gastrointestinal tract and abdomen
DIVERTICULAR DISEASE
John P. Welch, MD, FACS, and Jeffrey L. Cohen, MD, FACS, FASCRS*
Diverticula are small (0.5 to 1.0 cm in diameter) outpouch-
ings of the colon that occur in rows at sites of vascular
penetration between the single mesenteric taenia and one of
the antimesenteric taeniae. At the sites of most diverticula,
the muscular layer is absent [see Figure 1]. Technically, such
lesions are really pseudodiverticula; true diverticula (which
are much less common than pseudodiverticula) involve
all layers of the bowel wall. Nevertheless, both pseudo-
diverticula and true diverticula are generally referred to as
diverticula.
The sigmoid colon is the most common site of diverticula:
in 90% of patients with diverticulosis, the sigmoid colon is
involved.1 If a diverticulum becomes inflamed as a result
of obstruction by feces or hardened mucus or of mucosal
erosion, a localized perforation (microperforation) may
occur—a process known as diverticulitis. The incidence of
diverticulitis has been estimated to be about 10 to 25% in
patients with colonic diverticula.1 Limited prospective data
suggest that the risk of developing diverticulitis is low in
patients with symptomatic diverticulosis.2 Both diverticulo-
sis and variants of diverticulitis may be subsumed under the
more encompassing term diverticular disease.
The incidence of diverticular disease increases with age.
Diverticula are quite common in elderly patients, being
present in more than 80% of patients older than 85 years.
Vascular Diverticulum
Structure
Antimesenteric
Taenia
Mesenteric
Taenia
Antimesenteric
Epiploic Intertaenial Area
Appendage
Figure 1 Anatomic findings in a segment of colon containing diver-
ticula. Diverticula are located at sites where blood vessels enter the
colonic wall.229
* The authors and editors gratefully acknowledge the contribu-
tions of the previous authors, Rafal Barczak, MD, and Louis
Reines, MD, MBA, to the development and writing of this
review.
© 2014 Decker Intellectual Properties Inc
Consequently, as the population of the United States contin-
ues to age, the overall risk of diverticular complications
continues to increase. Before the 20th century, diverticular
disease was rare in the United States. By 1996, however,
131,000 patients were being admitted to hospitals with
diverticulitis each year.3 Hospitalizations with this diagnosis
are increasing, especially in young patients.4
A diet containing refined carbohydrates and low-fiber
substances, such as is currently widespread in many devel-
oped countries (especially in the West), has been associated
with the emergence of this disease entity. A low-residue diet
facilitates the development of constipation, which can lead
to increased intraluminal pressure in the large bowel. In
addition, elevated elastin levels are commonly noted at
colon wall sites containing diverticula,5 and this change
causes shortening of the taeniae.1 High-pressure zones or
areas of segmentation may develop [see Figure 2], usually in
the sigmoid colon, and diverticula begin to protrude at these
locations.6 If microperforation of a thin-walled diverticulum
takes place, local or, uncommonly, widespread contamina-
tion with fecal organisms may ensue. The pericolic tissue
(typically, the mesentery and the pericolic fat) thus becomes
inflamed, whereas the mucosa tends to remain otherwise
normal, with some peridiverticular inflammation.7
Several factors appear to promote the development of
diverticular disease and its complications, including the
summer season in the United States,8 decreased physical
activity,9,10 obesity,10–12 intake of nonsteroidal antiinflamma-
tory drugs (NSAIDs),13,14 smoking,15,16 and constipation from
any cause (e.g., diet or medications). The well-known West-
ern afflictions cholelithiasis, diverticulosis, and hiatal hernia
frequently occur together (the Saint triad). Obesity has been
Figure 2 A schematic representation of the process termed
segmentation in the colon. It has been theorized that high-pressure
compartments lead to the development of diverticula.230
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gastro diverticular disease — 2

Patient has suspected diverticulitis

History

Characteristic findings include

• Abdominal pain
Management of • Left lower quadrant (LLQ) tenderness
• Irregular bowel habits
Diverticulitis • Fever
Obstruction, abscess, fistula, or free
perforation is indicative of complicated
diverticulitis.

Physical examination

Uncomplicated diverticulitis: LLQ tenderness

with variable guarding and rebound tenderness;
possible mass; bleeding (uncommon); localized
inflammation; possible phlegmon
Complicated diverticulitis: mass; evidence of
fistula; abdominal distention; abdominal
tenderness, marked in cases of free perforation;
hypotension or oliguria; bleeding

Physical signs are mild Physical signs are marked

Manage on outpatient basis.

Obtain complete blood count.
Hospitalize patient.
Place patient on liquid diet.
Institute NPO regimen.
Give oral antibiotics.
Give I.V. antibiotics.
Perform CT scan with
contrast to confirm diagnosis.

Symptoms resolve Symptoms recur Symptoms worsen

Perform colonoscopy Consider surgical

or contrast study. treatment.

Patient has uncomplicated Patient has complicated Patient has other

diverticulitis diverticulitis diagnosis
Consider surgical treatment [See Figure 12.] Treat as appropriate.
if recurrent.
Consider colonoscopy later.

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gastro diverticular disease — 3

associated with the intake of low-fiber diets,17 and growing

numbers of young, obese patients with diverticulitis are
being seen by physicians.18 Consumption of nuts, corn, or
popcorn does not increase the incidence of diverticulitis or
diverticular bleeding.19

Clinical Evaluation

history
Uncomplicated
(Simple) Diverticulitis
The classic symptoms
of uncomplicated acute
diverticulitis are left
lower quadrant abdomi-
nal pain, a low-grade
fever, irregular bowel
habits, and, possibly,
urinary symptoms if the affected colon is adjacent to the
bladder. If the sigmoid colon is highly redundant, pain may
be greatest in the right lower quadrant. Diarrhea or consti-
pation may occur, together with rectal urgency. Vomiting
is not characteristic, and there may have been previous
episodes.20 In the clinical setting, it may be difficult to make
an accurate diagnosis without imaging studies.21
The differential diagnoses are listed here [see Table 1].22 Figure 3 Barium enema shows a napkin-ring carcinoma (arrow) in
Chronic diarrhea, multiple areas of colon involvement, peri- the middle of multiple diverticula in a redundant sigmoid colon.
anal disease, perineal or cutaneous fistulas, or extraintestinal
signs are suggestive of Crohn disease. Rectal bleeding should
raise the possibility of inflammatory bowel disease, isch-
emia, or carcinoma; such bleeding is uncommon with diver- despite the low incidence of diverticula in this segment of
ticulitis alone. Given the prevalence of diverticula, it is the colon. Patients tend to be elderly and to have cardiovas-
not surprising that colon carcinoma may coexist with diver- cular disease and hypertension. Regular intake of NSAIDs
ticular disease [see Figure 3]. However, diverticulitis does may increase the risk of this complication. Although patients
not appear to increase the risk of developing colorectal may lose 1 to 2 units of blood, the bleeding usually ceases
adenomas or carcinomas.23 spontaneously,27 and expeditious operative treatment is
generally not necessary.
Complicated Diverticulitis The most common form of complicated diverticulitis
Some cases of diverticulitis are classified as complicated, involves the development of a pericolic abscess, typically
meaning that the disease process has progressed to obstruc- signaled by high fever, chills, and lassitude. Such abscesses
tion, extensive phlegmon, abscess, fistula, or free perforation may be small and localized or may extend to more distant
[see Figure 4]. Complicated diverticulitis may be particularly sites (e.g., the pelvis). They may be categorized according to
challenging to manage,24 especially because patients usually the Hinchey classification of diverticular perforations,28 in
have no history of diverticulitis.25 Lower gastrointestinal which stage I refers to a localized pericolic abscess and stage
(GI) bleeding is also a complication of diverticular disease in II to a larger mesenteric abscess spreading toward the pelvis
4 to 48% of cases, and in the United States, 33% of acute [see Figure 5]. On rare occasions, an abscess forms in the ret-
lower GI bleeding is caused by diverticulosis.26 When diver- roperitoneal tissues, subsequently extending to distant sites
ticular hemorrhage occurs, it is usually associated with such as the thigh or the flank. The location of the abscess can
diverticulosis rather than with diverticulitis. Approximately be defined precisely by means of computed tomography
50% of diverticular bleeding originates in the right colon, (CT) with contrast.
Some abscesses rupture into adjacent tissues or viscera,
resulting in the formation of fistulas. Recurrent attacks of
Table 1 Differential Diagnoses of diverticulitis may antecede fistula formation.25 The types
Uncomplicated (Simple) Diverticulitis most commonly seen (50 to 65% of cases) are colovesical
fistulas. This complication is less common in women
Gynecologic and urinary disorders
Perforated colon carcinoma
because of the protection afforded by the uterus. Symptoms
Crohn disease of colovesical fistulas tend to involve the urinary tract (e.g.,
Ischemic colitis pneumaturia, hematuria, and urinary frequency). Fecaluria
Epiploic appendagitis is diagnostic of colovesical or enterovesical fistulas. Colo-
Appendicitis vaginal fistulas (which account for 25% of all diverticular

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gastro
Acute Diverticulitis
Perforation
Hemorrhage
Muscular Hypertrophy
Obstruction
Pericolic Abscess
Colovesical
Fistula
Figure 4 Major complications of diverticular disease of the sigmoid
colon.231
fistulas) are usually seen in women who have undergone
hysterectomies. The diseased colon is adherent to the vagi-
nal cuff. Most commonly, patients complain of a foul vagi-
nal discharge; however, some patients present with stool
emanating from the vagina.
About 10% of colon obstructions are attributable to diver-
ticulitis. Acute diverticulitis can cause colonic edema and a
functional obstruction that usually resolves with antibiotic
infusion and bowel rest. Stricture formation is more com-
mon, usually occurring as a consequence of recurrent attacks
of diverticulitis. Circumferential pericolic fibrosis is noted,
and marked angulation of the pelvic colon with adherence
to the pelvic sidewall may be seen. Patients complain of con-
stipation and narrowed stools. Colonoscopy can be difficult
and potentially dangerous in this setting. Differentiating a
diverticular stricture from carcinoma may be impossible by
any means short of resection.
The term malignant diverticulitis has been employed to
describe an extreme form of sigmoid diverticulitis that is
characterized by an extensive phlegmon and inflammatory
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diverticular disease — 4
reaction extending below the peritoneal reflection, with
a tendency toward obstruction and fistula formation.29
Malignant diverticulitis is seen in fewer than 5% of patients
older than 50 years who are operated on for diverticulitis.29
The process is reminiscent of Crohn disease, and CT scans
demonstrate extensive inflammation. The use of this term
should be discouraged as it is unrelated to a neoplastic
process. In this setting, a staged resection might be prefera-
ble to attempting a primary resection through the pelvic
phlegmon. Although the degree of pelvic inflammation may
subside significantly after diversion, the chronic nature of
this entity makes the operation at any time a challenging
undertaking.29
A dangerous but rare complication of acute diverticulitis
(occurring in 1 to 2% of cases) is free perforation,30 which
includes both perforation of a diverticular abscess through-
out the abdomen leading to generalized peritonitis (puru-
lent peritonitis; Hinchey stage III) and free spillage of stool
through an open diverticulum into the peritoneal cavity
(fecal peritonitis; Hinchey stage IV). The incidence of free
perforations may be increasing, at least in the southwestern
United States.31 The overall mortality in this group is
between 20 and 30%, with purulent peritonitis at approxi-
mately 13% and fecal peritonitis at about 43%.30
physical
examination
Uncomplicated
Diverticulitis
Physical examination
reveals localized left
lower quadrant abdomi-
nal tenderness with vari-
able degrees of guarding
and rebound tenderness.
A mass is occasionally
felt. The stool may con-
tain traces of blood, but
gross bleeding is unusual. Localized inflammation of the
perforated diverticulum and the adjacent mesentery is pres-
ent, and a phlegmon may be seen as well. Depending on the
severity of the physical findings, patients may be managed
either as inpatients or outpatients.32
Complicated Diverticulitis
In a patient with a pericolic abscess, a mass may be detect-
able on abdominal, rectal, or pelvic examination. In a patient
with a colovaginal fistula, a site of granulation tissue and
drainage is seen at the apex of the vaginal cuff. When
patients develop obstruction, there may be marked abdomi-
nal distention, usually of slow onset; abdominal tenderness
may or may not be present, but if tears develop in the cecal
taeniae, right lower quadrant tenderness is typically seen. In
a patient with a free perforation, there is marked abdominal
tenderness, usually commencing suddenly in the left lower
quadrant and spreading within hours to the remainder
of the abdomen. Hypotension and oliguria may develop
later. Patients with rectal bleeding usually have no com-
plaints of abdominal pain or tenderness, and they may
be hypovolemic and hypotensive, depending on the rapidity
of the bleeding.
gastro diverticular disease — 5

Localized Pericolic Abscess Large Mesenteric Abscess

(Hinchey Stage I) (Hinchey Stage II)

Free Perforation Free Perforation Causing Fecal Peritonitis

(Hinchey Stage III) (Hinchey Stage IV)

Figure 5 The Hinchey classification divides diverticular perforations into four stages. Mortality increases significantly in stages III and IV.28

Investigative Studies may follow extravasation of barium [see Figure 8 and Figure 9].
Furthermore, in the acute setting, only the left colon should
imaging be evaluated. Carcinoma is suggested by an abrupt transi-
The most useful diagnostic imaging study in the setting tion to an abnormal mucosa over a relatively short segment;
of suspected diverticulitis is a CT scan with oral and rectal diverticulitis is usually characterized by a gradual transition
contrast.33 Localized thickening of the bowel wall or inflam-
mation of the adjacent pericolic fat is suggestive of diver-
ticulitis; extraluminal air or fluid collections are sometimes
seen together with diverticula [see Figure 6]. The most
frequent findings (seen in 70 to 100% of cases) are bowel
wall thickening, fat stranding, and diverticula.34 In some
cases, small abscesses in the mesocolon or bowel wall are
not detected. The diagnosis of carcinoma cannot be excluded
definitively when there is thickening of the bowel wall.
Limited studies show that magnetic resonance imaging
has high sensitivity and specificity for acute diverticulitis,
and this technique does not expose the patient to ionizing
radiation.35
Although CT has tended to replace contrast studies in the
evaluation of diverticulitis,34 the latter may be more useful
in differentiating carcinoma from diverticulitis.36 A contrast
study can also be complementary when the CT scan raises
the suspicion of carcinoma [see Figure 7].33 When diverticuli-
tis is suspected, water-soluble contrast material should be Figure 6 Computed tomographic scan showing thickening of the
used instead of barium because of the complications that sigmoid colon (arrow) caused by acute diverticulitis.

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gastro diverticular disease — 6

a b

Figure 7 (a) Computed tomographic (CT) scan showing a thickened left colonic wall and diverticulum (arrow). Diverticulitis was considered
the most likely diagnosis. (b) CT scan through an adjacent plane showing deformity of the mucosa, suggesting a possible apple-core lesion
(arrow). Subsequent endoscopy revealed a carcinoma that was obstructing the colon almost completely.

into diseased colon over a longer segment, with the mucosa

remaining intact. If the contrast study reveals extravasation
of contrast outlining an abscess cavity [see Figure 9], an
intramural sinus tract, or a fistula, diverticulitis is likely.1
Colonoscopy is avoided when acute diverticulitis is sus-
pected because of the risk of perforation. It may, however,
be done 6 to 8 weeks after the process subsides to rule
out other disorders (e.g., colon cancer) [see Figure 10].
When a patient does not respond to therapy, gentle flexible
sigmoidoscopy may detect a carcinoma or some other

Figure 9 Extravasation into an abscess cavity (arrow) from

Figure 8 Contrast study showing local extravasation from the diverticulitis at the sigmoid colon–descending colon junction in a
sigmoid colon (arrow); a diverticulum is visible. postevacuation film.

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gastro
Figure 10 Colonoscopic view of several sigmoid diverticula reveals
no evidence of active diverticulitis (e.g., edema or narrowing).
abnormality.37,38 If diverticular disease is advanced, the
endoscopic procedure may be difficult; the diverticular
segment must be fully traversed for the examiner to be able
to exclude a neoplasm with confidence. When major lower
GI bleeding occurs, colonoscopy is done to search for
polyps, carcinoma, or a site of diverticular bleeding. In the
case of massive bleeding, selective arteriography is useful
for localizing the source, and superselective embolization
frequently quells the hemorrhage. The actual risk of bowel
ischemia is low when superselective techniques are
employed. Bleeding at the time of arteriography may be
facilitated by the infusion of heparin or urokinase; however,
this is a risky approach that should be taken only when
other attempts at localization have failed and recurrent
bouts of bleeding have occurred.
a
Figure 11 (a) Computed tomographic (CT) scan in a patient with a colovesical fistula showing air in the thickened tract (arrow) adjacent to the
sigmoid colon. (b) CT scan through an adjacent plane showing air in the bladder (arrow) as a result of the fistula. No contrast is present in the
bladder.
diverticular disease — 7
When a colovesical fistula occurs, contrast CT with narrow
cuts in the pelvis can be very helpful. The classic findings
are sigmoid diverticula, thickening of the bladder and the
colon, air in the bladder, opacification of the fistulous tract
and the bladder, and, possibly, an abscess [see Figure 11].
Cystoscopy is less specific, showing possible edema or
erythema at the site of the fistula. A contrast enema helps
rule out malignant disease. The diagnostic tests that are
most useful for detecting colovaginal fistulas are contrast CT
and vaginography via a Foley catheter. Charcoal ingestion
helps confirm the presence of colovesical or colovaginal
fistulas. On rare occasions, colocutaneous fistulas may
develop, causing erythema and breakdown of the skin.
Colouterine fistulas may occur as well; these are also
quite rare.
Management
medical
Uncomplicated diver-
ticulitis is usually man-
aged successfully on
an outpatient basis39 by
instituting a liquid or
low-residue diet and
administering an oral
antibiotic combination
that covers anaerobes and
gram-negative organisms (e.g., ciprofloxacin or amoxicillin–
clavulanic acid with metronidazole or clindamycin) over
a period of 4 to 10 days.40 If patients are admitted to the
hospital, they usually can be discharged expeditiously on
oral antibiotics.41,42 A recent randomized trial, however,
has shown that antibiotic treatment for acute uncomplicated
diverticulitis neither expedited recovery nor prevented
complications or recurrence.43 Provided that symptoms and
signs have subsided, the colon may be evaluated more fully
several weeks later with a contrast study or colonoscopy if
the diagnosis of diverticular disease has not already been
b
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gastro diverticular disease — 8

established. If symptoms worsen, hospitalization should be
considered. Over the long term, patients should be main-
tained on a high-fiber diet, although it may take months
for the diet to have an effect on symptoms. Limited trials
suggest that other substances such as probiotics and antiin-
flammatory agents such as mesalazine may help prevent
recurrent attacks.44,45
If more significant physical findings and symptoms of
toxicity develop, hospitalization is warranted [see Figure 12].
Patients are placed on a nihil per os (NPO) regimen, and
intravenous fluids and antibiotics are administered (e.g., a
third-generation cephalosporin with metronidazole) until
abdominal pain and tenderness have resolved and bowel
function has returned. As a rule, resolution occurs within
several days. If there is clinical evidence of intestinal
obstruction or ileus, a nasogastric tube is placed. In most
cases, ileus-related symptoms resolve with antibiotic
treatment. CT scans are useful for establishing the correct
diagnosis in the emergency department46; furthermore, the
severity of diverticulitis on CT scans predicts the risk of sub-
sequent medical failure. At times surgical judgment over-
rides scan findings: for example, a stable patient with limited
pneumoperitoneum can be treated successfully with antibi-
otics and supportive treatment.47,48 By observing early trends
in the leukocyte count and the maximum temperature in
patients with acute diverticulitis, one can predict whether
they will recover quickly as expected or if they will likely
require prolonged intravenous antibiotics and/or an opera-
tion.49 Following levels of C-reactive protein may help assess
the treatment’s effectiveness.50,51 It has been estimated that
15 to 30% of patients admitted with acute diverticulitis will
require surgical treatment during the same admission.1
If fever and leukocytosis persist despite antibiotic therapy,
the presence of an abscess should be suspected.52 Small
(< 5 cm) abscesses may respond to antibiotic infusion and
bowel rest. Larger abscesses that are localized and isolated
may be accessible to percutaneous drainage [see Figure 13].53
Generally, this technique is reserved for abscesses greater
than 5 cm in diameter in low-risk patients who are not
immunocompromised. It often leads to resolution of sepsis
and the resulting symptoms and signs (e.g., abdominal pain
and tenderness and leukocytosis), usually within 72 hours,
thereby facilitating subsequent elective surgical resection
of the colon. In addition, percutaneous drainage offers cost
advantages in that it reduces the number of operative pro-
cedures required and shortens hospital stay.54 Patients with
severe comorbidities at times can be managed with drainage
alone.55
Access to a pelvic collection may be difficult to obtain, and
the drainage procedure typically must be done with the
patient in a prone or lateral position. If the catheter drainage
amounts to more than 500 mL/day after the first 24 hours, a
fistula should be suspected. Before the catheter is removed,
a CT scan is done with injection of contrast material through
the tube to determine whether the cavity has collapsed. If
this approach fails (as it usually does in patients with mul-
tiple or multiloculated abscesses), an expeditious operation
may be necessary.31

Patient has complicated diverticulitis

Disease has progressed to obstruction,

abscess or fistula formation, free
perforation, or significant bleeding.

Obstruction (signaled by Abscess (signaled by localized Fistula (signaled by fecaluria

marked abdominal distention) peritonitis and fever) and pneumaturia)
Perform diagnostic imaging. Perform diagnostic imaging. Perform diagnostic imaging; look
for bladder air.
Treat medically.
Resect colon and fistula in one-
stage procedure.

Small bowel Large bowel

obstruction obstruction
Small abscess Large abscess
High grade: Cecal distention
treat surgically. present: treat surgically. Attempt percutaneous drainage.
Low grade: Cecal distention
treat medically; absent: treat medically;
consider surgical consider surgical
treatment if indicated. treatment if indicated.
Drainage succeeds Drainage fails
Initiate early surgical treatment.

Perform elective one-stage resection.

Figure 12 Algorithm outlining treatment options for complicated diverticulitis. GI = gastrointestinal; RBC = red blood cell.

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gastro diverticular disease — 9

b
a

Figure 13 (a) Computed tomographic scan showing a pericolic abscess (arrow) caused by a contained perforation arising from sigmoid
diverticulitis. (b) A pigtail catheter (arrow) has been placed into the abscess cavity by the interventional radiologist.

surgical who have complicated diverticulitis. The recurrence rate is

Overall, approximately 20% of patients with diverticulitis
require surgical treatment.56 Patients with diverticular dis-
ease have worse, costlier outcomes than individuals with
colon cancer having the same operations.57 Surgical proce-
dures are reserved for patients who experience recurrent
episodes of acute diverticulitis that necessitate treatment as
an inpatient or outpatient (the most common indication) or
in the range of 25 to 35%.58,59 Frequently, the same colonic
segment is involved,60 and some of the early recurrences are
a consequence of incomplete treatment. In 2000, a task force
of the American Society of Colon and Rectal Surgeons rec-
ommended sigmoid resection after two attacks of diverticu-
litis.61 A subsequent cost analysis using a Markov model
suggested that cost savings could be achieved if resection

Free perforation (signaled by generalized Bleeding (lower GI)

peritonitis and rigid abdomen)
Initiate urgent surgical treatment.
Consider performing diagnostic imaging;
look for free air. Massive bleeding Moderate bleeding

Administer transfusions. Observe patient.

Perform angiography. Perform colonoscopy.
Hinchey stage III Hinchey stage IV

Perform resection with Perform Hartmann

anastomosis; alternatively, procedure. Angiogram is positive Angiogram is negative
perform Hartmann procedure
or laparoscopic peritoneal Perform superselective Observe patient.
lavage and drainage. embolization. Consider RBC scanning.

Embolization succeeds Embolization fails

Observe patient. Treat surgically.

Figure 12 Continued from previous page.

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gastro
was done after three attacks.62 There is a growing tendency
to question arbitrary guidelines for surgical management of
recurrent attacks,63 with the exception of certain groups,
such as immunocompromised patients.64–67 Current practice
guidelines state that the recommendation to perform elec-
tive sigmoid resection after recovery from uncomplicated
acute diverticulitis should be made on a case-by-case basis.68
The decision-making process should be influenced by the
age69 and medical condition of the patient,70 the frequency
and severity of attacks, and the presence of symptoms after
the acute attack. Relief of symptoms is complete in most of
these patients following colectomy.71,72 Elective resection is
also recommended after an episode of complicated diver-
ticulitis.68 Efforts are made to time surgical treatment so that
it takes place during a quiescent period after the last attack,
although some patients develop recurrent diverticulitis
during that time that necessitates an operation.73,74 Barium
enema or colonoscopy may be employed to evaluate the
diverticular disease and rule out carcinoma. CT findings
suspicious of carcinoma include wall thickness more than
6 mm, abscess, obstruction, or lymphadenopathy.75 The
bowel can then be prepared mechanically and with antibiot-
ics (e.g., oral neomycin and metronidazole) on the day
before operation.
Elective resection is a common sequel to successful percu-
taneous drainage of a pelvic abscess in an otherwise healthy,
well-nourished patient.76 The timing of surgery may be
guided by the extent of the inflammatory changes (as docu-
mented by CT scanning) and the patient’s clinical course.
Most patients can be operated upon within 6 weeks. Elective
resection with a possible diverting ileostomy is the preferred
approach to diverticular fistulas as well.77 Colovesical
fistulas are usually resected because of the risk of urinary
sepsis and the concern that a malignancy might be over-
looked. Preferably, the operation is done when the acute
inflammation has subsided.
Elective resection is done via either the open route or,
increasingly, the laparoscopic route.78,79 Most patients have
complete relief of symptoms,71 although up to 20% have
functional complaints following the operation.80 The learn-
ing curve for laparoscopic colectomy is 20 to 50 cases.81
Obese patients with severe colonic inflammation are poorer
candidates for laparoscopic resection.78 In our institution,
the development of hand-assisted procedures widened the
opportunities for using minimally invasive surgery, allow-
ing all types of diverticular resections, including complex
ones,82 to be performed more safely,83,84 with lower conver-
sion rates and shorter operative times compared with purely
laparoscopic procedures.85 With increasing experience,
pure laparoscopic procedures have become routine. Today
laparoscopic colectomies are done safely in obese patients86
and the conversion rate is low.81,87,88 Minimally invasive pro-
cedures also have several advantages over open procedures
[see Table 2]. The technical details of the procedures are
addressed elsewhere in this review.
There is a spectrum of presentations of perforated diver-
ticulitis, from mild abdominal pain to septic shock. The 5-
year survival is only in the range of 50%.89 Some patients
require emergency resection because of free perforation
and widespread peritonitis. In such patients, the American
Society of Anesthesiologists (ASA) physical status score90
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diverticular disease — 10
Table 2 Advantages of Minimally Invasive
Procedures over Operative Procedures
Decreased intraoperative trauma
Fewer postoperative adhesions
Reduced postoperative pain
Shorter duration of ileus
Quicker discharge from the hospital
Earlier return to work
and the degree of preoperative organ failure may be signifi-
cant predictors of outcome.91,92 Unfavorable systemic factors
(e.g., hypotension, renal failure, diabetes, malnutrition,
immunocompromise, and ascites) are associated with worse
patient outcomes91; the severity of the peritonitis (i.e., extent,
contents, and speed of development), African-American
race,93,94 insurance coverage,95 and smoking or advanced
patient age also correlate with outcomes.96–98 One of the
unfortunate limitations of the Hinchey classification (based
on operative findings) is that it does not take these comor-
bidities into account.90
As a general rule, resection and immediate anastomosis
(open or laparoscopic)88,99 are suitable for Hinchey stage I
and some stage II diverticular perforations, whereas resec-
tion and diversion without anastomosis (Hartmann proce-
dure) are favored for stage IV (feculent peritonitis) and some
cases of stage III perforations (purulent peritonitis).100,101
There is evidence that an anastomosis involving the left
colon is risky when done under emergency conditions with
extensive fecal contamination.102 Many of the patients with
stage IV perforation have multiple comorbidities, including
advanced age, which likely account for the persistently
high mortality rates in the range of 20% or higher in this
group.101,103
Management of stage III perforations is more controver-
sial, but two trends have emerged internationally. The first,
laparoscopic peritoneal lavage and drainage,104 evolved from
the widespread use of diagnostic laparoscopy in evaluating
acute abdominal illnesses over the last two decades. This
procedure gives the opportunity to perform an anastomosis
or to terminate the operation and provide supportive
care, with plans to perform a later elective resection.105,106
However, there is the risk of missing an overt perforation,
and these patients must be monitored closely.107 Another
approach includes resection, wound vac drainage, and a
“second look” operation with possible anastomosis.108,109 In a
prospective trial of 100 patients with diverticulitis selected
for peritoneal lavage, 92 had lavage alone (there were eight
stage IV perforations). Two pelvic abscesses occurred post-
operatively, and the morbidity and the mortality were only
4% and 3%, respectively. Only two patients presented with
recurrent diverticulitis, with a median follow-up of 36
months.110 Most other series are small and retrospective;
given that some Hinchey II patients are included, it is con-
ceivable that some patients may have done as well receiving
antibiotics and supportive care alone. In a literature review
of more than 300 patients undergoing peritoneal lavage, the
morbidity and mortality were 18% and 0.25%, respective-
ly.111 It is possible that this technique will become definitive
for certain cases of purulent peritonitis in the future, but
further prospective data are needed.
gastro diverticular disease — 11

Second, increasing numbers are undergoing primary

anastomosis at the time of emergent resection.91,112–116
Frequently, the anastomosis is protected with a diverting
ileostomy,100,101,117 which is preferred to a colostomy because
of simplicity of closure.118 The advantage of this approach is
that the colostomy takedown, frequent postoperative com-
plications,119 and the attendant 4% mortality are avoided.120
Furthermore, at least 30% of patients who undergo the
Hartmann operation never return for colostomy closure,
despite the fact that the stoma tends to be a detriment to
their quality of life.121 On the other hand, because the bowel
is not prepared preoperatively, the surgeon, especially the
low-volume or weekend operator,122 may feel uncomfortable
doing an anastomosis. On-table lavage may be considered,123
but it adds to the time spent under anesthesia during an
emergency procedure. A literature review of more than
1,000 patients undergoing primary resection showed similar
Figure 14 Computed tomographic scan showing marked thickening
morbidity and mortality for the Hartmann procedure and of the sigmoid wall (arrows) in a patient with diverticular disease who
for resection and anastomosis (anastomotic leak rate of presented with symptoms of intractable constipation. No contrast is
20%).103 The first randomized prospective trial to address present in the lumen (curved arrow).
this issue favored primary anastomosis with diverting ileos-
tomy, despite similar morbidity and mortality, because the
stomal reversal rate was higher, and serious complications, loading of the colon is usually managed by performing
operative time, hospital length of stay, and hospital costs a Hartmann procedure, although on-table lavage may be
were reduced in the anastomosis group.124 considered.31 A survey of GI surgeons in the United States
Above all, the surgeon’s decision as to the type of opera- indicated that 50% would opt for a one-stage procedure in
tion to perform must be individualized on the basis of each low-risk patients with obstruction, whereas 94% would opt
patient’s condition and needs. Grading of comorbidities for a staged procedure in high-risk patients.135
with classification systems such as Acute Physiology and
Chronic Health Evaluation II (APACHE II) or the Mannheim
peritonitis index can facilitate decision making between
primary anastomosis versus diversion.125,126 Some surgeons
use scoring systems useful for predicting the risk of compli-
cations following Hartmann closures.127 Further multicenter
trials are warranted.128
The risk of complications inherent in operations on the
colon should always be kept in mind, especially in the rela-
tively few patients undergoing emergency procedures.129,130
In this setting, the bowel is unprepared and systemic sepsis
may be present, and the mortality increases to 8.8%,
compared with 1.4% for elective procedures.131 Potential
complications include ureteral injuries, anastomotic leakage,
anastomotic stricture, and postoperative intra-abdominal
abscesses; perioperative bleeding involving the mesentery,
adhesions, the splenic capsule, or the presacral venous
plexus; postoperative small bowel obstruction; stomal
complications; wound infection,132 wound dehiscence, and
abdominal compartment syndrome; acute respiratory dis-
tress syndrome; and multiple organ dysfunction syndrome.
Even after successful operations, some patients continue
to have abdominal pain attributable to conditions such as
irritable bowel syndrome.133,134
Large bowel obstruction secondary to diverticulitis can
lead to considerable morbidity and may necessitate surgical
intervention.117 The obstruction is usually partial [see
Figure 14 and Figure 15], allowing preparation of the bowel
in many cases. High-grade obstruction represents a complex
problem. If the cecum is dilated to a diameter of 10 cm or Figure 15 Contrast study showing high-grade retrograde obstruc-
greater and there is tenderness in the right lower quadrant, tion, multiple diverticula, and a long proximal sigmoid stricture.
expeditious surgery is necessary because of the risk of cecal A tiny extraluminal tract (possibly intramural) from a diverticulum
necrosis and perforation. High-grade obstruction with fecal (arrow) is seen.

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gastro
Small bowel obstruction may also complicate the clinical
picture. Mechanical small bowel obstruction may occur as a
consequence of adherence of the small bowel to a focus of
diverticulitis, especially in the presence of a large pericolic
abscess. Whereas small bowel obstruction tends to cause
periumbilical, crampy abdominal pain and vomiting, these
characteristic manifestations may be obscured in part by
pain attributed to diverticulitis. The concern in this situation
is that ischemic small bowel may be ignored, with poten-
tially disastrous consequences. Formation of a fistula into
the small bowel should raise the possibility of Crohn dis-
ease. CT scanning often helps the surgeon differentiate
between primary and secondary small bowel obstruction,
but, ultimately, exploratory surgery may be required for
both diagnosis and treatment.
Lower GI bleeding caused by diverticular disease rarely
calls for emergency resection because the bleeding is
self-limited in most patients (80 to 90%). Furthermore, acute
diverticulitis is rare when active bleeding is the presenting
symptom. Attempts are made to establish the active bleed-
ing site by means of colonoscopy,136 tagged red blood cell
nuclear scans, or angiography; barium contrast studies
have no role to play in this situation. Emergency resection
is indicated if the bleeding is life-threatening and if colonic
angiography and attempted superselective embolization
prove unsuccessful. In an unstable patient, total abdominal
colectomy is necessary if the site of bleeding is unknown,
although identification of the bleeding site with intraopera-
tive colonoscopy has been reported. In a stable patient with
ongoing bleeding, repeat angiography at a later time is
appropriate, or so-called pharmacoangiography (infusion of
heparin) can be employed in an attempt to induce bleeding.
Special Types of Diverticulitis
cecal diverticulitis
In the United States, diverticulitis rarely involves the
cecum or the right colon. Right-side diverticula occur in only
15% of patients in Western countries, compared with 75% in
Singapore.1 The incidence of cecal diverticulitis appears
to be related to the number of diverticula present.137 A
classification system has been proposed that divides cecal
diverticulitis into four grades [see Figure 16] to facilitate
comparisons between different clinical series and to help
surgeons formulate treatment plans in the operating room.68
Some cecal diverticula are true diverticula, containing all
layers of the bowel wall, but the majority are pseudodiver-
ticula. Diverticulitis of the hepatic flexure and the transverse
colon is even less common and can present with symptoms
suggesting appendicitis.138
Patients with right-side disease tend to be younger and
to have less generalized peritonitis than patients with left-
side diverticulitis.137,138 Because they typically present with
right lower quadrant pain, fever, and leukocytosis, acute
appendicitis is usually suspected. CT scans are helpful for
differentiating cecal diverticulitis from appendicitis or colon
cancer [see Figure 17].139 If cecal diverticulitis is suspected (as
in a patient who has previously undergone appendectomy
or in a patient with known right-side diverticulosis who has
experienced similar attacks in the past), medical manage-
ment with observation and antibiotics is generally the
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diverticular disease — 12
favored strategy, just as with simple sigmoid diverticulitis140;
at times, abscesses can also be treated conservatively.141 In a
Korean series, outpatient treatment was frequently effec-
tive.142 In Japan, where right-side diverticulitis also is more
common, medical treatment has been successfully used for
recurrent attacks of uncomplicated right-side diverticuli-
tis.143 After a few weeks, colonoscopy should be performed
to rule out a colonic neoplasm.
If the patient has significant peritonitis or the diagnosis is
unclear, laparoscopy or laparotomy is indicated. It is impor-
tant that one or the other be done because the mortality
associated with delayed treatment of perforated cecal diver-
ticulitis is high. Assuming a reasonable comfort level with
laparoscopic techniques, this is the preferred modality when
the diagnosis is uncertain. The ability to evaluate the entire
abdomen is invaluable in this situation. When inflammation
is localized and minimal, colectomy is unnecessary, and
incidental appendectomy should be considered if the cecum
is uninvolved at the base of the appendix.144 If desired, the
diverticulum may be removed as well.
Diverticulectomy should be done only under certain con-
ditions [see Table 3]. Localized diverticulectomy, in general,
should be reserved for grade I and grade II disease.137,145
Sometimes the ostium of the inflamed diverticulum is pal-
pable if the cecum is mobilized surgically. On-table cecos-
copy through the appendiceal stump has also been helpful
in establishing the diagnosis in the operating room.144 Grade
III and IV cecal diverticulitis may be difficult to differentiate
from carcinoma; resection is favored for these lesions. An
anastomosis may be created if contamination is limited,
but, generally, primary resection, ileostomy, and a mucous
fistula are favored for treatment of grade IV disease.
diverticulitis in young patients
Diverticulitis in patients younger than 40 years has been a
focus of considerable attention in the literature, although
this group represents only about 2 to 5% of the patients
in large series.61 The incidence of diverticulitis in young
patients may be increasing, and obese Latino men appear
to be at particular risk.146 This predominance in males may
reflect a tendency to underdiagnose acute diverticulitis in
young women.147 Some authors have asserted that diverticu-
litis is particularly virulent in young patients. However, cur-
rent data do not support this concept,148 suggesting instead
that patients with mild diverticulitis are misdiagnosed when
hospitalized or are treated as outpatients. The high rate of
early operation in young patients probably reflects misdiag-
nosis of diverticulitis as acute appendicitis rather than the
development of particularly severe forms of diverticulitis.146
Unlike elderly patients, hospitalized young patients with
diverticulitis tend to have few comorbidities other than
obesity.149 Furthermore, young patients hospitalized for
diverticulitis tend to have relatively advanced disease,
perhaps as a consequence of delayed diagnosis, whereas
elderly patients hospitalized with an admitting diagnosis
of diverticulitis tend to exhibit a wider spectrum of disease
severity. Young patients appear not to have a higher rate of
recurrent diverticulitis than older patients do; thus, aggres-
sive resection is not necessary at the time of the first attack.146
However, a finding of advanced diverticulitis on CT scans
is a predictor of subsequent disease complications in this
population.75
gastro diverticular disease — 13

Pus

Grade I Grade II Grade III

Pus

Grade IV

Figure 16 Proposed classification of pathologic types of cecal diverticulitis. Grade I is a specific inflamed diverticulum; grade II is a cecal mass;
grade III is characterized by a localized abscess or fistula; and grade IV represents a free perforation or a ruptured abscess with peritonitis.137

In general, diverticulitis should be approached in the

same fashion in younger patients as in older patients.150,151
The pathophysiology of the disease is probably identical. As
in the elderly, elective resection is recommended after recur-
rent attacks, not after a single attack; with follow-up, the
majority of patients hospitalized with acute diverticulitis do
not require operation.64,150,152,153

Table 3 Necessary Conditions for

Diverticulectomy in Patients with
Cecal Diverticulitis137
1. Carcinoma can be ruled out
Figure 17 Computed tomographic scan showing inflammation in 2. The resection margins are free of inflammation
the pericecal area (arrow) and cecal edema, which could represent 3. The ileocecal valve and the blood supply of the bowel are not
cecal diverticulitis. Because the appendix is not clearly visualized, compromised
4. Perforation, gangrene, and abscess are absent
appendicitis cannot be ruled out.

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gastro diverticular disease — 14

diverticulitis in immunocompromised patients

Table 4 Unusual Extra-Abdominal Presentations
In view of their known predisposition to infection, immu- of Diverticulitis232
nocompromised patients (e.g., chronic alcoholics, transplant
Dermatologic
patients,154 and persons with metastatic tumors who are
Erythema nodosum166
receiving chemotherapy) with diverticulitis are at particular Pyoderma gangrenosum
risk.155,156 There is no evidence that the incidence of diver- Urinary
ticulitis or the recurrence rate of diverticulitis157 is higher in Ureteral obstruction
this population than in the general population. It is clear that Coloureteral fistula
Soft tissue
immunocompromised patients have higher rates of opera- Thigh abscess
tion once diverticulitis develops and that their postoperative Necrotizing fasciitis
mortality is higher.158 Corticosteroid intake causes a number Orthopedic
of significant problems, such as thinning of the colonic wall, Osteomyelitis
lessening of the physical findings with diverticulitis, and an Arthritis
Gynecologic
attenuated inflammatory response. Colouterine fistula
Any immunocompromised patient with abdominal pain Ovarian tumor/abscess
should be evaluated aggressively. Contrast-enhanced CT is Genital
the imaging study of choice. The risk of perforation is Epididymitis
Pneumoscrotum
increased in this setting, as is the risk of postoperative com-
Neurologic
plications such as wound dehiscence. For an immunocom- Coloepidural fistula
promised patient who has recovered from an episode of Pneumocranium164
symptomatic diverticulitis, elective surgical treatment is rec- Vascular
ommended. A renal transplant patient with asymptomatic Femoral vein thrombosis
Mesenteric vein thrombosis
diverticulosis, however, need not undergo prophylactic Colovenous fistula
colectomy. Pretransplantation colonic screening of patients Mycotic aneurysm165
older than 50 years does not reliably predict posttransplan- Pylephlebitis162 (liver abscess)163
tation colonic complications.159 Perineal
Fournier gangrene
atypical presentations Complex anal fistula

Diverticulitis may give rise to various unusual manifesta-

tions involving multiple organ systems [see Table 4]. Not sur-
prisingly, immunocompromised patients are at particular
risk.
Retroperitoneal abscesses can track into anatomic planes
(e.g., along the psoas muscle) [see Figure 18, a and b] or
through the obturator foramen to areas such as, the thigh,
the knee, the groin160,161 [see Figure 18c], and the genitalia. CT
scanning is essential to outline the extent of such abscesses.
Contrast enemas show the diverticula along with a sinus
tract into the abscess cavity. Cultures of the abscess demon-
strate the presence of colonic organisms such as Bacteroides
fragilis. Definitive treatment consists of wide abscess
drainage and colon resection. Without aggressive surgical
management, mortality is high.
The protean manifestations of diverticulitis also include
pylephlebitis162 (which causes liver abscesses),163 arthritis,
pneumocranium,164 mycotic aneurysm,165 and erythema
nodosum.166 Diverticulitis has, in fact, replaced appendicitis
as the most common source of liver abscesses of portal
origin. Simple abscesses may be drained percutaneously
if they are not too large, and multiple loculated abscesses
may be managed with open drainage. The main risk factors
for mortality from liver abscesses are immunosuppression,
underlying malignancy, the presence of multiple organisms,
and liver dysfunction. If the decision is made to perform a
colectomy, the procedure may be done after drainage of the
liver abscess or simultaneously with drainage during an
open procedure.
giant diverticula
An anatomic curiosity sometimes encountered in patients
with diverticular disease is a giant diverticulum, also termed
a giant gas cyst or a pneumocyst of the colon.167 These
lesions, which may reach diameters of 40 cm, are believed to
develop as a consequence of a ball-valve mechanism created
by intermittent occlusion of the neck by fecal material
that traps air in the diverticulum. Most giant diverticula are
minimally symptomatic, causing only mild abdominal pain,
and perforation is rare. A mobile mass may be palpable, and
the gas-filled cyst can be seen on plain abdominal films. As
many as two thirds of giant diverticula are opacified during
a barium enema and can thereby be differentiated from
other abnormalities (e.g., a mesenteric cyst, emphysematous
cholecystitis, or a colon duplication) [see Figure 19]. The
cyst tends to adhere densely to adjacent structures (e.g., the
bladder and the small bowel). The treatment of choice is
resection of the colon and the cyst; performing diverticulec-
tomy alone can lead to the development of a colocutaneous
fistula.
recurrent diverticulitis after resection
Recurrent diverticulitis is rare after a colectomy for diver-
ticulitis, occurring in 1 to 10% of patients.168 As many as 3%
of patients who have undergone resection for diverticulitis
will require repeat resection. The differential diagnoses
are listed here [see Table 5]. CT and colonoscopy should
be carried out. Particular care should be taken to review
pathologic specimens for evidence of Crohn disease.
The only significant determinant of recurrent diverticulitis
is the level of the anastomosis; the high pressure in the

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gastro diverticular disease — 15

a b

Figure 18 Selected imaging of a 73-year-old patient with perforated diverticulitis. Extensive gas is seen in the left retroperitoneal space (a, b)
and in the left groin (c).

sigmoid colon distal to the anastomosis appears to be
responsible. In one study, the risk of recurrence was four
times greater in patients with a colosigmoid anastomosis
than in those with a colorectal anastomosis.169 Reoperation
requires a dissection that commences in noninflamed tissue.
Dissection may be particularly difficult near the pelvic
sidewall because of fibrosis; ureteral stenting may facilitate
identification of the ureters.
subacute and atypical diverticulitis
A small number of patients experience recurrent episodes
of left lower quadrant abdominal pain that are not accompa-
nied by the classic findings of acute diverticulitis (e.g., fever
and leukocytosis). The inflammatory changes associated
with diverticula in this subgroup have been referred to as
atypical, subacute, or smoldering diverticulitis.170–172 Surgery
has been effective in management of smouldering disease.173

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gastro
Figure 19 Giant sigmoid diverticulum opacified during a barium
enema examination.167
In this setting, there is not always a direct association
between endoscopic and clinical findings; endoscopic
evidence of diverticular inflammation has been seen in
asymptomatic patients.174 Endoscopic findings suggestive of
subacute or smoldering diverticulitis are a relatively rigid
sigmoid colon or increased spasm along with a thickened
colon. It has been suggested that there is a relation between
diverticular disease and colitis (diverticular colitis).175 This
may represent a different disease entity than traditional sig-
moid diverticulitis.67 Patients with chronic lower abdominal
pain should undergo imaging studies and endoscopic evalu-
ation, and other disorders (e.g., irritable bowel syndrome,
inflammatory bowel disease, drug-induced symptoms,
and bowel ischemia) should be excluded. In most cases of
atypical diverticulitis, endoscopic findings are normal.171 In
carefully selected patients, colectomy often eliminates the
abdominal pain, and many of these patients are eventually
found to have histologic signs of acute and chronic mucosal
inflammation.171
Preoperative Evaluation
The extent of the preoperative evaluation received by
patients undergoing surgical treatment of diverticular
disease is dictated predominantly by the urgency of the
situation. Whereas patients with recurrent symptoms will
undergo repeated assessments with myriad diagnostic tests
before the decision is made to proceed with surgical inter-
vention, patients with perforated diverticulitis may have
Table 5 Differential Diagnoses of Recurrent
Diverticulitis
Crohn disease
Irritable bowel syndrome
Carcinoma
Ischemic colitis
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diverticular disease — 16
only a chest x-ray documenting free air before they are taken
to the operating room. Given the varied complications
of diverticular disease and the numerous options for surgi-
cal treatment, it is most convenient to divide the relevant
operations into emergency procedures and elective proce-
dures. Such a division facilitates discussion of technical
issues, preoperative evaluation, and management of
complications.
As noted, in the emergency setting, a demonstration of
pneumoperitoneum may be the only workup performed. In
fact, in most patients with perforated diverticulitis, pneumo-
peritoneum is the initial presentation.176,177 In patients who
present with massive lower GI hemorrhage, angiographic
demonstration of the bleeding site is known to reduce
operative mortality, even if therapeutic superselective
embolization is unsuccessful in controlling the bleeding.178,179
The other complication of diverticular disease that may
necessitate an emergency operation is colonic obstruction.
A careful history may reveal progressive obstructive symp-
toms, but if the patient presents with complete obstruction
and cecal dilatation, urgent decompression is required.
In this setting, retrograde administration of a water-soluble
enema may be very helpful—at least for delineating
the level of the obstruction, if not the specific cause.176,180
Communication with the radiologist should be maintained
to prevent both overly forceful instillation of the contrast
material and the use of barium, which may cause problems
if the agent cannot be evacuated.
When surgical treatment of diverticular disease is to be
performed in the elective setting, a detailed preoperative
evaluation is imperative. The key point here is that objective
evidence of diverticulitis must be obtained at some point in
the care of the patient. Too often, symptoms of irritable bowel
syndrome are confused with those of diverticulitis, with the
result that the patient carries an incorrect diagnosis.181–184 In
the most common scenario, CT scanning is performed when
a patient is experiencing left-side pain, possibly associated
with fever, nausea, anorexia, or abdominal distention. A
finding of pericolonic inflammation in an area of diverticu-
losis is the definitive radiographic presentation.185,186 Preop-
erative endoscopic evaluation of the colon, whenever
feasible, is extremely valuable not only for confirming the
presence of diverticulosis but also for ruling out inflamma-
tory bowel disease or even a neoplastic lesion.
It is possible to expend a great deal of effort on trying to
demonstrate a diverticular fistula. In many circumstances,
however, this task proves difficult to accomplish. In our
view, demonstration of a diverticular fistula should not be
considered a mandatory precondition for operative treat-
ment. A strong history of either a colovaginal or a colovesi-
cal fistula with suggestive findings on CT scans (e.g., air in
the bladder or pericolonic inflammation contiguous with
either the bladder or the vagina) constitutes a sufficient
indication for surgical resection.187,188
Operative Planning
In planning the operative approach to a patient with
diverticular disease, the major decision is whether to perform
gastro
a one-stage or a two-stage procedure. Traditionally, an
emergency operation for perforation, obstruction, or
massive bleeding includes a temporary stoma procedure to
eliminate the risk of anastomotic leakage.28,189 The operation
most commonly performed in this setting is the Hartmann
procedure [see Emergency Procedures, Hartmann Proce-
dure, below], named after Henri Hartmann, who first
described the use of this operation to treat colon cancer in
1923.190 The obvious advantage of the Hartmann procedure
is that it removes the inflammatory focus without putting
the compromised patient at risk for anastomotic leakage.
Unfortunately, to restore intestinal continuity after this
procedure, it is necessary to perform a potentially difficult
second operation; as many as one third of patients never
undergo reversal of their colostomy.191,192
Another therapeutic option is to perform a primary anas-
tomosis with a diverting loop ileostomy instead of a colos-
tomy.116,124 In this situation, the risk of anastomotic leakage
with possible fecal peritonitis is still avoided, but only a
relatively minor second procedure is necessary to reverse
the ileostomy.193 Primary anastomosis with a defunctioning
stoma may be the optimal strategy for selected patients with
diverticular peritonitis (Hinchey III or IV); it may represent
a good compromise between postoperative adverse events,
long-term quality of life, and the risk of a permanent
stoma.194 Occasionally, it may be appropriate to perform
on-table colonic lavage with a primary anastomosis. This
approach is most useful in the setting of colonic obstruction
secondary to a diverticular stricture in a patient who is
otherwise hemodynamically stable but has a large fecal load
proximal to the intended anastomosis.195,196
Laparoscopic intestinal surgery has shown tremendous
development in the past decade, benefited by both signifi-
cant technological improvements and growing surgical
experience with advanced laparoscopic procedures.79,197–201
Given that patients prefer the laparoscopic approach, it has
been difficult to carry out randomized trials of open versus
laparoscopic techniques.202 Furthermore, the steep learning
curve associated with laparoscopic intestinal surgery has
led to inconsistent application of these techniques in many
hospital settings. At our center, hand-assisted techniques
have reduced the learning curve and shortened the operat-
ing time,203,204 although with continued experience and
improvement in technology, this approach is being used
less often [see Figure 20]. Fast-track protocols have now been
extensively applied to laparoscopic procedures,205 with a
resultant decrease in hospital stay as well as reduced cost.
Minimum-access techniques have been shown to reduce the
risk of postoperative wound infection and hernia forma-
tion.206 A randomized prospective controlled trial showed
similar good outcomes with open and laparoscopic sigmoid
colectomies for diverticular disease, although the cosmetic
results of the laparoscopic procedures were preferable.207
Recent literature suggests that fistulizing diverticular dis-
ease and other forms of complex diverticulitis can be resected
safely via a laparoscopic approach with good clinical out-
come.83,208–211 In our own institution, the ultimate success in
completing these complex procedures laparoscopically has
been facilitated by hand-assisted techniques.83 New frontiers
in elective diverticular resection include single-access/port
diverticular disease — 17
operations with an operating laparoscope,212–214 robotic-
assisted colectomies,215 and transvaginal low anterior resec-
tion216 natural orifice translumenal endoscopic surgery.
Consequently, minimal-access surgery is rapidly becoming
the approach of choice in the management of nearly all
elective diverticular resections.217–220
Emergency Procedures
Patient setup and positioning are similar for all emergen-
cy operations. The patient is placed in a modified lithotomy
position to facilitate access to the rectum. Urinary drainage
with a Foley catheter and temporary gastric decompression
with a nasogastric tube are performed. When feasible, the
stoma site is marked by an enterostomal therapist before
operation.
hartmann procedure
Step 1: Incision and Initial Exploration
A lower midline incision is made and extended above
the umbilicus as necessary. The abdomen is thoroughly
explored to confirm the diagnosis of diverticular disease
and to wash out any gross fecal spillage. A self-retaining
retractor (e.g., a Bookwalter retractor) is placed, with care
taken to pad the abdominal wall.
Step 2: Mobilization and Division of Sigmoid Colon
The patient is placed in the Trendelenburg position, with
the small bowel carefully retracted into the upper abdomen.
The sigmoid colon is mobilized away from the lateral
peritoneal attachments. Mobilization is continued into the
pelvis lateral to the upper portion of the rectum.
Troubleshooting If a severe phlegmon is stuck to the
pelvic sidewall, it may be helpful at some point in the mobi-
lization to dissect cephalad from below the mass so as to
isolate the area from above and below.
Step 3: Identification of Ureter
As the sigmoid colon is retracted medially, the ureter can
usually be identified where it crosses over the bifurcation of
the iliac vessels. The gonadal vessels are usually identified
first; the ureter lies slightly medial and deep to them [see
Figure 21].
Step 4: Division of Sigmoid Colon
The proximal sigmoid colon is divided through nonin-
flamed tissue with a linear cutting stapler [see Figure 22a].
The sigmoid vessels are sequentially divided (with attention
paid to their relation to the left ureter) up to the rectosig-
moid junction, which is identified by the loss of the taeniae
coli. The rectum is then transected through noninflamed
tissue with a linear cutting stapler [see Figure 22b].
Troubleshooting The top of the rectal stump can be
marked with a nonabsorbable suture to facilitate subsequent
identification.
Step 5: Construction of Colostomy
The proximal colon is delivered through the previously
marked stoma site in the left lower quadrant with a muscle-
splitting incision in the rectus abdominis (with care taken
not to twist it on its mesentery), and a colostomy is created.
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gastro diverticular disease — 18

100

90

80

70

60

50

40

30

20

10

0
2005 2006 2007 2008 2009 2010

HALS LAP Open

268 177 54

HALS % LAP % Open %

Figure 20 Trends in operative techniques, Hartford Hospital 2005–2010, for scheduled procedures for diverticulitis. HALS = hand-assisted
laparoscopic surgery; LAP = pure laparoscopic procedure.

Step 5—Alternative (Primary Anastomosis with Diverting
Ileostomy): Creation of Colorectal Anastomosis
As an alternative to a colostomy, the surgeon may elect to
perform a primary colorectal anastomosis with a diverting
ileostomy. The anvil of a circular stapler is positioned in the
proximal colon, and a purse-string suture is placed around
it. If there is any gaping of the tissue around the shaft of the
anvil, a second suture may be added for reinforcement.
The stapler is inserted through the anus, with the shaft
being brought out through either the anterior wall of the
rectum or the top of the rectal stump, adjacent to the staple
line. The stapler is then engaged, with care taken to ensure
that no extraneous tissue is caught between the body of the
stapler and the anvil and that the proximal bowel is not
twisted on its mesentery. The stapler is fired to create the
anastomosis, and the integrity of the anastomosis is tested
by occluding the proximal bowel and placing the anasto-
motic area under water while air is insufflated into the
rectum via a rigid proctoscope.
Troubleshooting It is helpful to divide the mesentery
where it is draped over the anvil. This measure diminishes
the risk of bleeding from the circular staple line while also
providing a greater length of colon for the anastomosis.
If there is any question regarding possible tension on the
anastomosis, the splenic flexure should be fully mobilized.
Step 6—Alternative (Primary Anastomosis with Diverting
Ileostomy): Construction of Loop Ileostomy
A loop ileostomy is created in the right lower quadrant
using a muscle-splitting incision in the rectus abdominis.
Loop ileostomies can usually be designed to be diverting;

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Figure 21 Hartmann procedure. The relation of the ureter to other
structures in the left lower quadrant is illustrated.
however, stapling the distal end and leaving it at skin level
will ensure complete diversion.
Troubleshooting If there is a column of stool between
the ileostomy and the anastomosis, it should be washed out
before the ileostomy is completed.
a b
Figure 22 Hartmann procedure. (a) The colon is divided above the level of the inflammatory mass. (b) The rectum is divided below the inflam-
matory mass; division must be through normal tissue.
diverticular disease — 19
on-table colonic lavage
Steps 1 through 4
Steps 1, 2, 3, and 4 of on-table colonic lavage are the same
as the first four steps of the Hartmann procedure.
Step 5: Mobilization of Flexures
After the sigmoid resection, the hepatic flexure and
the splenic flexure are carefully mobilized to facilitate the
washout process.
Step 6: Placement of Tubing
Corrugated anesthesia tubing is placed in the colon
proximal to the resected segment and secured in place with
umbilical tape. The distal end of the tubing is passed off the
operating table and is connected to a device that collects the
effluent [see Figure 23].
Step 7: Construction of Appendicostomy
An appendicostomy is performed, a Foley catheter is
placed, and a purse-string suture is tied around the tube
with the balloon inflated. If the patient has previously
undergone an appendectomy, the terminal ileum is used
instead.
Step 8: Irrigation of Colon
The colon is washed with an irrigant until the effluent is
relatively clear. It may be necessary to manipulate the colon
so as to initiate flushing of formed stool.
Step 9: Excision of Appendix and Creation of Colorectal
Anastomosis
A formal appendectomy is performed. The corrugated
anesthesia tubing is removed from the colon, and a colorectal
anastomosis is performed, usually with a circular stapler.
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gastro
Figure 23 On-table colonic lavage. Full mobilization of the colon,
with corrugated anesthesia tubing secured in the colon and connected
to a collection system, is shown. A Foley catheter is inserted through
an appendicostomy into the base of the cecum.
laparoscopic lavage
Step 1: Placement of Trocars
The first port is placed at a periumbilical location by
means of an open Hasson approach, and a 30° laparoscope
is inserted (a vertical incision is preferable as some cases will
need to be converted to open). After pneumoperitoneum is
achieved, the other ports are placed under direct vision:
5 and 12 mm ports are placed in the right lower quadrant
[see Figure 24]. These ports can be placed sequentially so as
to assess the feasibility of laparoscopic lavage prior to
committing to placing the 12 mm port.
5 mm
(optional)
5 mm
Camera
12 mm
Figure 24 Laparoscopic sigmoid resection. Recommended port
placement is shown. The midepigastric 5 mm port is essential for
mobilization of the splenic flexure.
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diverticular disease — 20
Step 2: Evacuation of the Pelvic Fluid
Prior to placing the patient in the Trendelenburg position,
as much fluid as possible should be evacuated from the
abdomen and pelvis. Once accomplished, the patient can
be placed in the Trendelenburg position to remove the
small bowel from the pelvis and facilitate evaluation of the
pathology.
Step 3: Mobilization of the Sigmoid Colon
Careful dissection of the sigmoid colon should be
performed so as to identify the site of perforation. Once
visualized, an assessment can be performed as to the appro-
priateness of continuing with a lavage and drainage versus
the need for a resection. Should there be a large perforation
with active spillage of fecal contents, the best alternative at
this point is a Hartmann resection. If the perforation is small
and sealed off, then continuing with laparoscopic lavage is
warranted. Another advantage of mobilizing the sigmoid
colon from the lateral pelvic sidewall is to identify and drain
a contained abscess, which commonly forms in this area.
Step 4: Lavage and Placement of Drain
Once the site of the pathology has been identified and any
abscess cavity is drained, several liters of warm saline can be
used to wash out the abdomen and pelvis. Care should
be taken to evacuate as much of the fluid as possible after
completing the lavage. At this point, a large Jackson-Pratt
drain can be left in the pelvis adjacent to the site of previous
perforation of the colon. If this is brought out through the
12 mm port site, an attempt should be made to close the fascial
defect around the drain to help prevent a port-site hernia.
Elective Procedures
open resection
Open resection in the elective setting consists of steps 1
through 4 of the Hartmann procedure, followed by creation
of a primary colorectal anastomosis and a diverting loop
ileostomy (alternative steps 5 and 6) [see Emergency Proce-
dures, Hartmann Procedure, above].
laparoscopic resection
The patient is placed in a low lithotomy position with
minimal hip flexion. The right arm is well padded and
tucked at the side because both surgeons will be operating
from the right side of the table. Video monitors are placed
on both sides of the table. It is beneficial to place the patient
on a bean bag because a significant portion of the operation
will be performed with the patient in extremes of positioning.
Step 1: Placement of Trocars
The first port is placed at a periumbilical location by
means of an open Hasson approach, and a 30° laparoscope
is inserted. After pneumoperitoneum is achieved, the other
ports are placed under direct vision: 5 and 12 mm ports are
placed in the right lower quadrant, and an optional 5 mm
port may be placed in the midepigastrium [see Figure 24].
The midepigastric port facilitates mobilization of the left
colon and is essential for mobilization of the splenic flexure.
gastro
Step 2: Mobilization of Sigmoid Colon
After the abdomen has been explored, the patient is placed
in a steep Trendelenburg position, with the right side tilted
down. This position allows gravity to retract the small bow-
el into the upper abdomen. The sigmoid colon is mobilized
from its lateral peritoneal attachments, and the colon is
thereby converted to a midline structure. Mobilization is
extended superiorly along the descending colon and inferi-
orly to the pelvic cul-de-sac. The left ureter is then identified
and swept laterally away from the base of the mesentery [see
Video 1].
Division of colovaginal or colovesical fistula In most
patients, the fistula can be pinched off with no visible defect
in either the bladder or vagina or a very small defect.
Management options include leaving a Foley catheter for
7 to 10 days or placing a few absorbable sutures over the
defect and leaving a closed suction drain behind the bladder
or vagina.
Alternative approach to colonic mobilization and divi-
sion In place of the conventional approach (see above),
a medial-to-lateral approach can be undertaken. In this
approach, the initial dissection proceeds from the right side
of the colon, mobilizing the superior rectal vessels from the
sacral promontory. The left ureter is then visualized through
the window thus created before the sigmoid mesentery is
divided. Division of the sigmoid mesentery is performed in
a proximal-to-distal direction, with the inferior mesenteric
vessels generally divided first. Once the sigmoid mesentery
has been completely divided, the bowel is transected with
staplers at the rectosigmoid junction.
The advantage of the traditional approach is that sur-
geons are more familiar with it from corresponding open
procedures. In our view, given the difficulty of mastering
laparoscopic colon surgery, the medial-to-lateral approach
Video 1 Lateral to medial mobilization of the sigmoid colon.
diverticular disease — 21
to colonic mobilization only increases the steepness of the
learning curve without affording any significant benefit.
Step 3: Division of Rectum and Sigmoid Mesentery
An incision is made in the peritoneum along the right side
of the rectosigmoid mesentery and extended inferiorly to the
pelvic cul-de-sac. A window is created between the upper
rectum and its mesentery and enlarged to allow insertion of
an endoscopic gastrointestinal anastomosis (GIA) stapler
[see Figure 25]. The stapler is then fired once or twice to
divide the rectosigmoid bowel. The mesentery of the
sigmoid colon is sequentially divided with staplers, clips,
an ultrasonic scalpel, or the LigaSure system (Valleylab,
Boulder, CO) [see Video 2].
Step 4: Exteriorization of Sigmoid Colon
Once the colon is mobilized and the blood supply is
divided, either the Hasson incision is enlarged or a Pfan-
nenstiel incision is made to exteriorize the bowel, which is
then divided proximally. The anvil of a circular stapler is
inserted in the proximal colon and secured with a purse-
string suture. The bowel is then replaced into the abdomen,
and the incision is closed.
Step 5: Creation of Colorectal Anastomosis
After pneumoperitoneum is recreated, the circular stapler
is inserted transanally. The shaft is brought out through
either the top of the rectal stump or the anterior wall of
the rectum [see Figure 26]; the former is preferred if bowel
length is an issue. After the stapler is engaged but before it
is fired, the proximal colon is inspected to confirm that it is
not twisted. The stapler is then fired, and the anastomosis is
then tested under water to confirm the absence of an air
leak. Intraoperative colonoscopy may also be performed to
ensure the integrity of the anastomosis. If a leak is detected,
laparoscopic sutures can be placed across the anastomosis
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gastro diverticular disease — 22

Figure 26 Laparoscopic sigmoid resection. The shaft of the circular

stapler is guided through the top of the rectal stump by applying
countertraction with a laparoscopic instrument.

hand-assisted laparoscopic resection

Steps 1 and 2
The first two steps of a hand-assisted laparoscopic
Figure 25 Laparoscopic sigmoid resection. Division of the rectum resection are identical to steps 1 and 2 of a full laparoscopic
with the endoscopic stapler is shown. resection.

Step 3: Placement of Hand Device

and tied either intracorporeally or extracorporeally. This A 6 to 8 cm muscle-splitting incision is made in the
process is more challenging for leaks detected in the poste- left lower quadrant, and the hand device is placed [see
rior aspect of the staple line. Underwater testing is then Figure 27]. The surgeon’s left hand is placed through this
repeated [see Video 3]. device into the abdomen.

Video 2 Hand-assisted division of the superior rectum and division of the rectosigmoid mesentery.

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Video 3 Creation of colorectal anastomosis.
Step 4: Division of Rectum and Sigmoid Mesentery
The surgeon’s left hand is used to facilitate creation of a
window between the rectum and the underlying mesentery.
An endoscopic GIA stapler is safely guided through this
window, and the bowel is divided [see Figure 28a]. The hand
is then used to isolate segments of the mesentery for divi-
sion [see Figure 28b], as well as to help control vessels that
continue to bleed despite having been divided.
Steps 5 and 6
Steps 5 and 6 are identical to steps 4 and 5 of a full
laparoscopic resection.
Troubleshooting Having the surgeon’s hand in the
pelvis greatly facilitates engagement of the circular stapler
Figure 27 Hand-assisted laparoscopic resection. Placement of one
of the hand devices through which the surgeon’s hand is advanced
into the pelvis is shown.
diverticular disease — 23
and makes its closure safer by protecting the surrounding
structures [see Figure 29]. Furthermore, the presence of the
hand in the pelvis not only assists in testing the anastomosis
but also helps the surgeon better assess the degree of tension
(if any) on the anastomosis. Given that the size of the hand
port is similar to that of the extraction site in a full laparo-
scopic resection, we recommend that a hand-assisted
approach be used in difficult or complex cases.
laparoscopic hartmann closure
Step 1: Placement of Trocars
A port is placed by means of the Hasson technique at an
upper midline location, cephalad to the previous incision
if possible. A 30° laparoscope is inserted through this port.
After pneumoperitoneum is achieved, two 5 mm ports are
placed in the right lower quadrant to facilitate dissection of
pelvic and midline adhesions as necessary.
Step 2: Mobilization of Colostomy and Rectal Stump
All adhesions and attachments should be cleared away
from the intra-abdominal portions of the colostomy [see
Figure 30]. In addition, the top of the Hartmann pouch
should be cleared of all adherent small bowel or adjacent
structures. Occasionally, other ports may have to be placed
to facilitate takedown of adhesions, especially those from
the original midline incision. The colostomy is detached
from the skin circumferentially. The anvil of a circular sta-
pler is then placed in the proximal bowel after the exposed
portion of the colostomy has been resected.
Step 3: Placement of Hand and Completion of Anastomosis
(for Hand-Assisted Approach)
The colostomy site is enlarged slightly so that the sur-
geon’s left hand can be placed in the abdomen. The stapler
is engaged and fired while the surgeon’s hand keeps any
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gastro diverticular disease — 24

a b

Figure 28 Hand-assisted laparoscopic resection. (a) Placement of the surgeon’s hand intracorporeally facilitates division of the rectum. (b) The
surgeon’s hand isolates mesenteric vessels for subsequent division.

extraneous tissue away from the anastomotic area. The Complications

anastomosis is then tested by placing it under water and
insufflating air via a proctoscope.
Troubleshooting It is often easier to bring out the shaft
of the stapler through the anterior wall of the rectum, espe-
cially if there has been a significant inflammatory response
around the area of the Hartmann pouch. Occasionally, the
end of the Hartmann pouch cannot be reached with the
stapler secondary to rectal tortuosity and a lengthy stump.
The operator can guide the stapler with his or her hand,
attempt further mobilization and resection of the stump,
and/or bring the spike through at a more distal location
and leave a blind segment of rectum, as long as the distal
sigmoid colon is resected.
Operative management of diverticular disease poses
distinct challenges, the level of which is proportional to the
degree of inflammation present and to the urgency of the
procedure. Although many of the complications encoun-
tered are not specific to this setting but are common to all
abdominal procedures, there are several that warrant
particular attention in the context of surgical treatment of
diverticular disease.
anastomic leakage
The most serious and potentially life-threatening compli-
cation of procedures for diverticular disease is the develop-
ment of an anastomotic leak. Many factors contribute to the

a b

Figure 29 Hand-assisted laparoscopic resection. (a) The surgeon’s hand guides engagement of the circular stapler, protecting surrounding
pelvic structures from the stapler. (b) The anvil and stapler are engaged and the circular stapler has been fired to complete the anastomosis.

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gastro
Figure 30 Laparoscopic Hartmann closure. A laparoscopic view of
the colostomy after intra-abdominal adhesions have been divided is
shown.
maintenance of anastomotic integrity, ranging from the
surgeon’s technical ability to the patient’s comorbidities.
Of these factors, however, the single most important one is
probably the setting in which the operation is carried out.
Patients undergoing emergency procedures are at four times
higher risk for anastomotic leakage than those undergoing
elective procedures.221,222 Furthermore, the mortality has
been 13% in recent decades in patients presenting with
purulent peritonitis and 43% in those presenting with
feculent peritonitis; these figures suggest that performing
an anastomosis in these settings is unwise.28,189,223,224 The
mortality following emergency procedures for perforation
has remained high, in the range of 13 to 20%, in more recent
series.101,103,225
As with any anastomosis, the long-established basic tech-
nical principles—using healthy, uninflamed tissue; ensuring
an adequate blood supply; and avoiding tension on the
anastomosis—should be strictly adhered to. If any of these
principles cannot be followed, then either the patient should
undergo proximal diversion or (preferably) the problem
with the anastomosis should be corrected. For instance, in a
situation where the sigmoid inflammatory process extends
into the rectal mesentery, attempts should be made to resect
below the level of the inflammation, even if the process is
reaching well into the rectum itself. Another technical point
worth mentioning involves preserving the superior rectal
vessels, although no randomized prospective study has yet
been performed to determine whether this measure has any
significant positive effect.
recurrent disease
It is unusual for a recurrent diverticular fistula to develop
after takedown with resection of the involved colon. Much
more likely than the persistence of a diverticular fistula is
the development of a recurrent colovesical or colovaginal
fistula secondary to an anastomotic leak with drainage
through the point of least resistance (i.e., the anastomosis).
diverticular disease — 25
There is some question as to whether a recurrence of
diverticulitis after sigmoid resection is actually a complica-
tion of the procedure. Although it has been shown that
resection of all diverticulum-bearing colon is not required
for successful treatment of the disease process, it does
appear that the location of any remaining diverticulosis
influences the recurrence of the disease. Studies have dem-
onstrated that if a sigmoid resection with a colorectal anas-
tomosis is performed, the recurrence rate is 5%, whereas if
the anastomosis is performed to the distal sigmoid colon, the
recurrence rate rises to 12%.168,226 When recurrent diverticu-
litis develops, it is important to reexamine the histologic
findings from the original operation to rule out the possibil-
ity that the patient was misdiagnosed. Occasionally, diver-
ticulosis and Crohn disease coexist; recurrence of Crohn
disease is much more common than recurrence of diverticu-
losis and, given a long enough follow-up period, is actually
to be expected.
ureteral injury
Ureteral injuries occur in as many as 1% of patients under-
going diverticular resection.227 Because of the inflammatory
process associated with severe diverticular disease, it may
be difficult to identify the ureter as it crosses the bifurcation
of the iliac vessels; however, it is always possible to identify
the ureter more proximally and then follow it down to the
inflamed area. If a difficult dissection is anticipated or
if technical difficulties are encountered intraoperatively,
ureteral stents may be placed. These stents do not prevent
injuries from occurring, but they can facilitate early identifi-
cation of developing problems. Ureteral injuries should
always be repaired at the time of operation, in consultation
with the urologist.
anastomotic resection
Occasionally, patients may experience feelings of incom-
plete evacuation, tenesmus, or abdominal bloating. These
symptoms may be indicative of an anastomotic stricture.
Confirmation may be obtained using a Gastrografin enema
or flexible endoscopy. The incidence of symptomatic anasto-
motic stenosis after elective laparoscopic sigmoidectomy
is reported to be as high as 17.6%.228 Although no single
risk factor could be identified, adherence to good surgical
principles of a tension-free anastomosis with adequate
blood supply is essential. It is our opinion that less than an
intraluminal 29 mm stapler (Ethicon) or an end-to-end anas-
tomosis 31 mm stapler should never be used to perform the
anastomosis. The treatment of fibrotic strictures ranges from
dilatation or division with electrocautery to resection of the
stricture with performance of a new anastomosis.
Financial Disclosures: John P. Welch, MD, FACS, and Jeffrey L. Cohen, MD, FACS,
FASCRS, have no relevant financial relationships to disclose. This review was previ-
ously authored by Rafal Barczak, MD, and Louis Reines, MD, MBA, with disclosure
made at the time of initial publication. This review has been reviewed, updated, and
rereleased by the authors listed.
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Acknowledgments
Figures 1, 2, 4, 5, and 16 Alice Y. Chen
Figures 21 and 22 Dragonfly Media Group
Figure 24 Tom Moore