12- to 48-month follow-up. This approach merits further assessment as an alternative to the traditional open surgical management. Am J Surg. 1998;171:432-434.
eneralized peritonitis due to perforated diverticular disease of the left colon poses a number of distinct, but related, clinical problems. A precise diagnosis is rarely possible without resorting to surgery. Because acute appendicitis seems the most likely cause, many patients are explored through an oblique, right iliac fossa incision, which may be inappropriate to assess or deal with the primary problem. In addition, there is controversy regarding the most effective method of managing the perforated diverticular segment.‘-’ Immediate resection of the involved colonic segment is appropriate where there is a major unsealed perforation and fecal contamination. In the vast majority of patients with generalized peritonitis due to perforated diverticular disease, there is no evidence of fecal contamination, and the perforation is already sealed or cannot be found at surgery.6 In these circumstances, it is unclear whether or not immediate definitive surgery is required, although many surgeons favor this policy, as the patient has already been committed to a laparotomy and abdominal incision.
G
From the Department of Surgery, Mercy Hospital and National Jniversity of Ireland, Cork, Ireland. A video of this technique was shown at M.I.M.S., Florida 1993. Requests for reprints should be addressed to Dr. Gerald C. 3’Sullivan, MCh, FRCSI, Department of Surgery, Mercy Hospital, Cork, Ireland. Manuscript submitted July 3, 1995 and accepted in revised form October 21, 1995.
432
THE
AMERICAN
JOURNAL
OF SURGERY’=
VOLUME
171
In this paper, we report on 8 patients who presented with generalized peritonitis secondary to perforated diverticular disease of the left colon that was diagnosed laparoscopitally. All patients were treated conservatively by laparoscopic peritoneal lavage and administration of parenteral fluids and antibiotics.
PATIENTS
AND
METHODS
Patients It is the policy of our service that patients with an acute abdominal process, other than that with a vascular cause, who are clinically selected for surgery, are initially subjected to laparoscopy, provided it is not contraindicated by gross intestinal dilatation or previous extensive intraperitoneal surgery. Over a 37-month period, July 1991 to August 1994, 8 patients presented with generalized peritonitis due to perforated diverticular disease of the left colon.. Each patient was given intravenous fluids and antibiotics, and when adequately resuscitated, was taken to the operating room for laparoscopy. Although in all adult patients with a clinical diagnosis of generalized peritonitis, perforated diverticular disease is considered a possible diagnosis, such a diagnosis was not established prior to laparoscopy in :any of these 8 patients. Prior to this period, each of these patients would have been managed by open surgery. Four additional patients with protracted lower abdominal pain and pyrexia were found on laparoscopy to have acute diverticulitis without peritonitis. These patien.ts were treated by conservative management and are not discussed further. During this period, a 57-year-old woman, with a history of vagotomy and drainage, reflux esophageal stricture, and rheumatoid arthritis, who was taking steroid medications, presented with generalized peritonitis, pneumoperitoneum, and cardiovascular collapse. This patient did not receive a laparoscopy and was found at open surgery to have fecal peritonitis due to a large perforation of the sigmoid colon. This was treated by excision and left iliac colostomy with subsequent complete recovery. Methods Abdominal insufflation was performed with carbon dioxide gas (via a 6-mm cannula inserted through the subumbilical incision), after which general anesthesia with full muscle relaxation was induced. After initial diagnosis was made, the umbilical port was changed to a lo-mm port to facilitate attachment to a video camera. A second cannula was inserted under direct vision through the lower abdominal wall in the suprapubic or right iliac fossa region, depending on the laparoscopic findings, to facilitate manipulation of the intestines and lavage of the peritoneal cavity. APRIL
1996
) LAPAROSCOPIC
Where necessary to facilitate cleansing of the upper abdomen, the telescope was replaced via the suprapubic port, and the suction/irrigation apparatus via the umbilical port. The peritoneal cavity was thoroughly inspected to rule out alternative causes of peritonitis. Treatment All patients were initially resuscitated with intravenous fluids. Patients were given intravenous metronidazole and cephalosporins before surgery. One patient with a known penicillin hypersensitivity was treated with metronidazole and erythromycin. The intravenous antibiotics were continued for 4 days after surgery, at which time they were changed to oral equivalents. At laparoscopy, the peritoneum was thoroughly and vigorously irrigated with warm 0.9% saline and suctioned clean of purulent material. In 2 patients, a Shirley-type drain was placed laparoscopically in the pelvis, for continued drainage of a pelvic abscess in 1, and to facilitate the sealing of a visible perforation in the other patient, in whom the omentum had been interposed in the pelvis between the sigmoid colon and uterus.
RESULTS Eight patients presented during the 37-month period, of whom 5 were men and 3 women, with a mean age of 57 years (range 30 to 67). All patients complained of abdominal pain and vomiting, and on physical examination, all but 1 had signs of generalized peritonitis. The mean oral temperature on admission was 385°C (range 37.5 to 40.0), with a mean white cell count of 17.9 X 109/L (range 5.2 to 25.3). In 1 female patient, there was radiologic evidence of perforation with free gas under the diaphragm. On laparoscopic examination, each patient had generalized peritonitis with purulent material above and below the liver, in both paracolic gutters, the pelvis, and among loops of bowel. There was thickening of the pelvic colon, which was adherent to the side wall of the pelvis. No patient had evidence of fecal peritonitis. One patient had a small visible perforation, which was seen when the rectosigmoid junction was gently pushed off the posterior wall of the uterus; this patient had free gas under the diaphragm visible on her preoperative chest radiograph. Seven of the 8 patients had a pelvic abscess. Apart from 1 patient who had previously undergone appendectomy, a normal appendix was visualized in all cases. Each patient, therefore, had stage III diverticular disease (generalized purulent peritonitis), under the Hinchey et al’ classification. Six patients recovered fully without complications. One patient developed a myocardial infarction either during or after recovery from anesthesia. This patient had severe angina pectoris prior to surgery and had previously been investigated and found unsuitable for coronary artery revascularization or angioplasty. This patient, the first case in the study, developed an arrhythmia intraoperatively and therefore was treated conservatively by the laparoscopic method. The rapid resolution of his abdominal signs, within 36 hours, and the successful outcome in this case, prompted the further use of this approach in patients with generalized peritonitis due to perforated diverticular disease without fecal contamination. One other patient, a morbidly obese woman, THE
AMERICAN
MANAGEMENT
OF PERITONITIS/O’SULLIVAN
ET AL 1
developed right lower-lobe pneumonia, from which she recovered fully. All patients resumed full diet within 5 to 8 days and were discharged from the hospital within 7 to 17 days, with a mean stay of 10 days. All patients underwent colonoscopy and double-contrast barium enema 1 month after discharge from the hospital, by which time all but 1, the patient with the postoperative myocardial infarction, had returned to normal activities. These studies confirmed diverticular disease in all patients. In 1 patient, the study showed evidence of diverticulitis and a mild degree of stenosis immediately proximal to the rectosigmoid junction. A subsequent repeat study, 6 months later, showed complete resolution of the stenosis. Two patients were readmitted to the hospital at 4 and 8 months with lower abdominal pain; these patients were treated with conservative management. Currently, all patients remain well on followup varying from 12 to 48 months, without further surgical intervention.
COMMENTS This study suggests that suppurative peritonitis due to perforated diverticular disease can be managed safely by peritoneal lavage supplemented by antibiotics and intravenous fluid replacement. This contrasts with the previous policy of this unit, where these patients would have been managed by open surgery and colon resection. Laparoscopy permits an accurate diagnosis in the patient with generalized peritonitis and facilitates appropriate siting of an incision, if necessary, with minimal physiologic disturbance. Fecal contamination or a major perforation, necessitating open surgical intervention, would be detected. In those patients managed by nonoperative measures, reliable decisions based on subsequent sequential clinical examinations of the abdomen are possible without the compounding influence of a major and painful incision. Radiologic investigations, in certain situations, may be of value in elucidating the underlying cause. Plain radiographs, by demonstrating pneumoperitoneum, may indicate a perforation. Although common in those patients with a free perforation, pneumoperitoneum is, not seen in all patients with a perforated intra-abdominal viscus.’ Ultrasonography and computed tomography may show thickening of the bowel wall or abscess formation when it is present. In most cases, however, these features are inconclusive, and the majority of causes remain undiagnosed until direct visualization of the pathologic process, either at laparoscopy or at laparotomy. This is an uncontrolled series, and therefore the therapeutic contribution of laparoscopic suction lavage of the peritoneal cavity is unknown. Removal of purulent material is necessary to facilitate reliable evaluation of the pelvic colon for perforation and to exclude other abnormalities such as acute appendicitis and perforated duodenal ulcer. This maneuver is similar to that performed during open surgery, in this setting, and did not appear to contribute to morbidity in this series. Laparoscopic suction/irrigation was the sole technique used in the treatment of associated pelvic abscesses in 6 patients, thus obviating the necessity for peritoneal drains. Indeed, the pelvic drain placed in 1 case may not have been necessary. JOURNAL
OF SURGERYa
VOLUME
171
APRIL
1996
433
LAPA-
Major colonic perforations are found in a minority of patients presenting with acute, complicated, diverticular disease.6 They often have a catastrophic onset, and plain radiographs may show pneumoperitoneum. At operation they are found to have fecal soiling, with a minimal localizing response. In contrast, most patients with acute suppurative peritonitis do not have a pneumoperitoneum on radiography. At operation they do not have fecal soiling, but rather have inflammation, edema, adhesions, and abscess formation involving the pelvic colon. Our experience suggests that it is possible to assess this latter subset by laparoscopy, and to manage them safely without recourse to open surgery. Colonic resection therefore may be reserved for those patients who have free intraperitoneal perforations, fecal peritonitis, or who fail to respond to nonoperative management. In patients who have emergency left colectomy for generalized fecal peritonitis presumed secondary to perforated diverticular disease, 20% to 25% may actually have an unsuspected carcinoma.‘Therefore, it is our policy that all patients treated for suppurative peritonitis by nonoperative means undergo a complete large-bowel screen as soon as is feasible, usually in 4 to 6 weeks. Suppurative peritonitis due to perforated diverticular disease of the pelvic colon may be managed by laparoscopic peritoneal lavage, antibiotics, and intravenous fluid replace-
434
THE
AMERICAN
JOURNAL
OF SURGERY”
VOLUME
171
ment, provided that fecal soiling or a major perforation is excluded. A major abdominal incision and (colon resection may not be necessary in many of these patients. This approach merits further assessment as an alternative to the traditional open surgical management.
REFERENCES 1. Pain J, Cahill J. Surgical options for left sided large bowel emergencies. Ann R Coil Surg Engl.. 1991;73:394-397. 2. Peoples JB, Vilk D, Maguire JP, Elliott DW. Re:messment of primary resection of the perforated segment for severe colonic diverticulitis. Am J Surg. 1990;159:291-293. 3. Drumm J, Clain A. The management of acute colonic diverticulitis with suppurative peritonitis. Ann R CoU Surg Eng!. 1984;66:90-91. 4. Risholm L. Primary resection in perforated diverticulitis of the colon. World ] Surg. 1982;6:490-491. 5. Gregg R. An ideal operation for diverticulitis of the colon. Am J h-g. 1987;153:285-290. 6. Krukowski ZH, Matheson NA. Acute diverticulitis. Ret Adv Surg. 1988;13;125-141. 7. Hinchey EJ, Schaal PGH, Richards MB. Treatment of perforated diverticulitis of the colon. Adv Surg. 1978;12:85-105. 8. Alanis A, Papanicolaou GK, Tadros RR, Fielding P. Primary resection and anastmosis for treatment of acute diverticulitis. Dis Colon Rectum. 1989;32:933-939, 9. Krukowski ZH, Matheson NA. Emergency surgery for diverticular disease complicated by generalised and faecal peritonitis. Br J Surg. 1984;71:921-927.
APRIL
1996
of Generalized Peritonitis Colonic Diverticula
Gerald C. O’Sullivan, MCh, FRCSI, Dermot Murphy, MB, FRCSI, Michael G. O’Brien, MB, FRCSI, Adrian Ireland, MB, FRCSI, Cork, Ireland
PURPOSE: The use of laparoscopic peritoneal lavage in conjunction with parenteral fluids and antibiotic therapy in the management of generalized peritonitis secondary to perforated diverticular disease of the colon was assessed. PATIENTS AND METHODS: This cohort comprised 8 patients with generalized peritonitis secondary to perforated diverticular disease of the left colon that was diagnosed laparoscopically. All the patients had purulent peritonitis, but no fecal contamination. They were treated with laparoscopic peritoneal lavage and intravenous fluids and antibiotics. RESULTS: All patients made a complete recovery, with resumption of normal diet within 5 to 8 days. No patient has required surgical intervention during a 12- to 48-month follow-up. This approach merits further assessment as an alternative to the traditional open surgical management. Am J Surg. 1998;171:432-434.
eneralized peritonitis due to perforated diverticular disease of the left colon poses a number of distinct, but related, clinical problems. A precise diagnosis is rarely possible without resorting to surgery. Because acute appendicitis seems the most likely cause, many patients are explored through an oblique, right iliac fossa incision, which may be inappropriate to assess or deal with the primary problem. In addition, there is controversy regarding the most effective method of managing the perforated diverticular segment.‘-’ Immediate resection of the involved colonic segment is appropriate where there is a major unsealed perforation and fecal contamination. In the vast majority of patients with generalized peritonitis due to perforated diverticular disease, there is no evidence of fecal contamination, and the perforation is already sealed or cannot be found at surgery.6 In these circumstances, it is unclear whether or not immediate definitive surgery is required, although many surgeons favor this policy, as the patient has already been committed to a laparotomy and abdominal incision.
G
From the Department of Surgery, Mercy Hospital and National Jniversity of Ireland, Cork, Ireland. A video of this technique was shown at M.I.M.S., Florida 1993. Requests for reprints should be addressed to Dr. Gerald C. 3’Sullivan, MCh, FRCSI, Department of Surgery, Mercy Hospital, Cork, Ireland. Manuscript submitted July 3, 1995 and accepted in revised form October 21, 1995.
432
THE
AMERICAN
JOURNAL
OF SURGERY’=
VOLUME
171
In this paper, we report on 8 patients who presented with generalized peritonitis secondary to perforated diverticular disease of the left colon that was diagnosed laparoscopitally. All patients were treated conservatively by laparoscopic peritoneal lavage and administration of parenteral fluids and antibiotics.
PATIENTS
AND
METHODS
Patients It is the policy of our service that patients with an acute abdominal process, other than that with a vascular cause, who are clinically selected for surgery, are initially subjected to laparoscopy, provided it is not contraindicated by gross intestinal dilatation or previous extensive intraperitoneal surgery. Over a 37-month period, July 1991 to August 1994, 8 patients presented with generalized peritonitis due to perforated diverticular disease of the left colon.. Each patient was given intravenous fluids and antibiotics, and when adequately resuscitated, was taken to the operating room for laparoscopy. Although in all adult patients with a clinical diagnosis of generalized peritonitis, perforated diverticular disease is considered a possible diagnosis, such a diagnosis was not established prior to laparoscopy in :any of these 8 patients. Prior to this period, each of these patients would have been managed by open surgery. Four additional patients with protracted lower abdominal pain and pyrexia were found on laparoscopy to have acute diverticulitis without peritonitis. These patien.ts were treated by conservative management and are not discussed further. During this period, a 57-year-old woman, with a history of vagotomy and drainage, reflux esophageal stricture, and rheumatoid arthritis, who was taking steroid medications, presented with generalized peritonitis, pneumoperitoneum, and cardiovascular collapse. This patient did not receive a laparoscopy and was found at open surgery to have fecal peritonitis due to a large perforation of the sigmoid colon. This was treated by excision and left iliac colostomy with subsequent complete recovery. Methods Abdominal insufflation was performed with carbon dioxide gas (via a 6-mm cannula inserted through the subumbilical incision), after which general anesthesia with full muscle relaxation was induced. After initial diagnosis was made, the umbilical port was changed to a lo-mm port to facilitate attachment to a video camera. A second cannula was inserted under direct vision through the lower abdominal wall in the suprapubic or right iliac fossa region, depending on the laparoscopic findings, to facilitate manipulation of the intestines and lavage of the peritoneal cavity. APRIL
1996
) LAPAROSCOPIC
Where necessary to facilitate cleansing of the upper abdomen, the telescope was replaced via the suprapubic port, and the suction/irrigation apparatus via the umbilical port. The peritoneal cavity was thoroughly inspected to rule out alternative causes of peritonitis. Treatment All patients were initially resuscitated with intravenous fluids. Patients were given intravenous metronidazole and cephalosporins before surgery. One patient with a known penicillin hypersensitivity was treated with metronidazole and erythromycin. The intravenous antibiotics were continued for 4 days after surgery, at which time they were changed to oral equivalents. At laparoscopy, the peritoneum was thoroughly and vigorously irrigated with warm 0.9% saline and suctioned clean of purulent material. In 2 patients, a Shirley-type drain was placed laparoscopically in the pelvis, for continued drainage of a pelvic abscess in 1, and to facilitate the sealing of a visible perforation in the other patient, in whom the omentum had been interposed in the pelvis between the sigmoid colon and uterus.
RESULTS Eight patients presented during the 37-month period, of whom 5 were men and 3 women, with a mean age of 57 years (range 30 to 67). All patients complained of abdominal pain and vomiting, and on physical examination, all but 1 had signs of generalized peritonitis. The mean oral temperature on admission was 385°C (range 37.5 to 40.0), with a mean white cell count of 17.9 X 109/L (range 5.2 to 25.3). In 1 female patient, there was radiologic evidence of perforation with free gas under the diaphragm. On laparoscopic examination, each patient had generalized peritonitis with purulent material above and below the liver, in both paracolic gutters, the pelvis, and among loops of bowel. There was thickening of the pelvic colon, which was adherent to the side wall of the pelvis. No patient had evidence of fecal peritonitis. One patient had a small visible perforation, which was seen when the rectosigmoid junction was gently pushed off the posterior wall of the uterus; this patient had free gas under the diaphragm visible on her preoperative chest radiograph. Seven of the 8 patients had a pelvic abscess. Apart from 1 patient who had previously undergone appendectomy, a normal appendix was visualized in all cases. Each patient, therefore, had stage III diverticular disease (generalized purulent peritonitis), under the Hinchey et al’ classification. Six patients recovered fully without complications. One patient developed a myocardial infarction either during or after recovery from anesthesia. This patient had severe angina pectoris prior to surgery and had previously been investigated and found unsuitable for coronary artery revascularization or angioplasty. This patient, the first case in the study, developed an arrhythmia intraoperatively and therefore was treated conservatively by the laparoscopic method. The rapid resolution of his abdominal signs, within 36 hours, and the successful outcome in this case, prompted the further use of this approach in patients with generalized peritonitis due to perforated diverticular disease without fecal contamination. One other patient, a morbidly obese woman, THE
AMERICAN
MANAGEMENT
OF PERITONITIS/O’SULLIVAN
ET AL 1
developed right lower-lobe pneumonia, from which she recovered fully. All patients resumed full diet within 5 to 8 days and were discharged from the hospital within 7 to 17 days, with a mean stay of 10 days. All patients underwent colonoscopy and double-contrast barium enema 1 month after discharge from the hospital, by which time all but 1, the patient with the postoperative myocardial infarction, had returned to normal activities. These studies confirmed diverticular disease in all patients. In 1 patient, the study showed evidence of diverticulitis and a mild degree of stenosis immediately proximal to the rectosigmoid junction. A subsequent repeat study, 6 months later, showed complete resolution of the stenosis. Two patients were readmitted to the hospital at 4 and 8 months with lower abdominal pain; these patients were treated with conservative management. Currently, all patients remain well on followup varying from 12 to 48 months, without further surgical intervention.
COMMENTS This study suggests that suppurative peritonitis due to perforated diverticular disease can be managed safely by peritoneal lavage supplemented by antibiotics and intravenous fluid replacement. This contrasts with the previous policy of this unit, where these patients would have been managed by open surgery and colon resection. Laparoscopy permits an accurate diagnosis in the patient with generalized peritonitis and facilitates appropriate siting of an incision, if necessary, with minimal physiologic disturbance. Fecal contamination or a major perforation, necessitating open surgical intervention, would be detected. In those patients managed by nonoperative measures, reliable decisions based on subsequent sequential clinical examinations of the abdomen are possible without the compounding influence of a major and painful incision. Radiologic investigations, in certain situations, may be of value in elucidating the underlying cause. Plain radiographs, by demonstrating pneumoperitoneum, may indicate a perforation. Although common in those patients with a free perforation, pneumoperitoneum is, not seen in all patients with a perforated intra-abdominal viscus.’ Ultrasonography and computed tomography may show thickening of the bowel wall or abscess formation when it is present. In most cases, however, these features are inconclusive, and the majority of causes remain undiagnosed until direct visualization of the pathologic process, either at laparoscopy or at laparotomy. This is an uncontrolled series, and therefore the therapeutic contribution of laparoscopic suction lavage of the peritoneal cavity is unknown. Removal of purulent material is necessary to facilitate reliable evaluation of the pelvic colon for perforation and to exclude other abnormalities such as acute appendicitis and perforated duodenal ulcer. This maneuver is similar to that performed during open surgery, in this setting, and did not appear to contribute to morbidity in this series. Laparoscopic suction/irrigation was the sole technique used in the treatment of associated pelvic abscesses in 6 patients, thus obviating the necessity for peritoneal drains. Indeed, the pelvic drain placed in 1 case may not have been necessary. JOURNAL
OF SURGERYa
VOLUME
171
APRIL
1996
433
LAPA-
Major colonic perforations are found in a minority of patients presenting with acute, complicated, diverticular disease.6 They often have a catastrophic onset, and plain radiographs may show pneumoperitoneum. At operation they are found to have fecal soiling, with a minimal localizing response. In contrast, most patients with acute suppurative peritonitis do not have a pneumoperitoneum on radiography. At operation they do not have fecal soiling, but rather have inflammation, edema, adhesions, and abscess formation involving the pelvic colon. Our experience suggests that it is possible to assess this latter subset by laparoscopy, and to manage them safely without recourse to open surgery. Colonic resection therefore may be reserved for those patients who have free intraperitoneal perforations, fecal peritonitis, or who fail to respond to nonoperative management. In patients who have emergency left colectomy for generalized fecal peritonitis presumed secondary to perforated diverticular disease, 20% to 25% may actually have an unsuspected carcinoma.‘Therefore, it is our policy that all patients treated for suppurative peritonitis by nonoperative means undergo a complete large-bowel screen as soon as is feasible, usually in 4 to 6 weeks. Suppurative peritonitis due to perforated diverticular disease of the pelvic colon may be managed by laparoscopic peritoneal lavage, antibiotics, and intravenous fluid replace-
434
THE
AMERICAN
JOURNAL
OF SURGERY”
VOLUME
171
ment, provided that fecal soiling or a major perforation is excluded. A major abdominal incision and (colon resection may not be necessary in many of these patients. This approach merits further assessment as an alternative to the traditional open surgical management.
REFERENCES 1. Pain J, Cahill J. Surgical options for left sided large bowel emergencies. Ann R Coil Surg Engl.. 1991;73:394-397. 2. Peoples JB, Vilk D, Maguire JP, Elliott DW. Re:messment of primary resection of the perforated segment for severe colonic diverticulitis. Am J Surg. 1990;159:291-293. 3. Drumm J, Clain A. The management of acute colonic diverticulitis with suppurative peritonitis. Ann R CoU Surg Eng!. 1984;66:90-91. 4. Risholm L. Primary resection in perforated diverticulitis of the colon. World ] Surg. 1982;6:490-491. 5. Gregg R. An ideal operation for diverticulitis of the colon. Am J h-g. 1987;153:285-290. 6. Krukowski ZH, Matheson NA. Acute diverticulitis. Ret Adv Surg. 1988;13;125-141. 7. Hinchey EJ, Schaal PGH, Richards MB. Treatment of perforated diverticulitis of the colon. Adv Surg. 1978;12:85-105. 8. Alanis A, Papanicolaou GK, Tadros RR, Fielding P. Primary resection and anastmosis for treatment of acute diverticulitis. Dis Colon Rectum. 1989;32:933-939, 9. Krukowski ZH, Matheson NA. Emergency surgery for diverticular disease complicated by generalised and faecal peritonitis. Br J Surg. 1984;71:921-927.
APRIL
1996