Surgical-Pathological Conference
Date：
Speaker：R
/
/
CR
（M /D/00）
VS
I、Basic Data：
Gender：
Age：
Chart No：
Date of admission：
Final diagnosis：
Date of operation：
Occupation:
Education:
II、Chief Complaints：
III、Brief History：（Including P.H.）
IV、Physical Examination：
V、Laboratory Data and Images Study：
VI、Course and Treatment ：（Including operation procedure）
VII、Discussions：(請以文章形式書寫，勿用條列式，同時引用的文獻，請於
Discussions 當中加入索引編號，如下頁範本所示。)
VIII、References：
說明：
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2. I-VI 部分請案例單位完成，VII 以後請組織病理科完成。
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，完
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範例 7. 爲增進現場互動，簡報檔一開始請勿直接公佈 Final diagnosis，但 protocol
仍需列出，印製時會刪除。
VII、Discussions：
Colonic diverticula (diverticulosis) are present in about 20~30 % of general
population, with increased prevalence in older adults. The frequency of diverticulosis
is about 5% in patients aged 30-39 years and increases to 60% in those over 80 years
old. (1) Diverticula of the right colon are more common among Eastern populations,
whereas in Western populations the left colon is the anatomical location of
diverticula in the great majority of cases. (2, 3) The formation of colon diverticula is
related to deficiency in vegetable fiber in the diet. Its possible mechanism is
structural changes in the colon wall with hyperelastosis related to ageing and
disordered motility. When segmentation of the narrow-caliber colon occurs with high
intraluminal pressure, the colonic mucosa protrudes. The protrusion occurs at weak
points where the terminal arterial branches penetrate the circular muscle adjacent to
the taenia.
Diverticulitis, defined as inflammation and/or infection of diverticula, is the most
common clinical complication of diverticulosis. It occurs when inspissation of stool
in the neck of a diverticulum induced local bacterial proliferation and inflammation
in the surrounding colon wall. It is estimated that approximately 10~30% of all
patients that develop diverticula will have diverticulitis. And it will recur in about
22% of all patients that develop diverticulitis. More recurrences are found in patients
less than 50 years old, so more primary operations are performed in patients less than
50 years old and operation was suggested after two episodes of acute diverticulitis. (4)
However, previous reports about colonic diverticulitis almost focused on left colon
due to majority of diverticula located in left colon in Western populations. The right
colon diverticulitis was rare in Western countries. Its symptoms and signs are similar
to acute appendicitis. It is about one case for every 300 cases of appendicitis occurs
in Western countries compares to a ratio of 1/40~1/180 in Asia. Conservative
treatment was suggested in noncomplicated cases and surgery was suggested for
complicated diseases such as abscess, localized perforation or generalized peritonitis.
(5)
The evaluation tools of colonic diverticulitis include sonography, CT and the
water-soluble contrast enema. Sonography was proved effective in detecting acute
right colonic diverticulitis with a sensitivity of 91.3% and overall accuracy of 99.5%.
(6)
But CT was demonstrated the better radiological exam of colon diverticulitis
because its higher sensitivity then water-soluble contrast enema (98% vs. 92%) and
higher performance in the detection of severe infection. (7) The CT findings of
diverticulitis include bowel wall thickening, increased soft tissue density, phlegmon
or abscess and extraluminal air. And CT can help to the decision making about when
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to operate.
The management of acute right colonic diverticulitis had some controversy before
due to less case numbers. Recent studies in Asia also had different opinions. Fang et
al in Taiwan (2003) recommended aggressive surgical resection for patients with a
cecal diverticulitis and no resection only in uncomplicated patients whose diagnosis
is in doubt, because less than half patients had successful conservative treatment. (8)
But Komuta et al in Japan (2004) suggested medical treatment alone for acute
uncomplicated right colon diverticulitis due to high success rate of conservative
treatment for first attack and recurrence. (9) Broderick-Villa et al (2005) thought
routine elective colectomy is unnecessary, because only first recurrence predicted
rerecurrences. (10) Yang et al in Taiwan (2006) suggested that colectomy is indicated
for complications or suspected malignancy. (11) Leung et al in Hong Kong (2007)
demonstrated emergent colectomy for uncomplicated right colon diverticulitis had
higher complication rate and slower recovery, and they suggested minimal surgery
for uncomplicated cases. (12) According to previous studies, surgery to complicated
cases and conservative treatment initially for noncomplicated cases are the best
choices. But when to operate for recurrent patients and which surgical procedure
better are still controversial.
We retrospectively reviewed the data of the patients who received laparoscopic
right hemicolectomy for complicated right colon diverticulitis in Far Eastern
Memorial Hospital. From October 2002 to September 2007, 16 patients were
retrieved. The male-female ratio is 7:9. The mean age is 47.1 (range 26 to 78). Ten
patients received emergent operation and 6 received elective operation. The
diagnostic tools included LGI barium studies for elective patients and computed
tomography for emergency operation in most patients. Eight patients presented with
acute perforation with local abscess, 6 patients presented with severe local
inflammatory change and 2 patients presented with repeat attack of diverticulitis.
There were only 5 patients who had leukocytosis before operation, and there was no
septic shock before operation. The procedure of laparoscopic right hemicolectomy is
uniform. We created one 1cm wound in periumbilical area for endoscope, and three
0.5cm wounds in subxyphoid area, lower mid-abdomen and right lower abdomen for
manipulation. After mobilization of right colon laparoscopically, the periumbilical
wound was extended to 3~ 4 cm for specimen retrieval and primary hand sewn
anastomosis. The mean length of postoperative hospital stay is 7 days (range 6 to 10
days). The mean operation time is 148 minutes. The mean blood loss is 44.3 ml. All
procedures were completed laparoscopically without open conversion. There was no
anastomosis leakage but wound infection developed in 5 patients.
We concluded that laparoscopic right hemicolectomy for complicated right colon
diverticulitis is feasible with acceptable outcome. Preoperative CT scan is indicated
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in patients with delayed or atypical presenting right side abdominal pain or in patients
with old age. Surgical treatment for complicated right colon diverticulitis needs to be
further defined especially in the era of laparoscopy.
VIII、References：
1. Peppas G, Bliziotis IA, Oikonomaki D, et al. Outcomes after medical and surgical
treatment of diverticulitis: a systematic review of the available evidence. J
Gastroenterol Hepatol 2007; 22: 1360-8
2. Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular
disease. Ann Surg 1984; 200: 466-78
3. Chia JG, Wilde CC, Ngoi SS, et al. Trends of diverticular disease of the large
bowel in a newly developed country. Dis Colon Rectum 1991; 34: 498-501
4. Makela J, Vuolio S, Kiviniemi H, et al. Natural history of diverticular disease:
when to operate? Dis Colon Rectum 1998; 41: 1523-8
5. Le P, Blondon H, Billey C. Right colon diverticulitis. J Chir 2004; 141: 11-20
6. Chou YH, Chiou HJ, Tiu CM, et al. Sonography of acute right side colonic
diverticulitis. Am J Surg 2001; 181: 122-7
7. Ambrosetti P, Becker C, Terrier F. Colonic diverticulitis: impact of imaging on
surgical management – a prospective study of 542 patients. Eru Radiol 2002; 12:
1145-9
8. Fang JF, Chen RJ, Lin BC, et al. Aggressive resection is indicated for cecal
diverticulitis. Am J Surg 2003; 185: 135-40
9. Komuta K, Yamanaka S, Okada K, et al. Toward therapeutic guidelines for
patients with acute right colonic diverticulitis. Am J Surg 2004; 187: 233-7
10.Broderick-Villa G, Burchette RJ, Collins JC, et al. Hospitalization for acute
diverticulitis does not mandate routine elective colectomy. Arch Surg 2005; 140:
576-81
11.Yang HR, Huang HH, Wang YC, et al. Management of right colon diverticulitis: a
10-year experience. World J Surg 2006; 30: 1929-34
12.Leung WW, Lee JF, Liu SY, et al. Critical appraisal on the role and outcome of
emergency colectomy for uncomplicated right-sided colonic diverticulitis. World J
Surg 2007; 31: 383-7
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