Complicated Sigmoid Diverticulitis Research Articles

Laparoscopic sigmoid colectomy for diverticulitis – stricture: A case report with review of literature

Diverticulosis is a common condition in the western world. It is often asymptomatic. However, its inflammation and the occurrence of its complications precipitate symptoms. Uncomplicated diverticulitis can be managed conservatively, most of the times. Complicated diverticulitis may need an endoscopic, interventional radiological, or surgical intervention. Herein, we report the case of a 53-year-old patient with complicated sigmoid diverticulitis, i.e., stricture caused by repetitive attacks of acute diverticulitis, who underwent a laparoscopic sigmoid colectomy followed by primary anastomosis.

Chronic sigmoid diverticulitis causing tubo-ovarian abscess and colo-uterine fistula

Abstract Colo-uterine fistulas are rarely reported in the literature, and its presentation in the presence of a tubo-ovarian abscess secondary to chronic sigmoid diverticulitis is currently not reported. As such, its presentation may pose a diagnostic dilemma. Here, we present a 68-year-old woman who was admitted under the colorectal service with a 1 month history of mild left iliac fossa pain, with computed tomography (CT) demonstrating complicated sigmoid diverticulitis. Progress CTs, however, demonstrated a progressively enlarging left iliac fossa mass, with air fluid levels, densely adherent to the sigmoid colon. The decision was eventually made to perform a laparoscopy, which demonstrated a left tubo-ovarian abscess communicating with the uterus and sigmoid colon, illustrating a colo-uterine fistula. Open resection of the sigmoid colon and uterus was performed and the patient recovered uneventfully. This case describes an uncommon complication of chronic sigmoid diverticulitis and the importance of its judicious surgical management.

Elective minimally invasive surgery for sigmoid diverticulitis: operative outcomes of patients with complicated versus uncomplicated disease.

The aim of this work was to compare the results of elective minimally invasive surgery between patients with complicated sigmoid diverticulitis and those with uncomplicated disease. An institutional review board-approved database was searched for all consecutive patients who underwent elective minimally invasive surgery, including laparoscopic, hand-assisted and robotic sigmoidectomy, for diverticulitis between 2010 and 2017; they were classified according to the modified Hinchey classification as having complicated (abscess, fistula, stricture, obstruction, bleeding or previous perforation) versus uncomplicated disease. Data recorded included baseline demographics, indications for surgery, operative details and complications. Three hundred and twenty-five patients underwent elective sigmoidectomy for complicated (n=105) and uncomplicated (n=220) diverticulitis. Surgical indications for complicated disease were abscess (n=74), stricture (n=14), fistula (n=28) and bleeding (n=7). The two groups were statistically comparable for age, gender, body mass index and American Society of Anesthesiologists score. Patients with complicated disease had higher rates of concomitant loop ileostomy creation (9.5% vs. 0.9%, p<0.001) and synchronous resections (9.5% vs. 2.7%, p=0.01), higher volumes of blood loss (177±140 vs. 125±92ml, p<0.001), longer length of stay (5.6±3 vs. 4.8±2days, p=0.04) and longer operating time (218.2±59 vs. 185.8±63min, p<0.001). There were no significant differences in anastomotic leakage (3% vs. 1%, p=0.3), conversion to laparotomy (4.8% vs. 2.3%, p=0.3) or overall complications (36% vs. 25.9%, p=0.06) for complicated versus uncomplicated disease, respectively. Minimally invasive surgery for complicated diverticulitis resulted in higher rates of construction of proximal ileostomy and synchronous resections and longer operating times and length of hospital stay. Otherwise, it has outcomes that are not significantly different from the results recorded in patients with uncomplicated disease.

Choice of operative procedure in diverticular disease : Taking the latest treatment strategies into consideration

There are various procedures to be considered in the surgical treatment of complicated diverticulitis, which must be selected depending on the classification of diverticular disease (CDD) type and the condition of the patient. Comparison of surgical procedures with respect to aspects such as morbidity, mortality, reconstructive surgery and postoperative quality of life. Evaluation, analysis and assessment of the current literature on surgical treatment of diverticular disease. Laparoscopic sigmoid resection with primary anastomosis is now considered the standard procedure for complicated sigmoid diverticulitis. It is preferable to open resection because of the better results of the minimally invasive approach with respect to the incidence of wound infections, abdominal abscesses and the occurrence of fascial dehiscence. In an emergency situation with perforation and peritonitis (CDD type2c1/2), primary anastomosis with protective ileostomy should be favored over discontinuity resection (Hartmann's procedure). In particular, it must be taken into account that in alarge proportion of patients there is no restoration of continuity after Hartmann's operation. The damage control strategy can be used in perforated sigmoid diverticulitis with generalized peritonitis (CDD type2c1/2). In individual cases, laparoscopic lavage with insertion of adrainage may be considered as atherapeutic treatment strategy for perforated sigmoid diverticulitis with purulent peritonitis (CDD type2c1). Selection of the surgical procedure for complicated sigmoid diverticulitis remains challenging. Randomized controlled trials of new treatment strategies as well as robotic-assisted surgery should be considered in the choice of surgical procedure in the future.

Systematic review of failure of nonoperative management in complicated sigmoid diverticulitis with abscess.

The aim of this systematic review was to determine the rates of failure following nonoperative management for acute sigmoid diverticulitis complicated by abscess. Pubmed and Medline were systematically searched by two independent researchers. Studies reporting outcomes of nonoperative management of diverticulitis with abscess revealed on CT scan were included. The endpoint of the study was failure of nonoperative management which included relapse and recurrence. Relapse was defined as development of additional complications such as peritonitis or obstruction that required urgent surgery during index admission or readmission within 30days. Recurrence was defined as development of symptoms after an asymptomatic period of 30-90days following nonoperative management. Nonoperative management included nil per os, intravenous fluids and antibiotics, CT-guided percutaneous drainage, and/or total parenteral nutrition. Twenty-four of 844 studies yielded by literature search totaling 12,601 patients were eligible for inclusion. Pooled relapse rate was 18.9%. The pooled rate of recurrence of acute diverticulitis was found to be 25.5%. 60.9% of recurrences were complicated diverticulitis. Failure rate appeared to be significantly increased in patients undergoing percutaneous drainage for distant abscess as compared with pericolic abscess (51% vs. 18%; p = 0.0001). The rate of failure of nonoperative management was 44.4%. The rate of relapse at 30days following nonoperative management was at 18.9%. Distant abscesses were associated with significantly increased rates of relapse compared with pericolic abscesses. The rate of recurrence following nonoperative management was 25.5% at themean follow-up of 38months.

An Unexpected Masquerader: A Case of Acute Fulminant Colitis Secondary to Ulcerative Colitis

Inflammatory bowel disease (IBD) has a bimodal age distribution with a second peak between 50 and 80 years. We report a case of fulminant colitis in a 74-year-old Caucasian Male presenting with diarrhea and intermittent left lower quadrant pain. His medical history was pertinent for an episode of acute complicated sigmoid diverticulitis with perforation, and abscess formation 2-months prior. A CT-guided drainage was performed then and he was treated with a course of piperacillin-tazobactam and amoxicillin-clavulanic acid. A sigmoidoscopy was performed 4 weeks later and findings included a sigmoid stricture, pseudo-membranes and a 4 cm sigmoid tubular adenoma; which was resected. A Clostridium Difficile test was positive and the patient was started on oral vancomycin. The patient reported worsening of his symptoms and developed hematochezia. His repeat diagnostic evaluation was remarkable for a mild neutrophilic leukocytosis of 13,200 cells/mm3, marked lactic acidosis and negative C. Difficile testing. A CT-scan of the abdomen revealed diffuse colitis and a repeat flexible sigmoidoscopy demonstrated ischemic changes and multiple areas of friable mucosa. The patient further deteriorated and underwent a total colectomy with ileostomy given concern for ischemic colitis. Saccharomyces Cervisiae IgA and IgG titers were positive and ANCA testing was negative. Pathology results revealed chronic active colitis with cryptitis, crypt abscesses, and absence of granulomas with multiple diverticula. Morphology was consistent with a diagnosis of fulminant colitis secondary to ulcerative colitis. The patient underwent a complicated post-operative course with the development of postoperative pneumonia, pulmonary edema and ventilator dependent respiratory failure requiring tracheostomy placement. This case serves to illustrate the importance of recognizing the bimodal distribution of inflammatory bowel disease (IBD), entertaining the diagnosis in elderly patients presenting with colitis, and the importance of a multi-disciplinary approach to establishing a diagnosis of IBD involving clinicians and pathologists. The presence of an anchoring bias to the diagnosis of acute diverticulitis when the first sigmoidoscopy was performed and the attribution of the patient's colitis to C. Difficile colitis and later ischemic colitis led to a late diagnosis of IBD with significant morbidity noted. The case also highlights the utility of serologies in diagnosing IBD.

The appropriateness of ceftriaxone and metronidazole as empirical therapy in managing complicated intra-abdominal infection-experience from Western Health, Australia.

PurposeThis study aims to assess the microbiological profile, antimicrobial susceptibility and adequacy of intravenous ceftriaxone and metronidazole as empirical therapy for surgical patients presenting with complicated intra-abdominal infection.MethodsThis retrospective audit reviews the microbiological profile and sensitivity of intra-abdominal cultures from adult patients with complicated intra-abdominal infection who presented to the emergency department at Western Health (Melbourne, Australia) between November 2013 and June 2017. Using the hospital’s database, an audit was completed using diagnosis related group (DRG) coded data. Ethics approval has been granted by the Western Health Human Research Ethics Committee. Results are stratified according to surgical conditions (appendicitis, cholecystitis, sigmoid diverticulitis and bowel perforation). The antimicrobial coverage of ceftriaxone and metronidazole is evaluated against these microbial profiles.ResultsA total of 1,412 patients were identified using DRG codes for intra-abdominal infection. All patients with microscopy and sensitivity results were included in the study. Patients without these results were excluded. 162 patients were evaluable. 180 microbiological cultures were performed through surgical intervention or radiologically guided aspiration of the intra-abdominal infection. Single or multiple pathogens were identified in 137 cultures. The most commonly identified pathogens were mixed anaerobes (12.6%), Escherichia coli (E. coli) (12.1%), mixed coliforms (11.6%) and Pseudomonas aeruginosa (7%). Other common pathogens (6% each) included Enterococcus faecalis, Streptococcus anginosus, Vancomycin-resistant Enterococci (VRE) and Extended Spectrum Beta-Lactamases (ESBL) producing E. coli. Organisms isolated in our study are consistent with existing literature. However, a significant proportion of antibiotic resistant organisms was identified in cases of perforated bowel and sigmoid diverticulitis. Broader spectrum antimicrobial therapy should therefore be considered in lieu of ceftriaxone and metronidazole in these cases. Ceftriaxone and metronidazole remain as appropriate empirical therapy for patients who presented with perforated appendicitis and cholecystitis.DiscussionThe empirical regime of ceftriaxone and metronidazole remains appropriate for intra-abdominal infection secondary to appendicitis and cholecystitis. In cases involving perforated small and large bowel, including complicated sigmoid diverticulitis, the judicious use of ceftriaxone and metronidazole is recommended.

Sigmoid resection versus observation after initial conservative treatment of a complicated sigmoid diverticulitis

Sigmoid resection versus observation after initial conservative treatment of a complicated sigmoid diverticulitis

Tu1696 - Clinical Outcomes of Complicated Sigmoid Diverticulitis with Associated Tubo-Ovarian Abscess

Tu1696 - Clinical Outcomes of Complicated Sigmoid Diverticulitis with Associated Tubo-Ovarian Abscess

Complicated Sigmoid Diverticulitis Presenting as Severe Necrotizing Soft Tissue Infection

Background: Necrotizing soft tissue infection is a rare and aggressive medical and surgical emergency characterized by intense and severe tissue destruction, rapid onset systemic toxicity, and high mortality. Diverticulitis is a common complication of diverticular disease. However, its presentation as necrotizing soft tissue infection is rare. It is always important to identify the precipitating cause of necrotizing soft tissue infection to assist in appropriate treatment and risk stratification. Case Presentation: The patient was an 84-year-old female with a history of hypertension and chronic obstructive pulmonary disease with long-term steroid dependency. She presented to the emergency department with abdominal tenderness, left abdominal wall cellulitis, crepitus, and septic shock. Abdominal and pelvic computed tomography findings showed intra-abdominal abscess secondary to perforated sigmoid diverticulitis with abdominal wall abscess and necrotizing soft tissue infection of abdominal wall, chest wall, groin, and back. After intravenous fluid resuscitation and antibiotics, the patient underwent urgent laparotomy. She was found to have a large abdominal wall abscess, perforated sigmoid diverticulitis, and extensive necrosis of the torso extending from the groin to chest wall including the back. Conclusion: Abdominal wall necrotizing soft tissue infection is an uncommon complication of perforated diverticulitis. In an elderly immunocompromised patient with septic shock, perforated diverticulitis, and necrotizing soft tissue infection, the prognosis is poor.

Laparoscopic peritoneal lavage: our experience and review of the literature.

IntroductionOver the years various therapeutic techniques for diverticulitis have been developed. Laparoscopic peritoneal lavage (LPL) appears to be a safe and useful treatment, and it could be an effective alternative to colonic resection in emergency surgery.AimThis prospective observational study aims to assess the safety and benefits of laparoscopic peritoneal lavage in perforated sigmoid diverticulitis.Material and methodsWe surgically treated 70 patients urgently for complicated sigmoid diverticulitis. Thirty-two (45.7%) patients underwent resection of the sigmoid colon and creation of a colostomy (Hartmann technique); 21 (30%) patients underwent peritoneal laparoscopic lavage; 4 (5.7%) patients underwent colostomy by the Mikulicz technique; and the remaining 13 (18.6%) patients underwent resection of the sigmoid colon and creation of a colorectal anastomosis with a protective ileostomy.ResultsThe 66 patients examined were divided into 3 groups: 32 patients were treated with urgent surgery according to the Hartmann procedure; 13 patients were treated with resection and colorectal anastomosis; 21 patients were treated urgently with laparoscopic peritoneal lavage. We had no intraoperative complications. The overall mortality was 4.3% (3 patients). In the LPL group the morbidity rate was 33.3%.ConclusionsCurrently it cannot be said that LPL is better in terms of mortality and morbidity than colonic resection. These data may, however, be proven wrong by greater attention in the selection of patients to undergo laparoscopic peritoneal lavage.

Role of minimally invasive surgery in the treatment of diverticular disease: an evidence-based analysis.

The clinical spectrum of diverticular disease varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications, such as perforation or bleeding. While the presence of diverticula is common, symptomatic diverticulitis is relatively uncommon, occurring in an estimated 10-30 % of patients. There is continued debate as to whether patients should undergo elective resection for diverticular disease and regarding the role of minimally invasive surgery. Since the first publication on laparoscopic colorectal procedures, the interest in minimally invasive surgery has kept growing. Laparoscopic sigmoid resection with restoration of continuity is currently the prevailing modality for treating acute and recurrent sigmoid diverticulitis. However, it still remains unclear whether laparoscopy should be recommended also for complicated sigmoid diverticulitis. The potential benefits of reduced pain and analgesic requirements, smaller scars, and shorter hospital stay but longer operative times are appealing to both patients and surgeons. Nevertheless, there many concerns regarding the time and the type of surgery. Although the role of minimally invasive surgery in the treatment of colonic diseases is progressively increased, current randomized controlled trials should demonstrate whether laparoscopic lavage, Hartmann's procedure or resection and anastomosis achieve the best results for patients. This review aimed to analyze the results of laparoscopic colonic resection for patients with uncomplicated and complicated forms of sigmoid diverticular disease and to determine what stages profit from a laparoscopic procedure and whether the approach can be performed with a low complication rate even for patients with complicated forms of the disease.

Acute and Elective Laparoscopic Resection for Complicated Sigmoid Diverticulitis: Clinical and Histological Outcome

BackgroundSurgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis. MethodsA retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results. ResultsNinety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified. ConclusionsLaparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.

Die Kolondivertikulose und ihre Komplikationen: Pathogenese, Klassifikation und Klinische Implikationen

Current understanding of the pathogenesis of colonic diverticulosis and its complications has certain implications for current therapy concepts, which are summarised here. Colonic diverticula in the Western world are pseudodiverticula predominating in the sigmoid colon. Pathogenesis is multifactorial and includes low-fibre diet, dysmotility, increased intraluminal pressure and morphological changes. Uncomplicated diverticulitis results from microperforations, contradicting the hypothesis of the "abscessed diverticulum". Administration of antibiotics for treatment is controversial. Complicated sigmoid diverticulitis is characterised by an intensive inflammatory infiltrate with macrophages. Immunosuppression and especially steroid intake are identified as risk factors. Nowadays, elective or emergency resection is generally recommended as therapy of first choice. However, contrary concepts with merely conservative treatment or drainage--even for perforated diverticulitis--are emerging. The pathogenesis of chronically recurrent diverticulitis is poorly understood and concepts are changing. Resection after the second episode is replaced by a risk-adapted strategy. Diverticular bleeding occurs due to rupture of a vas rectum at the fundus of the diverticulum. Conservative and endoscopic management is the first line and surgical resection plays a role as salvage-strategy in case of recurrent and life-threatening bleeding. Localising the bleeding, i.e., with angiography, is crucial prior to surgery. The pathophysiology of colonic diverticulosis is complex and incompletely understood and linked with several controversial issues, regarding treatment strategies.

Glucocorticoid‐induced tumour necrosis factor receptor expression: a potential molecular link between steroid intake and complicated diverticulitis?

Immunosuppression and steroid medication have been identified as risk factors for complicated sigmoid diverticulitis. The underlying molecular mechanisms have not yet been elucidated. We hypothesized that glucocorticoid-induced tumour necrosis factor receptor (GITR) and matrix metalloproteinase-9 (MMP-9) might play a role. GITR and MMP-9 were analysed at protein [immunohistochemistry/immunofluorescence (IF)] and messenger RNA level (real-time polymerase chain reaction) in surgical specimens with complicated and non-complicated diverticulitis (n=101). IF double staining and regression analysis were performed for both markers. GITR expression was correlated with clinical data and its usefulness as a diagnostic test was investigated. High GITR expression (≥41%) was observed in the inflammatory infiltrate in complicated diverticulitis, in contrast to non-complicated diverticulitis where GITR expression was low (P<0.001). High GITR expression was significantly associated with steroid use and pulmonary diseases (both P<0.001). MMP-9 expression correlated with GITR expression (R(2) =0.7268, P<0.0001, r=0.85) as demonstrated with IF double-staining experiments. Co-labelling of GITR with CD68, but not CD15, suggested that GITR-expressing cells in diverticulitis are macrophages. GITR expression was superior to C-reactive protein (CRP), white cell count and temperature in distinguishing complicated and non-complicated diverticulitis. Our results suggest that GITR expression in inflammatory cells might potentially indicate a molecular link between steroid use and complicated forms of acute sigmoid diverticulitis. Increased MMP-9 expression by GITR signalling might explain the morphological changes in the colonic wall of perforated and phlegmonous diverticulitis. Analysis of soluble GITR might be a promising strategy for future research.

Hepatic Portal Venous Gas from a Complicated Sigmoid Diverticulitis Masquerading as Hypoxemia and Pulmonary Embolism

Hepatic Portal Venous Gas from a Complicated Sigmoid Diverticulitis Masquerading as Hypoxemia and Pulmonary Embolism

Allergic Predisposition, Histamine and Histamine Receptor Expression (H1R, H2R) Are Associated with Complicated Courses of Sigmoid Diverticulitis

BackgroundWe aimed to evaluate our hypothesis that allergic predisposition and expression of histamine receptors might contribute to complicated courses of sigmoid diverticulitis. MethodsExpression of histamine and histamine receptors (H1R, H2R) was analysed on protein level (immunohistochemistry/immunofluorescence (IF)) as well as mRNA level (reverse transcription–PCR (RT-PCR) in surgical specimen of patients (n = 101) having undergone resection for sigmoid diverticulits (n = 57 complicated diverticulitis/n = 44 non-complicated diverticulitis). ResultsThe mean number of comorbid diseases per patient was 1.76 ± 1.25. Thirty-nine of 101 patients (38.6%) exhibited allergic predisposition (grass poll, food, drug, pets, etc.). Comorbid diseases were significantly associated with complicated diverticulitis (p = 0.027). Complicated sigmoid diverticulitis was significantly associated with high H1R and H2R expression (p < 0.001). Furthermore, an association of complicated diverticulitis with allergic predisposition was found (odds ratio = 3.2, p = 0.0097). IF double-labelling experiments showed a strong correlation of increased histamine expression with expression of H1R and H2R on intestinal enterocytes (histamine/H1R, rho = 0.841, p < 0.0001 and histamine/H2R, rho = 0.806, p < 0.0001). The results of increased H1R and H2R expression in complicated sigmoid diverticulitis were also detected on mRNA level in a subset of patients (RT-PCR, p = 0.009). ConclusionsOur findings suggest that allergic predisposition might be another important risk factor for complicated courses of acute sigmoid diverticulitis and linked with histamine receptor expression. Supportive therapies with antihistaminic drugs might become an option. Allergic predisposition might be worth considering when indicating surgery for sigmoid diverticulitis.

Association of steroid use with complicated sigmoid diverticulitis: potential role of activated CD68+/CD163+ macrophages

Immunosupression and, especially, intake of steroids have previously been identified as risk factors for complicated types of sigmoid diverticulitis. However, little is known about the underlying molecular and cellular mechanisms. We aimed to elucidate the potential role of activated macrophages in this respect. A consecutive series of n = 101 patients having undergone surgical resection for sigmoid diverticulitis at our institution was analyzed regarding the inflammatory infiltrate and prevalence of comorbid diseases as well as risk factors, including steroid use. Fifty-seven patients had complicated types of diverticulitis with severe inflammation (group A). Forty-four patients had moderate inflammation, most of whom had been operated for chronically recurrent diverticulitis (group B). Randomly selected 50 patients (n = 20/group A/n = 30 group B) underwent immunolabelling against CD68 and CD163. Using immunofluorescence double labeling experiments we found a strong positive correlation of CD68 expression with CD163 expression (т = 0.934). High CD68 expression (x ≥ 23%) and high CD163 expression (x ≥ 22%) within stromal cells of the lamina propria was significantly associated with steroid use (CD68, p = 0.012 and CD163, p = 0.004, respectively) and complicated sigmoid diverticulitis with severe inflammation (CD68, p = 0.0001 and CD163, p = 0.001, respectively). Inflammation, especially mediated by activated (CD68+/CD163+) macrophages in histopathological specimen might resemble the cellular link between steroid use and complicated types of sigmoid diverticulitis. Macrophages might be a suitable target for future supportive/preventive therapies. However, as long as we are lacking such strategies, we must bear in mind that steroid intake is a risk factor for complicated diverticulitis, especially when indicating surgical resection.

Surgical Dilemmas in Diverticular Disease

On completion of this educational activity, learners will be better able to: (1) Differentiate between the presentation and clinical course of diverticulitis in transplant patients and the nonimmunosuppressed population. (2) Illustrate that early and aggressive medical management or surgery can reduce the morbidity and mortality associated with diverticulitis in transplant patients. Transplant patients are at risk for a variety of gastrointestinal complications due to long-term immunosuppression. One such complication is colonic perforation in the setting of diverticular disease. While complicated diverticulitis has been reported in heart, lung, and kidney transplant patients, here we report the first case of complicated sigmoid diverticulitis in a patient after an orthotopic liver transplant. We also present a case where complicated diverticulitis can progress to free perforation in the setting of immunosuppression in transplant patients. Although not associated with an increased risk of development of diverticular disease, long-term immunosuppression not only increases risk of colonic perforation in the setting of diverticular disease but also masks the clinical signs and symptoms. Therefore, transplant patients with vague symptoms of abdominal pain should be evaluated and followed vigilantly for diverticulitis and signs of perforation.

Sind eine laparoskopische Diskontinuitätsresektion und eine spätere laparoskopische Rekonstruktion bei der komplizierten Sigmadivertikulitis möglich?

Surgery of complicated sigmoid diverticulitis should be as gentle as possible. Serious time pressure, unpredictable operation fields and unprepared bowel determine the surgical strategy. Hence, we examine whether minimal invasive surgery (MIS) (i. e., Hartmann procedure) is suited for emergency conditions in selected patients. Furthermore, the objective of the study was to -assess the feasibility of the reversal of Hartmann procedure in appropriate patients after a preceding classical or laparoscopic intervention. -Between 2005 and 2009 128 patients with sigma diverticulitis were operated, 72 patients of them with complicated sigmoid diverticulitis (peritonitis, haemorrhage, ileus, perforation), The classical Hartmann procedure was performed in 45 (35 %) patients, 39 of them being treated within 24 hours. The laparoscopically assisted Hartmann procedure was realised in 15 patients and could be successfully completed in 13 cases. The cor-responding mortality rate was 0 %. A Hartmann reversal could be performed in 26 patients (58 %). A laparoscopic approach was chosen in 16 patients and could be successfully completed in 14 cases. 12 patients were operated with classical Hartmann reversal. The respective mortality rates in both groups were 0 %. We therefore conclude that in cases of peritonitis due to sigmoid diverticulitis laparoscopic surgery, like laparoscopically assisted Hartmann procedure and a subsequent laparoscopically assisted reversal could be recommended in selected patients.