In this question we are presented with a clinical picture whose manifestations are compatible with acute diverticulitis, already asked on numerous occasions previously. A case of acute diverticulitis complicated with small mesenteric abscess (< 2-3 cm) is presented. Abscesses should be drained by CT-guided percutaneous puncture, since the intra-abdominal approach can spread the contents into the abdominal cavity. However, in small abscesses with Hinchey grade I divertciulitis, in patients without great deterioration of the general condition as in the proposed case, they can be managed by conservative treatment with intravenous antiobiotic therapy and absolute diet, therefore the correct option is 1. The urgent surgical approach should be reserved for cases that present peritonitis (grade III, IV) by resection of the affected segment and primary anastomosis in stable patients or carry out the Hartamn intervention that includes resection with terminal colostomy and closure of the distal rectal stump performing anastomosis in a second surgical time.

In this question we are presented with a clinical picture whose manifestations are compatible with acute diverticulitis, already asked on numerous occasions previously. A case of acute diverticulitis complicated with small mesenteric abscess (< 2-3 cm) is presented. Abscesses should be drained by CT-guided percutaneous puncture, since the intra-abdominal approach can spread the contents into the abdominal cavity. However, in small abscesses with Hinchey grade I divertciulitis, in patients without great deterioration of the general condition as in the proposed case, they can be managed by conservative treatment with intravenous antiobiotic therapy and absolute diet, therefore [HIDDEN]. The urgent surgical approach should be reserved for cases that present peritonitis (grade III, IV) by resection of the affected segment and primary anastomosis in stable patients or carry out the Hartamn intervention that includes resection with terminal colostomy and closure of the distal rectal stump performing anastomosis in a second surgical time.

An 80-year-old woman comes to the emergency department with abdominal pain starting in the epigastrium and radiating later to the left iliac fossa. An abdominal CT scan is performed, showing inflammation of the sigmoid walls and a 2 cm mesenteric abscess. The treatment of choice is:

Admission to the ward with absolute diet and broad-spectrum antibiotic treatment.

Urgent surgery with sigmoidectomy and colorectal anastomosis.

Danish national guidelines for treatment of diverticular disease.

In order to elaborate evidence-based, national Danish guidelines for the treatment of diverticular disease the literature was reviewed concerning the epidemiology, staging, diagnosis and treatment of diverticular disease in all its aspects.  The presence of colonic diverticula, which is considered to be a mucosal herniation through the intestinal muscle wall, is inversely correlated to the intake of dietary fibre. Other factors in the genesis of diverticular disease may be physical inactivity, obesity, and use of NSAIDs or acetaminophen. Diverticulosis is most common in Western countries with a prevalence of 5% in the population aged 30-39 years and 60% in the part of the population > 80 years. The incidence of hospitalization for acute diverticulitis is 71/100,000 and the incidence of complicated diverticulitis is 3.5-4/100,000. Acute diverticulitis is conveniently divided into uncomplicated and complicated diverticulitis. Complicated diverticulitis is staged by the Hinchey classification 1-4 (1: mesocolic/pericolic abscess, 2: pelvic abscess, 3: purulent peritonitis, 4: faecal peritonitis).  Diverticulitis is suspected in case of lower left quadrant abdominal pain and tenderness associated with fever and raised WBC and/or CRP; but the clinical diagnosis is not sufficiently precise. Abdominal CT confirms the diagnosis and enables the classification of the disease according to Hinchey. The distinction between Hinchey 3 and 4 is done by laparoscopy or, when not possible, by laparotomy.  Uncomplicated diverticulitis is treated by conservative means. There is no evidence of any beneficial effect of antibiotics in uncomplicated diverticulitis, but antibiotics may be used in selected cases depending on the overall condition of the patients and the severity of the infection.  Abscess formation is best treated by US- or CT-guided drainage in combination with antibiotics. When the abscess is < 3 cm in diameter, drainage may be unnecessary, and only antibiotics should be instituted.   The surgical treatment of acute perforated diverticulitis has interchanged between resection and non-resection strategies: The three-stage procedure dominating in the beginning of the 20th century was later replaced by the Hartmann procedure or, alternatively, resection of the sigmoid with primary anastomosis. Lately a non-resection strategy consisting of laparoscopy with peritoneal lavage and drainage has been introduced in the treatment of Hinchey stage 3 disease. Evidence so far for the lavage regime is promising, comparing favourably with resection strategies, but lacking in solid proof by randomized, controlled investigations.  In recent years, morbidity has declined in complicated diverticulitis due to improved diagnostics and new treatment modalities. Recurrent diverticulitis is relatively rare and furthermore often uncomplicated than previously assumed. Elective surgery in diverticular disease should probably be limited to symptomatic cases not amenable to conservative measures, since prophylactic resection of the sigmoid, evaluated from present evidence, confers unnecessary risks in terms of morbidity and mortality to the individual as well as unnecessary costs to society. Any recommendation for routine resection following multiple cases of diverticulitis should await results of randomized studies.  Laparoscopic resection is preferred in case of need for elective surgery. When malignancy is ruled out preoperatively, a sigmoid resection with preservation of the inferior mesenteric artery, oral division of colon in soft compliant tissue and anastomosis to upper rectum is recommended.  Fistulae to bladder or vagina, or stenosis of the colon may be dealt with according to symptoms and comorbidity. Resection of the diseased segment of colon is preferred when possible and safe; alternatively, a diverting stoma can be the best solution.

Diverticulitis

Antibiotics Mild uncomplicated diverticulitis without systemic inflammation should not be treated with antibiotics. For mild, uncomplicated, and non-purulent cases of acute diverticulitis, symptomatic treatment, IV fluids, and bowel rest have no worse outcome than surgical intervention in the short and medium term, and appear to have the same outcomes at 24 months. With abscess confirmed by CT scan, some evidence and clinical guidelines tentatively support the use of oral or IV antibiotics for smaller abscesses (<5 cm) without systemic inflammation, but percutaneous or laparoscopic drainage may be necessary for larger abscesses (>5 cm). Emergency surgery is required for perforated diverticulitis with peritonitis.

[Laparoscopic treatment of generalized peritonitis with diverticular perforation of the sigmoid colon. Report of 10 cases].

The classical treatment of perforated sigmoid diverticulitis with generalised peritonitis is based on the principle of two-stage surgical procedures with a temporary initial defunctioning colostomy. This approach is associated with significant morbidity, concerning mainly the abdominal wall. Ten consecutive patients, eight female and two male, with a mean age of 54.6 years, underwent an emergency laparoscopy for generalised peritonitis secondary to perforated diverticula. Six had had previous infectious episodes; six were obese; four were diabetic and two had chronic lung disease. After exploration of the abdominal cavity and discovery of a purulent peritonitis (n = 8) or faecal peritonitis (n = 2), an extensive peritoneal lavage was performed (average 15 litres), the contaminating sigmoid lesion was covered with biological glue and a drain inserted at the site of the lesion. In some cases, drainage of dependent zones was also performed. No colostomies were performed. Antibiotic therapy instituted as soon as the diagnosis had been made was continued, on average, for 7 days. There was no mortality. There was a low morbidity: one case of lymphangitis on catheter and one of broncho-pulmonary infection. No cases of abdominal wall sepsis or residual deep collections were observed. The mean duration of hospitalisation was 8 days. Nine patients underwent a sigmoid resection (laparoscopic in eight cases) 3 to 4 months later, with a mean duration of hospitalisation of 6 days. One conversion to laparotomy was necessary. Laparoscopic treatment of generalised peritonitis secondary to perforated sigmoid diverticulitis constitutes an alternative to classical surgery. It is associated with a decreased morbidity and a marked reduction in duration of the hospitalisation. Colostomy can be avoided and the patient's quality of life is improved during the period previous to secondary colectomy, performed by laparoscopy eight times out of nine. In addition, the cost of this approach is significantly lower.

Same admission colon resection with primary anastomosis for acute diverticulitis.

Current standard of care for complicated diverticulitis includes urgent resection with colostomy versus antibiotic treatment, followed by delayed resection with primary anastomosis at a second admission. In certain circumstances, it is possible to perform resection and anastomosis on the same admission for acute diverticulitis. A retrospective review was completed for patients undergoing surgery for diverticulitis from 1991 to 1998. Groups included: 1) sigmoid resection with primary anastomosis on same admission (n = 18); 2) resection with protective end colostomy (n = 16); and 3) in-patient antibiotic treatment alone, followed by a second admission for resection with primary anastomosis (n = 5). Four patients initially treated with antibiotics worsened symptomatically or developed radiographic evidence of perforation and required resection with colostomy. Five patients in Group 1 had abscesses or contained perforations based on radiographic studies. Findings on CT scans did not predict treatment. Group 1 patients had uneventful recoveries and few minor complications (wound infections and an incisional hernia). One anastomotic leak occurred in Group 2 after colostomy closure. Although there will continue to be a role for emergent operation for diverticulitis, same admission sigmoid resection with primary anastomosis after antibiotic treatment is safe, uses a shorter course of antibiotics, and has a low complication rate.

Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment.

In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of "perforated" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA. The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed. There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas "distant" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23). Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.

Position paper: management of perforated sigmoid diverticulitis.

Over the last three decades, emergency surgery for perforated sigmoid diverticulitis has evolved dramatically but remains controversial. Diverticulitis is categorized as uncomplicated (amenable to outpatient treatment) versus complicated (requiring hospitalization). Patients with complicated diverticulitis undergo computerized tomography (CT) scanning and the CT findings are used categorize the severity of disease. Treatment of stage I (phlegmon with or without small abscess) and stage II (phlegmon with large abscess) diverticulitis (which includes bowel rest, intravenous antibiotics and percutaneous drainage (PCD) of the larger abscesses) has not changed much over last two decades. On the other hand, treatment of stage III (purulent peritonitis) and stage IV (feculent peritonitis) diverticulitis has evolved dramatically and remains morbid. In the 1980s a two stage procedure (1st - segmental sigmoid resection with end colostomy and 2nd - colostomy closure after three to six months) was standard of care for most general surgeons. However, it was recognized that half of these patients never had their colostomy reversed and that colostomy closure was a morbid procedure. As a result starting in the 1990s colorectal surgical specialists increasing performed a one stage primary resection anastomosis (PRA) and demonstrated similar outcomes to the two stage procedure. In the mid 2000s, the colorectal surgeons promoted this as standard of care. But unfortunately despite advances in perioperative care and their excellent surgical skills, PRA for stage III/IV diverticulitis continued to have a high mortality (10-15%). The survivors require prolonged hospital stays and often do not fully recover. Recent case series indicate that a substantial portion of the patients who previously were subjected to emergency sigmoid colectomy can be successfully treated with less invasive nonoperative management with salvage PCD and/or laparoscopic lavage and drainage. These patients experience a surprisingly lower mortality and more rapid recovery. They are also spared the need for a colostomy and do not appear to benefit from a delayed elective sigmoid colectomy. While we await the final results ongoing prospective randomized clinical trials testing these less invasive alternatives, we have proposed (based primarily on case series and our expert opinions) what we believe safe and rationale management strategy.

Septic Shock Secondary to a Pyogenic Liver Abscess Following Complicated Appendicitis.

Pyogenic liver abscesses (PLAs) are a rare condition in North America and Europe and, rarer still, the cause of septic shock. This case report will describe the rare occurrence of a PLA producing septic shock in a 36-year-old male residing in the United Kingdom following a case of complicated appendicitis. The patient presented to the emergency department (ED) with a three-week history of intermittent loose stools, cramping abdominal pain, recurrent fevers, a heart rate of 111 beats per minute, a blood pressure of 94/58 mmHg, and a fever of 40.1 degrees Celsius. Despite prompt broad spectrum antibiotic administration and three liters of fluid resuscitation, the patient remained shocked which led to an ICU admission. A CT scan prior to transfer found a 7 cm x 6 cm x 6 cm lesion representing a liver abscess (LA) as well as gross inflammatory change affecting the distal small bowel. The LA was managed through insertion of a percutaneous drain under ultrasound guidance performed by the interventional radiology team, as well as ongoing IV antibiotics. Following growth of the gut commensal <iStreptococcus constellatus</i from the abscess fluid culture, a colonoscopy was performed which found a severely distorted and inflamed terminal ileum with an impassable stricture, raising not only the suspicion of appendicitis but also Crohn's disease. Following the colonoscopy, after a total of 10 days admission, the patient was allowed to go home with a four-week course of oral co-amoxiclav. After discharge, the patient's case was discussed in the gastroenterology inflammatory bowel disease (IBD) multi-disciplinary team meeting due to concerns raised about possible Crohn's disease from the admission CT and following colonoscopy findings. Given the absence of relevant IBD symptoms, a reassuring outpatient MRI small bowel scan (found considerable resolution of the right iliac fossa inflammatory process) and a fecal calprotectin of 29 four months post discharge (normal=0-51 μg/g), it was concluded the terminal ileum changes were most likely accounted for by a complicated course of appendicitis. When reviewed in a telephone clinic 10 weeks post discharge, he was found to have no persistent gastrointestinal (GI) symptoms and was subsequently discharged. This case highlights the importance of comprehensive imaging and colonoscopy in the work up of those patients with PLAs with no otherwise evident precipitating factor.

[Emergency interventions in complicated colonic diverticulosis].

An account is given in this paper of 480 patients who had been hospitalised for colonic diverticulosis or diverticulitis in the surgical department of the Municipal Waid Hospital of Zurich, between 1970 and 1986. Laparotomy had to be performed on 219 of them (45.6 per cent), among them 84 emergency interventions. The average age of these patients was 70.7 years. Indications for emergency surgery included diffuse or locally delimited peritonitis with abscess development in 72 patients, ileus in ten cases, and massive colon haemorrhage in two. The latter two cases were handled with good success by subtotal colectomy with ileorectostomy and, one of them with the source of bleeding known, by colotomy and suturing of that source of bleeding. Sigmaincontinence resection according to Hartmann has been considered the optional approach since 1977 to diffuse peritonitis and to many cases of ileus (n = 39). In more recent time, anastomosis has been used as primary approach to some patients who survived fibrinous abdominal peritonitis (n = 4). The mortality rate associated with drainage operations according to expectation, has been clearly higher than that following resection, the comparable figures being 32.3 and 17.2 per cent. That has been attributable to non-removal of the septic focus. After all, nowadays combined antibiotic therapy is commonly used for seven to ten days for simultaneous control of both aerobic and anaerobic pathogens. This has become routine practice and involves aminoglycoside, metronidazole, and ampicillin. Overall mortality associated with emergency interventions is clearly higher than that after planned operations, the figures being 22.6 and 4.4 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

[Management of complications of sigmoid diverticulosis].

Computed tomography (CT) with contrast enhancement for vascular and bowel opacification is the reference examination for suspected sigmoid diverticulitis because it makes it possible to confirm the diagnosis and look for signs of severity (pericolic abscess, or presence of air or extraintestinal contrast product). Therapeutic management depends on the patient's general condition and on the severity of the intraperitoneal infection, assessed according to Hinchey's 4-stage classification. For Hinchey stages I and II (pericolic or pelvic abscess), radiologically guided puncture-drainage is an effective treatment, combined with antibiotic therapy. Emergency surgery is only indicated if this drainage fails. Two to three months later, elective prophylactic sigmoidectomy, by laparoscopy, is indicated. In stage III or IV diverticulitis (generalized purulent or fecal peritonitis), the surgical treatment of reference is a Hartmann procedure (sigmoidectomy and left iliac colostomy with closure of the rectal stump). But because of burden of the procedure and the risk of failing to re-establish gastrointestinal continuity, it is preferable, if local conditions allow, to propose resection-anastomosis with a temporary protective stoma. Prophylactic sigmoidectomy is controversial. It is indicated regardless of the number of episodes and regardless of age in patients at high risk of recurrence, that is, those with a complicated clinical form or radiologic signs of severity. There is no consensus for patients aged younger than 75 years with a first uncomplicated episode, for whom the risk of recurrence is also elevated. Finally, for patients older than 50 years with an uncomplicated episode on CT, the role of prophylactic surgery, even after 2 or 3 episodes, has not been demonstrated, because of the very low risk (<5%) of subsequent complications. More than 80% of diverticular hemorrhages stop spontaneously but their rate of recurrence is high (25% of cases) and they sometimes require emergency colectomy.

[Perforated diverticular disease of the left colon. Proposed single-stage left colectomy protected by a three-way lavage and active aspiration tube (di Gullino) positioned inside or below the anastomosis. Experience in 65 cases].

The incidence of perforative diverticulitis of the left colon is steadily increasing. Today the decision is generally taken to perform two-stage surgery: segmentary resection without (Hartmann's operation) or with anastomosis, but protected by a colostomy ("limited intervention"). This study aimed to examine standard colectomy performed in a single operation ("ideal intervention"). Left colectomy with primary ligature of the lower mesenteric artery and vein at the source and outlet, en bloc removal of the colon-mesocolon and immediate transverse colorectal anastomosis. Anastomosis protected by the omentum which is also used to peritonise the retroperitoneum and to wrap around the anastomosis, and anastomosis also protected by the author's three-way lavage and active aspiration tube in either a trans- or subanastomosis and transanal position. Urgency is essential for this single-stage operation, together with massive dose antibiotic treatment limited to the pre- and postoperative stages, but above all peritoneal cleansing using accurate, methodical, repeated and abundant lavage with 8-10-20 or more litres, but only used 500 ml at a time. Of these 65 cases, 40 (62%) were purulent localised peritonitis and 25 (38%) were generalised (14 purulent, 4 fecaloid and 7 fecal). 8 cases (12.3%) underwent surgery in three stages and 16 (24.6%) underwent sigmoidectomy in one or two stages ("limited intervention"), 41 cases (63%) (1985-95, when Gullino's three-way tube became available) underwent standard colectomy in a single stage. Morbidity in 10 cases/65 (15%) and septic mortality in 5 cases/65 (7.7%) (limited to generalised peritonitis alone) only affected patients undergoing "limited interventions", but none of the 41 patients undergoing "ideal intervention". Mortality was significantly influenced by age: 50% of over 80 year-olds, none below 60. Postoperative hospitalisation was 17.1 days (in the first stage) of "limited interventions" and 9.7 days for "ideal interventions". The results argue clearly in favour of the "courageous" ideal colectomy with peritoneal lavage and protection of the colorectal anastomosis using Gullino's three-way tube.

Pyomyoma mimicking tubo-ovarian abscess: Two case reports.

Pyomyoma is an extremely rare complication, defined as an infection of a uterine leiomyoma. We describe two cases of pyomyoma that were initially considered to be tubo-ovarian abscesses but were later diagnosed as pyomyomas and managed with laparoscopic surgery. Case 1 was a 26-year-old nulliparous woman who was previously diagnosed with bilateral endometriomas and presented to the hospital with lower abdominal pain. Magnetic resonance imaging revealed bilateral endometrial cysts and a 4-cm mass consistent with a tubo-ovarian abscess. The patient experienced continuous pain, and the cyst in the left adnexa enlarged; thus, laparoscopic surgery was performed. The cystic tumor in her uterus contained purulent fluid. Therefore, an abscess in the degenerative subserous myoma was diagnosed. Case 2 was a 47-year-old nulliparous woman who had undergone total mastectomy and postoperative radiotherapy for breast cancer. She was undergoing hormone therapy when she presented to the hospital with lower abdominal pain, fever, and increased inflammatory markers. Computed tomography revealed a 7-cm tumor with rim enhancement in her left adnexa; therefore, a tubo-ovarian abscess was suspected. After admission, drainage was performed under transvaginal ultrasound guidance, and antibiotics were administered. However, these treatments did not relieve her abdominal pain. Emergency laparoscopic surgery was performed, and intraoperative findings demonstrated an abscess in the degenerative subserous myoma of the uterus with normal adnexa. Laparoscopic hysterectomy and bilateral salpingectomy were performed. Laparoscopic surgery was effective for both patients. Delayed diagnosis of pyomyoma can result in serious complications. Timely surgery with concomitant antibiotic treatment may facilitate good outcomes.

The Hartmann procedure. First choice or last resort in diverticular disease?

To critique changing trends in the surgical management of diverticular disease. Case series. Two hundred twenty-seven consecutive patients required surgery for diverticular disease from 1988 to 1993. Patient records were reviewed retrospectively. Operative procedures included primary resection in all patients with either anastomosis, anastomosis with proximal ileostomy, or the Hartmann procedure. Morbidity, mortality, and length of stay were then compared with each operative procedure and stage of disease. Patients were categorized according to the following pathologic stages: stage 0, no inflammation; stage I, chronic inflammation; stage II, acute inflammation with or without microabscesses; stage III, pericolonic or mesenteric abscess; stage IV, pelvic abscess; and stage V, purulent or feculent peritonitis. A university hospital and private affiliated hospitals in a large metropolitan area. Study outcome parameters included mortality, morbidity, length of hospital stay, and leak rates. These outcomes were then compared with different disease stages and treatments. Mean patient age was 66 years (range, 25-98 years). Male-female ratio was 84:143. Mean follow-up was 23 months (range, 1-132 months). There were 50 fistulas: 24 colovesical, 21 colovaginal, 3 colocolonic, 1 coloenteric, and 1 colouterine. Surgery was categorized as elective for 196 patients (86%), urgent for 12 (5%), and emergent for 19 (8%). Primary resection was performed in all cases. Primary anastomosis was performed in 200 patients (88%), 183 without and 17 with proximal diversion. Twenty-seven patients (12%) underwent a Hartmann procedure with colostomy; 19 patients (70%) have since undergone colostomy closure. Morbidity occurred in 52 patients (23%), including 4 anastomotic leaks (2%). There were 3 perioperative deaths (1%). Mean length of initial hospital stay was 11 days (range, 4-59 days). Length of stay was 5 days (range, 4-7 days) for ileostomy closure (7% morbidity) and 13 days (range, 7-35 days) for the colostomy closure after the Hartmann procedure (33% morbidity). Primary resection is virtually always possible in complicated diverticular disease. Primary anastomosis, with or without proximal diversion, is safe for patients with no abscesses or localized abscesses and should be considered on an individual basis for patients with pelvic abscesses and peritonitis. Colostomy closure after the Hartmann procedure is associated with significant length of hospitalization and morbidity and leaves one third of patients with permanent stomas.

Hybrid transvaginal natural orifice transluminal endoscopic surgery of radical sigmoidectomy for sigmoid colon cancer.

Transvaginal natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique - "scarless" abdominal operations performed with a multi-channel endoscope passed through a natural orifice (mouth, urethra, anus, vagina etc.) and offers less invasive and more excellent cosmetic results [1]. It is regarded as safe and feasible in patients with benign disease [2,3]. The first case of pure NOTES for sigmoid colon cancer was reported in 2012 [4]. We describe here a case of curatively intended resection for early-stage sigmoid colon cancer using the hybrid transvaginal NOTES approach. This video demonstrates the case of a 52-year-old woman with sigmoid colon cancer treated by hybrid transvaginal NOTES. Her body mass index was 20.4 kg/m<sup2</sup. A laparoscope was inserted above the umbilicus and tumor's position was located. Two 5 mm trocars inserted in the right lower abdominal quadrant were mainly used for the assistant's instruments to provide traction and exposure. A single-port was inserted into the abdominal cavity transvaginally through the colpotomy. Then all the procedures were performed transvaginally with conventional rigid laparoscopic instruments. The sigmoid colon was mobilized using a lateral to medial approach. Then the root of the inferior mesenteric artery and the inferior mesenteric vein were divided with absorbable clips. After complete isolation of the proximal rectum, the rectum was transected 5 cm distal to the lesion with a linear stapler inserted through the single port. The proximal resection margin of descending colon was identified and the transection of the colon was performed. The specimen was removed transvaginally. The colon was then exteriorized and the anvil was fixed in the colon. An end-to-end anastomosis was performed using a circular stapler, and a leak test was done. The operative time and estimated blood loss were 182 min and 50 mL. A 20 cm long segment of sigmoid colon was resected with negative tumor margins, and 16 lymph nodes were harvested. There was no intraoperative or postoperative morbidity. The patient was with out-of-bed activity on day 1, fluid diet on day 2, bowel movement on day3, and the drainage tube and catheter removing on day 4. On day 5, she was discharged. Pathological examination revealed a moderately-differentiated adenocarcinoma: 50 × 45 × 10 mm, with growing into subserosa, without vascular or nervous invasion, pT3N0M0 and pStage IIA. There were two scars less than 5 mm and one scar less than 10 mm visible on the abdominal wall at one month. The patient was alive without recurrence after one year's follow-up. Hybrid transvaginal NOTES of radical sigmoidectomy may be safe and feasible for selected patients with sigmoid colon cancer and give less pain, potentially low rates of complication, faster recovery, and better cosmesis. A future large study is warranted to better evaluate this procedure. Although there are many reasons for skepticism, there is undoubted interest in this field from both surgeon and patient.

[The value of peroperative colonic lavage in urgent colonic surgery. Apropos of 54 patients].

The effects of on-table colonic irrigation followed by primary large bowel resection and anastomosis for emergency left colonic disease were prospectively studied in 54 patients. Eighteen patients had a diverticular sigmoiditis complicated by localized (8) or generalized (4) peritonitis, 6 presented a complete sigmoid obstruction. Thirty six patients had a left colonic occlusive (33) or perforated (3) cancer. Anterograde colonic irrigation was carried out with a mean volume of 7.7 l. All patients received a double or triple antibiotic combination. The anastomosis was handsewn in 33 cases and stapled (Knight-Griffen) in 21. Seven patients with severe peritonitis had a proximal transitory stoma which was closed within 4 months. Two patients (3.7%) died postoperatively, one for anastomotic dehiscence and the second for evisceration. We observed 7 cases of hypothermia (< 34 degrees C) during the irrigation. Six patients developed a sepsis of the surgical wound, 2 a septicemia and l an abscess in the right iliac fossa which was percutaneously drained. All complications had a favourable outcome. This study confirms that in selected cases a single stage surgery for colonic emergencies preceded by on-table irrigation grants good results and is a safe and effective alternative to Hartmann's procedure.

[Surgical treatment of acute diverticulitis. Our experience].

The treatment of the acute diverticulitis is still a stimulating and complex problem sustained by several anatomopathological and clinical factors and the possibility of different therapeutic options, being the operative mortality among 5% and 45%. With the modern technologies it is possible to follow the evolution of the illness so to perform more appropriate therapeutic plan. From 1997 to 2007 we have observed 278 patients with acute diverticulitis. In 219 (78,7%) patients the inflammatory and sub-occlusive condition has been faced with medical therapy, with resolution of the disease in 170 (61%) cases. In 49 (17,6%) patients we have gotten the resolution of the inflammatory disease, but not of the sub-occlusion and therefore we liked to submit them to surgical treatment in election. In 1 case we have found a colovesical fistula. A total of 59 (21,2%) patients with signs of acute abdomen have been submitted to surgery in urgency, within the 24 hours from the hospitalization. We have performed a primary resection with anastomosis and without stoma in all the patients, except in 3 cases in which we have done the Hartmann procedure for the cheap general conditions. We have not recorded intra and postoperative mortality and only in 3 cases we have had a leakage, that has not needed a surgical treatment. In 9 cases we observed infection of the wound, treated with antibiotic therapy. In our experience, performing a surgical procedure, without derivative stoma and manual anastomosis, it seems to be the fittest and less expensive procedure, also in situation of emergency-urgency, without increase of mortality and morbidity.

Elective laparoscopically assisted sigmoidectomy for the sigmoid volvulus.

The laparoscopic approach for the treatment of sigmoid volvulus has been a rare surgical indication. This phase 2 study investigated the feasibility and surgical outcomes of elective laparoscopic surgery for sigmoid volvulus. Patients with sigmoid volvulus were first offered colonoscopic decompression for their acute colonic obstruction. If the colonic decompression was successful, complete bowel preparation was performed, followed by elective laparoscopically assisted sigmoidectomy. The details of the laparoscopic procedures are shown in the video. Briefly, the redundant sigmoid colon is totally mobilized by a laparoscopic medial-to-lateral dissection sequence, after which it is exteriorized, transected, and reconstructed by end-to-end anastomosis. In the authors' experience, the medial-to-lateral approach is highly efficient for the laparoscopic mobilization of the redundant sigmoid colon. We believe that the longer the lateral abdominal wall attachment of the sigmoid colon is preserved, the better the exposure and the easier the dissection. If the risk of anastomotic leakage is considered high in a specific case, protective ileostomy is selectively preformed. Before entering the current study, the patients were well informed about the advantages and disadvantages of laparoscopic surgery. The enrollment of patients was selective according to the appropriate eligibility criteria. This study was approved by the Institutional Review Board of the National Taiwan University Hospital. The patients' clinicopathologic data and surgical outcomes were prospectively evaluated. Between August 2001 and April, 2005, a total of 14 patients (10 men and 4 women) with sigmoid volvulus were treated with the described procedure. The age distribution of the patients was 68.4 +/- 12.2 years. The attack of sigmoid volvulus was the first episode for eight patients, the second episode for 4 patients, and the third episode (or more) for two patients. The body mass index (BMI) of the patients was 26.8 +/- 4.4 kg/m(2). The physical status (classification of American Society of Anesthesiology [ASA]) was 1 for five patients, 2 for eight patients, and 3 for 1 patient. During the laparoscopy, all the patients presented with the pathognomonic findings of sigmoid volvulus including redundant sigmoid colon, narrow sigmoid mesenteric pedicle, and mesosigmoiditis with mesenteric fibrosis and scarring, as shown in the video. The length of the resected colon was 32 +/- 6 cm. The operation time was 194.6 +/- 32.4 min, and the blood loss was 44.0 +/- 12.4 ml. The abdominal wound consisted of four 5 to 12 mm working ports and a 5 cm major wound for exteriorization of the sigmoid colon. Some surgeons have shown that a sigmoid volvulus can be resected through a 5-cm left lower quadrant incision with very little mobilization of the colon because of its redundancy. In this context, the laparoscopic approach competed with the minilaparotomy method in terms of adequate sigmoid resection, lysis of mesosigmoid adhesion, and tension-free colorectal anastomosis. Protective ileostomy was performed for the only patient with a physical status of ASA 3. There was no mortality in this case series. However, pneumonia developed postoperatively in one patient, acute myocardial infarction in one patient, and wound infection in two patients. Excluding the two patients who experienced postoperative pneumonia and acute myocardial infarction, the duration of the postoperative ileus was 48 +/- 12 h, the postoperative hospitalization was 7 +/- 1 days, and the degree of postoperative pain was 3.5 +/- 0.5 according to the visual analog scale. The return to partial activity required 18 +/- 2.5 days, and the return to full activity required 28.4 +/- 5.6 days. As compared with the overall costs for a conventional sigmoid colectomy, which are completely covered by the National Bureau of Health Insurance of Taiwan, the expenses for the patients undergoing laparoscopic procedures were significantly higher by approximately 24,000.0 NT dollars +/- 2,635.0 (1 U.S. dollar = 32 NT dollars). These higher expenses must be borne by the patients themselves. Considering that patients with sigmoid volvulus often are elderly and chronically ill, laparoscopic elective surgery after a successful colonoscopic decompression may be a good choice for a selected group of patients in terms of minimized surgical complications and quick convalescence.

Outpatient treatment in uncomplicated acute diverticulitis: 5-year experience.

Most cases of diverticular inflammation are mild and require only medical treatment with liquid diet and antibiotics. Until recently, this treatment required admission to hospitals, which consequently entailed costs. In most cases, treatment was conservative, and less than a quarter of patients admitted actually underwent surgery. In the last year, the outpatient treatment of these patients with uncomplicated diverticulitis has proven effective and safe. The aim of the present study was to describe our experience after 5 years of outpatient treatment with oral antibiotics. We conducted a retrospective revision study between January 2010 and December 2014. We included all patients admitted to the Emergency Department of the University General Hospital of Elche with a diagnosis of uncomplicated acute diverticulitis based on medical history, physical examination and abdominopelvic computed tomography (CT) scanning. Outpatient treatment consisted of oral antibiotics for 10 days (metronidazole 500 mg/8 h and ciprofloxacin 500 mg/12 h), a liquid diet and oral analgesics (acetaminophen 1 g/6 h). During the period from January 2010 to December 2014, 224 patients were treated on an outpatient basis at a success rate of over 92%. Only 18 patients (8%) required admission after outpatient treatment. Outpatient treatment of uncomplicated acute diverticulitis was demonstrated to be safe and effective.

Psoas muscle abscess simulating acute appendicits: A case report.

Psoas abscess is a rare clinical entity with vague symptomatology. We report a psoas abscess that simulated symptoms of acute appendicitis. A twenty-five year old male presented pain irradiating to the right iliac fossa and lumbar region associated with thigh flexion. Laboratorial exams revealed leukocytosis with a neutrophil shift to the left. Abdominal Ultrasound showed significant intestinal distension and a small quantity of free fluid at the right iliac fossa. Laparotomy and an appendectomy were performed. During immediate post-operative, the patient evolved with worsening of the pain and the leukocytosis, therefore, we chose to maintain his antalgic posture. An abdominal Computerized Tomography scan with contrast was solicited, revealing an increase of the iliac and psoas muscles of the right side, and multiple bacterial focuses. A retroperitoneal access was performed and 300ml of purulent secretion was drained. Afterwards, we implanted a Penrose Drain. The patient had a good post-op evolution, being discharged 7days after the drainage. The psoas muscle is a flexor of the thigh. Psoas abscess is an underdiagnosed condition, its main treatment is surgery associated with antibiotic therapy. CT scan seems to be the best choice of diagnostic image exam, although some authors prefer the nuclear magnetic resonance. The psoas muscle abscess is uncommon and poorly characterized in its etiology, clinical associations, and its therapeutic approach. On the other hand, acute appendicitis is the most common abdominal emergency, with a 7% death rate, and surgery is its main treatment.

Emergency laparoscopic surgery for complicated diverticular disease.

The aim of this study was to analyse the outcome of emergency laparoscopic surgical management of complicated diverticular disease. A prospectively collected electronic database of all colorectal laparoscopic procedures between April 2001 and September 2007 has been used to identify outcomes in patients presenting with complicated diverticular disease. Sixty-six patients (28 men), median age 69 years (23-95), ASA grade II (12), III (38), IV (16) have undergone emergency surgery for complicated diverticulitis--Hinchey grades I (27), II (29), III (7) and diverticular bleeding (3) over a 6(1/2)-year period: 43 high anterior resections, 17 Hartmann's resections and seven low anterior resections. Diverticular fistulas were seen in 16 patients: colovaginal (7), colovesical (2), colo-fallopian (4), entero-colic (3). The median operation time was 110 min (45-195 min). There was one conversion to open surgery. Postoperative analgesia was provided by intravenous Paracetamol in 33 patients (50%), patient-controlled analgesia in 24 (36%), oral Paracetamol and Oramorph (12%) and epidural opioid infusion (1.5%). The median time to normal diet was 24 h (4 h-6 days) and median hospital stay 5 days (2-30). There were two deaths (3.3%); anastomotic leak, ventricular fibrillation (VF) cardiac arrest. Other complications included: wound infection eight (12%), anastomotic leak four (8%), port-site hernia one and one case of Clostridium difficile colitis requiring colectomy. There were five (7.5%) returns to theatre and two readmissions (3%). Laparoscopic resectional surgery in complicated diverticular disease is a feasible, safe and a largely predictable operation that allows for early hospital discharge and, in our opinion, improved patient care. We are encouraged to continue to offer our patients the option of an emergency laparoscopic resection.

[Two cases of curative resection by laparoscopic surgery following preoperative chemotherapy with bevacizumab for locally advanced colon cancer].

Here we report 2 cases of curative resection following preoperative chemotherapy with bevacizumab for locally advanced colon cancer. Case 1 was a 62-year-old man admitted with constipation, abdominal distention, and abdominal pain. An abdominal computed tomography(CT)scan revealed an obstructive tumor of the sigmoid colon with invasion into the bladder. A diverting colostomy was performed, and chemotherapy with mFOLFOX6(infusional 5-fluorouracil/Leucovorin+ oxaliplatin) plus bevacizumab was initiated. The tumor shrunk markedly after 6 courses of this treatment. Thereafter, laparoscopy- assisted sigmoidectomy was successfully performed. Case 2 was a 61-year-old woman admitted with diarrhea, abdominal pain, and fever. An abdominal CT scan revealed an obstructive tumor of the sigmoid colon with invasion into the ileum, uterus and retroperitoneum. A diverting colostomy was performed, and chemotherapy with XELOX(capecitabine+ oxaliplatin)plus bevacizumab was initiated. The tumor shrunk markedly after 6 courses of this treatment. Thereafter, laparoscopy- assisted sigmoidectomy was successfully performed. Both cases demonstrated partial clinical responses to chemotherapy; thus, curative resection surgeries were performed. There were no perioperative complications. Therefore, we conclude that oxaliplatin-based chemotherapy plus bevacizumab and laparoscopic resection could be very effective for locally advanced colon cancer.

[Surgical tactics in complicated sigmoid diverticulitis].

Between January 1972 and February 1988 139 admissions (136 patients) for diverticulitis were registered. Treatment remained conservative in 47 cases. 23 cases underwent elective surgery. In 69 patients emergency-laparotomy had to be done. In 41 cases (3 deaths) the abdomen was washed out and drained, followed by a proximal colostomy. In 23 of these patients a free perforation had to be oversewn. 6 patients were treated by Hartmann resection (1 death). Primary resection, anastomosis and proximal colostomy were performed in 15 cases. 3 patients underwent exterritorization and resection. 4 patients with colonic ileus were initially treated by colostomy alone. There were 2 late deaths both from pulmonary embolism. Of the 63 patients who had a colostomy constructed 4 (6.3%) never had the stoma closed. There were 2 persistent stomas in the 41 patients who had a preliminary colostomy alone (4.9%) and the incidence of persistent stoma in 5 patients who had a Hartmann resection was 40% (2 cases). -The three-stage resection makes good results, provided that a free perforation is solidly oversewn to prevent further fecal contamination. Primary resection with anastomosis and proximal colostomy, which is more and more used in suitable cases, considerably shortens duration of treatment. Hartmann resection remains second choice because of the known high incidence of persistent stoma. It is submitted to surgeon's experience to choose at any situation the best procedure regarding age and general state, local findings and extent of peritonitis. With this tactic hospital lethality of emergency operation was 4 of 69 patients (5.8%), overall lethality 6 (8.7%). Intestinal continuity was restored in 94% of surviving patients.

Chronic abdominal pain after laparoscopic hernia repair due to mesh graft migration to the cecum: a case report.

Hernia repair with mesh graft is one of the most common procedures in general surgery. Mesh graft repair is the treatment of choice for umbilical and periumbilical hernias to minimize recurrence. One of the rare but serious complications is mesh graft migration to viscus. These complications can occur months to years after repair and their diagnosis can be challenging as they may present as vague abdominal pain only. A 74-year-old gentleman with multiple medical comorbidities was diagnosed with a para-umbilical hernia after which he underwent a laparoscopic hernia repair at our hospital using a mesh graft with no complications. On postoperative day 10, he presented to the emergency room (ER) complaining of colicky abdominal pain in the right iliac fossa for 1 day associated with diarrhea. A Computed Tomography (CT) scan of the abdomen and pelvis showed diffuse wall thickening of the cecum and terminal ileum with small free air worrisome for perforation. The decision was made in the ER to discharge him home on antibiotics. The patient then returned back multiple times to the ER for the same complaint along with bleeding per rectum for which he underwent further investigations. Months later, the patient presented again with the same symptoms. A CT scan revealed recurrence of a periumbilical hernia and thickening of the medial wall of the cecum with mesh graft material. The patient was then taken to surgery and intra-operative findings revealed migration of almost 50% of the mesh graft size to the cecum and part of the mesh graft was eroding the distal part of ileum just proximal to the ileocecal junction. Adhesolysis and limited right hemicolectomy with ileocolic anastomosis was done. The patient had an uneventful recovery after revisions surgery without any perioperative complications. He was discharged home on postoperative readmission day 5 and followed up at 2 weeks and 3 months without any delayed complications or subjective complaints. It is important to consider mesh graft migration to viscus as a cause of persistent abdominal pain and bleeding per rectum irrespective of the time of presentation post hernia repair.

Surgical options in acute diverticulitis: value of sigmoid resection in dealing with the septic focus.

The outcome of 78 patients hospitalized with acute diverticulitis was analysed to determine the indications for emergency operation and to examine the safety of sigmoid resection. Forty patients improved on medical therapy, but four relapsed soon after discharge. Forty-two (55%) patients had emergency operations for non-resolution of clinical sepsis (25), persistent symptoms or mass (14) and fistula (three). Operations performed were: sigmoid resection and primary anastomosis (23) with covering colostomy (six). Hartmann's operation (10), drainage with/without colostomy (seven) and right hemicolectomy (two). Findings at operation were: abscess (19), phlegmon (14), generalized peritonitis (six), colovesical fistula (three) and chronic diverticulitis (three). Complications included wound infections (six), respiratory complications (five) and one death. Six patients having drainage of the sigmoid inflammation alone as the first operation required subsequent resection, with prolonged and often complicated hospitalization. Minimal morbidity and shorter hospitalization were achieved when sigmoid resection was performed at the initial procedure.

Intraperitoneal abscess after an undetected spilled stone.

Gallbladder perforation with loss of calculi in the abdomen is frequent during laparoscopic cholecystectomy and can cause serious late complications. We report on a 65-year-old woman who underwent laparoscopic cholecystectomy for gallbladder empyema, during which a stone spilled into the peritoneal cavity. The spilled gallstone was not noticed during the initial operation. Three months later, she reported left upper quadrant pain of recent onset without associated symptoms such as fever, nausea, or weight loss. On examination, a palpable 2-cm tender subcutaneous mass was found. Abdominal ultrasound demonstrated an incarcerated hernia, and computed tomography (CT) scan showed an intraperitoneal abscess located in the back of the anterior abdominal wall in the left upper quadrant, which contained a recalcification figure. The patient was brought to surgery, at which time an incision was made over the mass. A chronic abscess in the back of the abdominal wall, also spreading into the subfascial space, was drained, and purulent material was obtained with a large stone, 2.8 cm in diameter, which had become lodged in the rectus abdominis after an undetected stone spillage during laparoscopic cholecystectomy. The patient continued receiving antibiotic treatment for 7 days, recovered well, and was discharged 7 days after drainage of the abscess.

Laparoscopic resection of a sigmoid colon lipoma in a young female patient: A case report and review of the literature.

Lipomas of the sigmoid colon are rare entities. The present case describes a 27-year-old Caucasian woman who underwent a laparoscopic sigmoidectomy following the detection of a giant lipoma. The young patient was referred to the Emergency Department of the University Hospital of Heraklion (Crete, Greece) in May 2013 after experiencing intermittent abdominal cramping during defecation, and altering episodes of diarrhea and constipation. In addition, the patient described the protrusion of a solid tissue mass shaped like a 'champagne bottle cork' from the anus following defecation. These symptoms had been present for 1 month prior to referral. Physical examination was unremarkable. An urgent colonoscopy revealed a polypoid lesion measuring 2.5 cm in diameter in the sigmoid colon, which was located ~12 cm above the anal ring, with a smooth surface and tissue fragility. Tissue samples were obtained and sent for histopathological analysis. Preoperative contrast-enhanced computed tomography was performed urgently and confirmed the presence of a solid mass in the sigmoid colon without enlargement of regional lymph nodes. Following adequate preparation, the patient underwent a laparoscopic sigmoidectomy with intracorporeal termino-terminal colorectal anastomosis, with the use of a circular stapler. The patient had a positive post-operative outcome without complications and was discharged on day 4 post-surgery in an optimal condition. Histopathological examination of the surgical specimen demonstrated a pedunculated lipoma shaped like a 'champagne bottle cork'. The tumor consisted of mature adipose cells. The overlying colonic mucosa showed hyperplastic crypts with regenerative changes. In the lamina propria mild inflammatory infiltration was observed. At 2 years post-surgery, the patient remains asymptomatic without any clinical evidence of recurrence.

Hot Topics in Surgical Management of Acute Diverticulitiss.

In this session different issues for the surgical management of diverticular disease DD) were considered. The first session debated about the antibiotic treatment for acute uncomplicated diverticulitis (AUD), and supports their use selectively rather than routinely in patients with AUD. The second session discussed the best surgical treatment for those patients. Open approach is a valid choice especially in acute setting, while the laparoscopic approach should be individualised according to the level of skills of the surgeon and the risk factors of the patient (such as obesity and state of health at the time of the operation). The third session debated about the peritoneal lavage and drainage, which is still a safe surgical procedure. However, it requires longer follow-up and results of other trials to draw an adequate conclusion. The last session covers the current surgical certainties in managing complicated DD: 1. urgent colectomy has higher mortality in immune-compromised patients, while in elective surgery is comparable with other populations; 2. laparoscopic peritoneal lavage (LPL) should be the choice in young/fit patients; 3. elective resection is safer in an inflammation free interval; 4. laparoscopic resection shows advantages in several outcomes (such as post-operative morbidity and lower stoma and re-operation rate); 5. in Hinchey III/fecal peritonitis, primary sigmoid resection and anastomosis (open or laparoscopic) could be proposed in young/ fit patient; 6. in case of emergency surgery, Hartmann procedure (open or laparoscopic) must be considered in critically ill/unstable patient.

[Laparoscopic treatment of sigmoid colon intussusception secondary to giant submucosal lipoma].

Colonic lipomas have very low frequency, are usually asymptomatic and diagnosis is made incidentally. Seventy-five per cent of lipomas larger than 4 cm are symptomatic, causing abdominal pain, rectal bleeding, obstruction and exceptionally invagination. The resection of invaginated segment is mandatory in cases with invagination and can be performed by laparoscopy when colonic dilation is moderate. We present a 73-year-old man who entered the emergency department complaining of intermitent abdominal pain, rectal bleeding, absence of bowel movements and flatulence, during four days. A CT scan showed a generalized colonic dilation until left lower quadrant. A colo-colonic invagination secondary to an endoluminal lipoma was observed in sigmoid colon. A laparoscopic sigmoidectomy was performed with extracorporeal termino-terminal anastomosis. The postoperative period was uneventful and the patient was discharged from the hospital five days later. A sumbmucous colonic lipoma was diagnosed in the pathological study.

[Sonographic diagnosis of diverticulitis: the burdensome way to acceptance].

Since the middle to the end of the 80 s, the sonographic detection of diverticulitis has been increasingly improved. In a paper including a larger number of patients published in 1992, W. B. Schwerk demonstrated a high sensitivity and specificity. The detection of diverticulitis was the final entry into the chapter of acute abdominal sonography, after the diagnosis of gastrointestinal perforation, acute appendicitis and ureterolithiasis had been achieved with high reliability. Until then, diverticulitis was a classic surgical disease and a contrast enema with water-soluble contrast medium the diagnostic method of choice. Invariably, the radiologist added the well known comment: Cancer of the sigmoid colon cannot be excluded with certainty. What has changed in the 12 years after Schwerk's publication? Many internists practising sonography have discovered the sonographic diagnosis of this condition and, depending on the severity, treat the less complicated cases with intravenous antibiotics and parental nutrition or with oral antibiotics and low-ballast diet. Soon, abscesses were healed with sonographically guided aspiration and drainage. For a long time, the older generation of surgeons stayed with contrast enemas and prolonged parenteral therapy and, in case of complications, surgical interventions, though surgeons early recognized the diagnostic contribution of sonography. Influenced by radiologists and the Anglo-American literature, surgeons increasingly used computed tomography (CT) as standard method for the initial diagnostic work-up for the last five to eight years. A physician dedicated to gastrointestinal sonography cannot accept this approach, in particular, since sonography is easy and reliable, provides a reasonable differential diagnosis and was found to help the surgeons. An exception is the deep-seated diverticulitis in the sometimes barely accessible distal sigmoid colon. Furthermore, an experienced clinician will anyhow proceed to CT in any unexplained discrepancy between clinical and sonographic findings. It reflects the high value given to sonography if our surgical colleagues use this diagnostic method in the primary diagnosis of acute diverticulitis and achieve results that are as good as the results of the expensive and by all criteria more elaborate CT. The extended application of ultrasound for the omentum and in necrotic epiploic appendagitis should be mentioned here as well. Altogether, CT can be easily refrained from in 80 % to 90 % of cases with suspected diverticulitis. In view of the DRG era, this is an important argument, and emphasizes the economic role of sonography, the necessity of correct coding of sonographic procedures and the need of more sonographic training. Only quality will increase the acceptance of sonography as diagnostic tool as repeatedly demanded and presented in this journal. If this fails, it is highly likely that the diagnostic potential of sonography will remain unexploited or, under the best of circumstances, rediscovered after a 5-year expiration date in a new literature search in 10 years.

Sterile abdominal abscess resulting from remnant laparoscopic clips after sigmoidectomy: a case report and literature review.

The occurrence of intra-abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74-year-old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine-needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory-white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.

Meckel's diverticulum abscess in the elderly population: A case report.

and importance: Meckel's Diverticulum (MD) is the most usual congenital anatomic abnormality of the gastrointestinal tract. It is present in almost 2% of the population and it rarely becomes symptomatic in adults. Herein, we report a rare case of an elderly woman with MD, its diagnostic algorithm and treatment, pointing out the significance of this pathology in the differential diagnosis of right lower quadrant pain. A 75-year-old woman presented in the emergency department due to sudden right lower quadrant abdominal pain and fever. After a comprehensive clinical and imaging evaluation, a diagnostic laparoscopy under general was performed. The appendix presented without inflammation, and a MD abscess was found about 50cm from the ileocaecal valve. The resection of the MD abscess, the appendix and the gallbladder (due to synchronous chololithiasis) were performed. The patient had an uncomplicated post-operative course and she was discharged from hospital on the fifth postoperative day after having been fed and mobilized enough. A complicated MD can be a life-threatening situation. Generally, the MD cannot be easily diagnosed through obtaining patient's medical history, clinical examination and laboratory testing and it is undiagnosed to up to 60% of the cases, while it is usually an incidental finding during a diagnostic laparoscopy or laparotomy. Clinicians should be aware that MD complications in the elderly population can vary. However, having under consideration the very low but true possibility of the MD in the old age may lead to an early and accurate diagnosis.

Four cases of laparoscopic colectomy for sigmoid colon and rectal cancer with persistent descending mesocolon.

Persistent descending mesocolon (PDM) is a congenital anomaly associated with the failure of fixation of the descending colon to the lateral abdominal wall. In the laparoscopic colectomy for colorectal cancer, it has been noticed that there are extensive adhesions and a distinctive anatomy of colonic vessels in cases with PDM. Therefore, it is necessary to have sufficient knowledge about PDM so that it can be appropriately treated during surgery. Case 1-a 79-year-old man underwent laparoscopic intersphincteric resection for rectal cancer. Preoperative barium enema (BE) revealed that the sigmoid colon was located at the right side of the abdomen. An enhanced computed tomography (CT) showed that the common trunk of the left colic artery (LCA) and the first sigmoid colonic artery (S1) branched from the inferior mesenteric artery (IMA). Case 2-a 68-year-old man underwent laparoscopic sigmoidectomy for sigmoid colon cancer and laparoscopic distal gastrectomy for gastric cancer synchronously. BE showed that the descending colon ran from the splenic flexure to medial caudal side. An enhanced CT showed that the distance from the LCA to the marginal artery was 1.0 cm. Case 3-a 68-year-old man underwent laparoscopic low anterior resection for rectal cancer. BE showed that the descending colon ran to the medial caudal side. An enhanced CT showed that the mesentery of the descending colon was comparatively shortened. Case 4-a 60-year-old man underwent laparoscopic sigmoidectomy for sigmoid colon cancer. An enhanced CT showed that the descending colon ran to the medial caudal side and predicted that the LCA and S1 formed a common trunk and branched radially from the IMA. We reported four cases with PDM recognized preoperatively as above. Three cases had a shortening of the mesocolon. While dissecting the vessels, although special attention was required to maintain the blood flow to the intestine, none of these cases developed any complications during the postoperative course. We considered that it is important to have positional awareness of the LCA and the marginal artery to perform the laparoscopic surgery safely when a colorectal cancer with PDM is diagnosed preoperatively using imaging methods.

Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis.

The severity of acute diverticulitis ranges from mild, simple inflammation to pericolic abscesses, or perforation with faeculent peritonitis. Treatment of diverticulitis has evolved towards more conservative and minimally invasive strategies. The aim of this review is to highlight recent concepts and advances in management. A literature review was performed on the electronic databases MEDLINE from PubMed, Embase and the Cochrane Library for publications in English. The keywords 'diverticulitis', 'diverticular' were searched for the past decade (to September 2013). Diverticulitis occurs frequently in the Western world, but only one in five patients develops complications (such as abscess and perforation) during the first acute presentation. The reported perforation rate is 3.5 per 100,000 population. Based on recent data, including the AVOD and DIVER trials, antibiotic therapy for mild episodes may be unnecessary and outpatient management reasonable in most patients. Antibiotics and admission to hospital is required for complicated diverticulitis confirmed on imaging and for patients with sepsis. Diverticular abscesses (about 5 per cent of patients) may require percutaneous drainage if antibiotics alone fail. Laparoscopic management of non-faecal perforated diverticulitis is feasible in selected patients, and peritoneal lavage in combination with antibiotic therapy may avoid colonic resection and a stoma. However, the collective, published worldwide experience is limited to fewer than 800 patients, and results from ongoing randomized trials (LapLAND, SCANDIV, DILALA and LADIES trials) are needed to inform better decision-making. The treatment of diverticulitis continues to evolve with a trend towards a more conservative and minimally invasive management approach. Judicious use of antibiotics in uncomplicated cases, greater application of laparoscopic techniques, and primary resection and anastomosis are of benefit in selected patients.