Diverticular Stricture Research Articles

CT Colonography Reporting and Data System (C-RADS): Version 2023 Update.

The CT Colonography Reporting and Data System (C-RADS) has withstood the test of time and proven to be a robust classification scheme for CT colonography (CTC) findings. C-RADS version 2023 represents an update on the scheme used for colorectal and extracolonic findings at CTC. The update provides useful insights gained since the implementation of the original system in 2005. Increased experience has demonstrated confusion on how to classify the mass-like appearance of the colon consisting of soft tissue attenuation that occurs in segments with acute or chronic diverticulitis. Therefore, the update introduces a new subcategory, C2b, specifically for mass-like diverticular strictures, which are likely benign. Additionally, the update simplifies extracolonic classification by combining E1 and E2 categories into an updated extracolonic category of E1/E2 since, irrespective of whether a finding is considered a normal variant (category E1) or an otherwise clinically unimportant finding (category E2), no additional follow-up is required. This simplifies and streamlines the classification into one category, which results in the same management recommendation.

Low incidence of occult colorectal carcinoma in a cohort of 150 consecutive patients with diverticular strictures

BackgroundThe symptoms of stricturing diverticulitis can overlap with those of colorectal cancer. Additionally, the stricture itself may mask a “hidden” colorectal cancer. We aimed to describe the demographics, operative details and outcomes, including occult colorectal cancer, in a cohort of consecutive resections for presumed diverticular strictures. MethodsIn this single-center, retrospective cohort study, all patients undergoing resection for a presumed diverticular stricture between January 2010 and December 2015 were included. Preoperative imaging and colonoscopies were individually reviewed. Only patients with radiographically, endoscopically and/or intraoperatively benign-appearing strictures were included. ResultsOne hundred fifty patients (72.7% female, mean age = 70.4 ± 11.8 years, 62.7% elective) were included. Only 34 (22.7%) had a complete preoperative colonoscopy. In 95 (63.6% of cohort) patients, the stricture was non-traversable colonoscopically. Overall, 47 (31.3%) patients did not have complete preoperative imaging or a colonoscopy.In total, 53.3% were open procedures and 62% had non-diverted primary anastomosis. Eleven (14.7%) underwent resection of adjacent organs (5 appendixes/5 right colons/7 fallopian tubes ± ovaries/3 small bowel resections/2 partial cystectomies/1 spleen). The median length of stay was 7 (5, 12.5) days. Only 2 cancers (1.3% of patients) involving the stricture (1 invasive moderately differentiated sigmoid adenocarcinoma/1 lymphoma) were found. Three additional cancers were found in organs involved in the inflammatory process (20% of concomitantly resected organs, 1 ovarian carcinoma/1 leukemia in a lymph node/1 appendiceal tumor). ConclusionDespite approximately one-third of the cohort not having undergone successful preoperative colonoscopy or imaging, the rate of neoplasia involving diverticular strictures was only 1.3%. A relatively high cancer rate was found in concomitantly resected organs involved in the stricturing process.

Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common Disorder

Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common Disorder

Outcomes After Colonic Self-Expanding Metal Stent Insertion Without Fluoroscopy: A Surgeon-Led 10-Year Experience

IntroductionColonic self-expanding metal stents (SEMS) can be used to relieve malignant and benign large bowel obstruction (LBO) as a bridge to surgery (BTS) and for palliation. Guidelines suggest the use of fluoroscopic guidance for deployment. This may be difficult to obtain after hours and in certain centers. We aimed to determine the outcomes of stenting under endoscopic guidance alone. MethodsAll patients who underwent SEMS insertion in our tertiary referral center between August 2010 and June 2021 were identified from a prospectively maintained database. Patient demographics (age/gender), disease characteristics (benign versus malignant/location/stage), stenting intent (BTS versus palliative), and outcomes (technical success/stoma/time from stenting to resection/death/study end) were analyzed. ResultsFifty-three (n = 39, 73.6% male) patients underwent SEMS insertion. Indications included colorectal carcinoma (n = 48, 90.6%), diverticular stricture (n = 3), and gynecological malignancy (n = 2). In five (9.4%) patients (four BTS and one palliative), SEMSs deployment was not completed because of the inability to pass the guidewire. All underwent emergency surgery. In the BTS cohort (n = 29, median 70.4 [range 40.3-91.8] years), 10 patients underwent neoadjuvant chemoradiotherapy. The permanent stoma rate was 20.7% (n = 6). There was no 30- or 90-d mortality. In the palliative cohort (n = 24, median age 77.1 [range 54.4-91.9]), 16 (66.7%) were deceased at the study end. The median time from stenting to death was 5.2 (2.3-7.9) months. ConclusionsSEMS placed under endoscopic visualization alone, palliatively and as a BTS, had acceptable stoma, morbidity, and mortality rates. These results show that SEMS insertion can be safely performed without fluoroscopy.

TP7.2.14 Long Term Outcome of Patients with Minimally Symptomatic Diverticular Stricture

Abstract Aims Minimally symptomatic diverticular stricture poses diagnostic and management dilemma for the Colorectal Surgeon. Long term outcome, risk of missing a cancer and complications are not well documented in the literature. This study aims at assessment of outcomes of patients with minimally symptomatic diverticular stricture who were treated conservatively. Methods Retrospective chart review of all patients with confirmed diverticular stricture on endoscopy and imaging scans who had minimal or mild symptoms over a 6-year period from January,2014 to June,2020 in a large tertiary referral hospital. Search methods included diverticular disease with stricture using ICD10 code K57 and K56.6. Outcome measures included complications while on conservative treatment including missed cancer, any subsequent surgery and complications including stomas. Results 29 patients fitted the inclusion criteria, 18 females with median age 75(43-92). Median follow up was 32.5 months (8-93). All had endoscopic and CT imaging confirmation of diverticular stricture. Repeat investigations were recorded as 16 endoscopies in 9 patients and 30 CT scans in 14 patients during follow up. Four patients had at least one episode of diverticulitis; only one underwent emergency surgery at 5 years from diagnosis. 2/29 (6.9%) patients presented with diverticular perforation requiring Hartmann’s procedure. One patient (3%) had elective sigmoid resection with average duration of follow up 29 months (11.5-59) months. There were no missed diagnosis of cancer and no mortality due to diverticular disease. Conclusions In this patient population, diverticular stricture runs a relatively benign course with few complications or surgical intervention during follow up.

1118 The Role of Emergency Surgery in Diverticular Strictures of Those Who Were Initially Managed Conservatively

Abstract Aim The presence of diverticulosis can lead to several different complications including formation of strictures. However, the literature concerning management of diverticular strictures is poor. The purpose of this study is to evaluate the patients who were initially treated non surgically and had to undergo emergency surgery. Method A retrospective study was performed using a cohort of patients between 2016 and 2020 where 84 patients with diverticular strictures were identified and followed up. Data on the management of diverticular stricture was captured using the hospital’s electronic medical records. Results Out of 84 patients with diverticular strictures, 9 had elective surgery without any medical treatment while 75 had medical treatment first. Out of the 75 patients who were medically treated, 12 underwent emergency surgery while 2/75 underwent elective surgery after receiving medical treatment due to ongoing symptoms. Out of the 12 patients that underwent emergency surgery, 9 patients presented with obstruction while 3 had a bowel perforation. 6 patients had Hartmann’s procedure, 5 had defunctioning colostomy and 1 patient had adhesiolysis. No patient deaths were recorded at 12 months. Conclusions Although medical management remains the preferred method of managing diverticular strictures in the UK, it is not without its complications. 1 in 5 patients had an acute surgical admission requiring emergency surgery. This raises the importance of a good ‘safety net’ in those managed non-surgically, to reduce delays associated with seeking medical advice. We also appreciate the importance of carrying out more extensive studies to establish the best way to manage diverticular strictures.

689 A Service Evaluation of Colonic Stent Procedures Over A 10 Year Period at University Hospital Bristol

Abstract Introduction The National Institute of Clinical Excellence (NICE) updated guidance in January 2020 and recommend colonic stent insertion for acute left-sided bowel obstruction as either palliative treatment or a bridge to elective surgery. Colonic stent insertion has shown improved outcomes in reducing hospital stay and stoma rate when compared to emergency surgery in patients presenting with large bowel obstruction. Objectives This service evaluation aimed to identify indications, complications, and outcomes of colonic stent insertion at University Hospital Bristol(UHB). Method Retrospective analysis of all colonic stent procedures performed at UHB between 1st January 2010 to 31st May 2020. Results 87 patients had a colonic stent procedure. 60(69%) were performed as an emergency and 27(33%) electives. Obstruction was secondary to a tumour in 84(97%) patients and diverticular strictures in 3(3%). 19(22%) had stent insertion as a bridge to elective surgery. 64(74%) stents were successfully deployed. 15(75%) required emergency surgery where the stent was unsuccessful. Complications occurred in 9(14%) successfully deployed stents, including: perforation(1;1%); per-rectal bleed(1;1%); dislodgement(1:1%); bacterial translocation(1;1%); tenesmus(2;2%); more than one stent required(3;3%). 30-day mortality was 11%. Conclusions The majority of colonic stent procedures at UHB were for patients presenting with acute large bowel obstruction secondary to malignancy. Few of these patients were suitable for surgery and stent insertion primarily for symptom relief. Where stent insertion is unsuccessful there is a high conversion (75%) to emergency surgery. Complications were observed in 14% of stent procedures and 30-day mortality was 11%.

A Case of Crossed Left Renal Ectopia Identified during Colostomy Reversal

Unilateral crossed renal ectopia without fusion is an uncommon anatomic anomaly, which often goes undiagnosed. We report a case of this renal variant discovered incidentally during colostomy reversal after Hartmann's procedure for diverticular stricture.

Technical and Clinical Outcomes Following Colonic Stenting: A Seven-Year Analysis of 268 Procedures.

To assess the factors contributing to the technical and clinical success of colorectal stenting for large bowel obstruction. 268 cases of colonic stenting for large bowel obstruction were performed in 249 patients of mean age of 72years (28-98) between 2006 and 2013. The majority of strictures were due to malignant disease, 244/268 (91%). Diverticular strictures accounted for 24/268 (9%). Overall technical success rate was 81% (217/268), with a clinical success rate of 65% (174/268). Duration of symptoms ranged from 0 to 180days (mean 8days). Technical success rate was seen to decrease with increasing symptom duration. For symptom duration of less than 1week, technical success was 85.4% (181/212) versus 69.6% (39/56) for those with symptoms of greater than a week (p<0.05). Clinical success rates fell from 71.3% (107/150) to 59.3% (70/118) (p<0.05) when attempting to stent lesions of greater than 5cm. There was also a significant reduction in clinical success when stenting lesions on a bend rather than a straight segment of colon 75.7% (109/144) versus 59.7% (74/124) (p<0.05). A total of 20 (7.46%) perforations were identified during the study. Stent migration occurred in 6.6% of cases. In-stent stenosis occurred in 3.3%. The overall 30-day all cause mortality rate was 9%. Lesion size, location and duration of obstructive symptoms are statistically significant determinants of patient outcome. These factors could be used to advise patient selection for colonic stenting or direct progression to surgical intervention.

Variation in caecal intubation rates between screening and symptomatic patients.

The caecal intubation rate (CIR) is an important quality standard for endoscopists, as well as for national bowel cancer screening programmes; however, individuals undergoing colonoscopy for bowel screening and symptomatic patients represent different groups, and their characteristics may affect colonoscopy performance. To compare colonoscopists' performance, as assessed by the CIR, in symptomatic patients compared to individuals undergoing colonoscopy for bowel cancer screening. Retrospective audit of CIRs for all patients undergoing colonoscopy at our institution during the year 2008. We retrieved the data from an endoscopy reporting software database and from the local bowel cancer screening programme database. Demographic data was extracted, as well as details of known factors that may affect completion of colonoscopy, such as poor bowel preparation, presence of diverticular disease, polyps, tumour and strictures. The unadjusted CIRs for colonoscopists participating in the screening programme were compared between the bowel screening and the symptomatic patient groups. Five screening colonoscopists performed 1056 colonoscopies, of which 488 were bowel screening procedures. The overall CIR was significantly lower in the symptomatic, compared to the screening, individuals (88.5% versus 93%, P < 0.02). No significant differences were observed between the two groups for risk factors that could impair the CIR. The CIR was <90% for two of the five colonoscopists in symptomatic patients, and just under 90% for one colonoscopist in screening individuals. Multivariate analysis revealed that non-screening colonoscopy was an independent predictor for an incomplete procedure (OR 1.8; 95% CI 1.2-2.8). The CIR, a key quality performance indicator for colonoscopy, is lower in symptomatic patients compared to individuals undergoing colorectal cancer screening. These results suggested that CIR should be monitored independently in screening and non-screening colonoscopies.

Mo1077 Clinical Efficacy of Same Day CT Colonography Following Incomplete Colonoscopy

Background: Colonoscopy is the preferred screening method for colorectal cancer (CRC) but may be incomplete in 4% to 25% of cases. CT colonography (CTC) is an adjunct to evaluate the colon after an incomplete colonoscopy (IC). No study has focused on same day CTC after an IC. Our primary aim was to determine the yield of same day CTC after IC. Methods: Our institution has the capability to perform same day CTC in patients with an incomplete colonoscopy. This was a retrospective review of all CTC done immediately following IC from January 2008 to December 2012. 198 CTC met inclusion criteria. Descriptive statistics were used. Results: Of 198 patients with IC and CTC 50 patients had 61 intracolonic findings. 23/50 (46%) were screening procedures, 1/50 (2%) high risk screening, 17/50 (34%) had a diagnostic colonoscopy and 9/50 (18%) surveillance colonoscopy. 10/50 patients had 12 findings on CTC on areas that were not reached by incomplete colonoscopy. 6 of these 10 patients had a follow up intervention: 2 had retrograde double balloon enteroscopy and 4 had colonoscopies. 3 findings correlated with CTC (1 ascending colon adenocarcinoma and 2 polyps) and 3 did not ( normal colonoscopy/DBE). 40 patients had 49 colonic findings on CTC on areas reached but not described during IC. 19/49 (39%) findings were not described during the initial colonoscopy. Only 6 of these 40 pts had a repeat colonoscopy. 9 findings did not correlate with subsequent complete colonoscopy. Only 1 CTC finding correlated with repeat colonoscopy. There were 30 colonic findings on CTC in areas that were reached and described during the incomplete colonoscopy. Nineteen were sigmoid diverticular strictures with no additional findings in the rest of the colon, 10 were diverticulosis of the sigmoid and 1 ascending colon adenocarcinoma with no synchronous lesions. Conclusions: Same day CTC can be of added value in patients with incomplete colonoscopy. Potential benefits include no need to repeat bowel cleansing and no extra day lost from work. Our data showed that correlation of findings by CTC in areas not visualized by incomplete colonoscopy was poor as 50% of patients had CTC abnormalities which did not correlate with a repeat colonoscopy. When CTC described an abnormality in an area already reached but not described during IC correlation was also poor as only one patient had correlation between CTC and repeat colonoscopy. When CTC reported the same findings described during IC correlation was 100%. More data on the efficacy and cost-effectiveness of same day CTC compared to repeating a colonoscopy or maybe performing a retrograde overtube assisted enteroscopy is needed to determine which effort is worthwhile.

Near-infrared (NIR) perfusion angiography in minimally invasive colorectal surgery

BackgroundAnastomotic leakage is a devastating complication of colorectal surgery. However, there is no technology indicative of in situ perfusion of a laparoscopic colorectal anastomosis.MethodsWe detail the use of near-infrared (NIR) laparoscopy (PinPoint System, NOVADAQ, Canada) in association with fluorophore [indocyanine green (ICG), 2.5 mg/ml] injection in 30 consecutive patients who underwent elective minimally invasive colorectal resection using the simultaneous appearance of the cecum or distal ileum as positive control.ResultsThe median (range) age of the patients was 64 (40–81) years with a median (range) BMI of 26.7 (20–35.5) kg/m2. Twenty-four patients had left-sided resections (including six low anterior resections) and six had right-sided resections. Of the total, 25 operations were cancer resections and five were for benign disease [either diverticular strictures (n = 3) or Crohn’s disease (n = 2)]. A high-quality intraoperative ICG angiogram was achieved in 29/30 patients. After ICG injection, median (range) time to perfusion fluorescence was 35 (15–45) s. Median (range) added time for the technique was 5 (3–9) min. Anastomotic perfusion was documented as satisfactory in every successful case and encouraged avoidance of defunctioning stomas in three patients with low anastomoses. There were no postoperative anastomotic leaks.ConclusionPerfusion angiography of colorectal anastomosis at the time of their laparoscopic construction is feasible and readily achievable with minimal added intraoperative time. Further work is required to determine optimum sensitivity and threshold levels for assessment of perfusion sufficiency, in particular with regard to anastomotic viability.Electronic supplementary materialThe online version of this article (doi:10.1007/s00464-014-3432-y) contains supplementary material, which is available to authorized users.

Sa1495 Elderly Veterans With Dual Eligibility: Where Do They Get Their Colonoscopy?

Data were collected about caecal intubation rate, bowel preparation, adverse events (serious gastrointestinal, minor gastrointestinal and cardiovascular) and diagnostic yield. Chi-Square test (p:0.01) was performed to analyze data. Results: In Group A colonoscopy was completed in 132 cases (68.3%) and in Group B in 177 cases (93.1%) (p 000.1). In Group A 14 pts (7.2 %) had incomplete examination for a neoplastic stenosis 21 pts. (10.8%) for poor bowel preparation, 18 pts (9.3%) for diverticular strictures and 8 pts (4.1%) for incomplete sedation. In Group B 12 pts ( 6.2%) had incomplete examination for a neoplastic stenosis and 4pts. (2.1%) for poor bowel preparation (p 0001). In Group A 176 pat (91.1%) had comorbid conditions and 124 (64.2%) more than one associated disease; in Group B 85 pts (44.0%) had comorbid conditions ( 0.0001). In Group A 4 patients (2.1%) had serious GI adverse events,106 pts.(59.9%) minor GI adverse events (p 0.001) and 4 pts (2.1%) cardiovascular adverse events. In group B no patients had serious GI adverse event,34 patients (17.6%) minor GI adverse events and 3 pts (1.5%) cardiovascular adverse events. In Group A 114 pts (59.0%) had normal colonoscopy (11.4%) or diverticulosis (47.5 %); in 8 patients with anemia (4.1%) the exam failed for divertucular stenosis; colonoscopy identified a problem that explained the patient’s symptoms in 72 cases only (37.3%). Conclusions: Our study shows a low caecal intubation rate. Failure to complete exams is mainly attributable to severe diverticular disease, but difficulties with bowel preparation and analgesia contribute too. Colonoscopy has a low diagnostic yield also in patients with symptoms. As diverticular stricture, sedation risks and incomplete preparation are major issues in the elderly, CT colonography might be the first line exam in patients with high risk to undergo incomplete colonoscopies.

PMO-206 Post colonoscopy cancers in 5-year interval

IntroductionTo evaluate the risk of colorectal cancer in a 5-year period after a negative colonoscopy (PCCRC).MethodsData of patients undergoing colonoscopy in a 1-year period from January to December 2004 collected...

Incomplete Colonoscopy: Maximizing Completion Rates of Gastroenterologists

Cecal intubation is one of the goals of a quality colonoscopy; however, many factors increasing the risk of incomplete colonoscopy have been implicated. The implications of missed pathology and the demand on health care resources for return colonoscopies pose a conundrum to many physicians. The optimal course of action after incomplete colonoscopy is unclear. To assess endoscopic completion rates of previously incomplete colonoscopies, the methods used to complete them and the factors that led to the previous incomplete procedure. All patients who previously underwent incomplete colonoscopy (2005 to 2010) and were referred to St Paul's Hospital (Vancouver, British Columbia) were evaluated. Colonoscopies were re-attempted by a single endoscopist. Patient charts were reviewed retrospectively. A total of 90 patients (29 males) with a mean (± SD) age of 58 ± 13.2 years were included in the analysis. Thirty patients (33%) had their initial colonoscopy performed by a gastroenterologist. Indications for initial colonoscopy included surveillance or screening (23%), abdominal pain (15%), gastrointestinal bleeding (29%), change in bowel habits or constitutional symptoms (18%), anemia (7%) and chronic diarrhea (8%). Reasons for incomplete colonoscopy included poor preparation (11%), pain or inadequate sedation (16%), tortuous colon (30%), diverticular disease (6%), obstructing mass (6%) and stricturing disease (10%). Reasons for incomplete procedures in the remaining 21% of patients were not reported by the referring physician. Eighty-seven (97%) colonoscopies were subsequently completed in a single attempt at the institution. Seventy-six (84%) colonoscopies were performed using routine manoeuvres, patient positioning and a variable-stiffness colonoscope (either standard or pediatric). A standard 160 or 180 series Olympus gastroscope (Olympus, Japan) was used in five patients (6%) to navigate through sigmoid diverticular disease; a pediatric colonoscope was used in six patients (7%) for similar reasons. Repeat colonoscopy on the remaining three patients (3%) failed: all three required surgery for strictures (two had obstructing malignant masses and one had a severe benign obstructing sigmoid diverticular stricture). Most patients with previous incomplete colonoscopy can undergo a successful repeat colonoscopy at a tertiary care centre with instruments that are readily available to most gastroenterologists. Other modalities for evaluation of the colon should be deferred until a second attempt is made at an expert centre.

Does colonoscopists' performance vary between bowel screening and patients with symptoms – a comparison of colonoscopy completion rates

IntroductionColonoscopy completion rates (CCR) are an important quality assurance parameter for individual endoscopists and for the national Bowel Screening Programme (BSP). The standard is set at an unadjusted completion rate...

An unusual case of chronic anal pain – a pin in the bum?

We report the case of a 70-year-old woman who had previously undergone anterior resection in 2001 for a diverticular stricture. Bleeding from pelvic veins intra-operatively necessitated the use of two thumbtacks to aid haemostasis. Over the next 7 years, she presented repeatedly with anal pain, bleeding and mucus discharge per rectum. Multiple lower gastrointestinal endoscopies failed to make a definitive diagnosis until a single thumbtack was found eroding through the rectal mucosa. This was removed and she has been subsequently asymptomatic. This condition was clearly difficult to diagnose and requires a high index of suspicion in those patients who have previously undergone pelvic surgery.

Outcome of patients after endoluminal stent placement for benign colorectal obstruction

Objective. Self-expanding metal stents (SEMS) have been successfully used as a “bridge to surgery” or as palliation for acute malignant colorectal obstruction. Little data on the use of stents for benign obstruction exists and the results vary. The purpose of this study was to evaluate the efficacy and safety of SEMS in benign colorectal obstruction. Material and methods. A total of 21 patients with 23 SEMS procedures between the years 1998 and 2008 were retrospectively studied. Eight patients had an obstruction in the surgical anastomosis. In addition, there were two patients with anastomotic strictures due to Crohn's disease. In 10 patients the obstruction was caused by diverticular disease and one patient had a stricture after radiation therapy. Results. Technical success was achieved for all the patients. Clinical success was achieved for 76% (16/21) of the patients. The anastomotic strictures were resolved with SEMS in 5 out of 8 cases (63%). Three patients with diverticular stricture (30%) were eventually resolved with SEMS. Nine (43%) patients in 10 out of 23 procedures (43%) had a complication, the majority being in patients with diverticular stricture. Conclusions. SEMS is a good treatment option for patients with anastomotic stricture of the colon and for patients with benign colonic stricture who are unfit for surgery. SEMS can be used as a bridge to surgery in diverticular obstruction but there seems to be a considerable risk of complications. If a SEMS is placed into a diverticular stricture, the planned bowel resection should be performed within a month.

CT colonography: accuracy of initial interpretation by radiographers in routine clinical practice

To investigate performance of computed-assisted detection (CAD)-assisted radiographers interpreting computed tomography colonography (CTC) in routine practice. Three hundred and three consecutive symptomatic patients underwent CTC. Examinations were double-read by trained radiographers using primary two-dimensional/three-dimensional (2D/3D) analysis supplemented by "second reader" CAD. Radiographers recorded colonic neoplasia, interpretation times, and patient management strategy code (S0, inadequate; S1, normal; S2, 6-9 mm polyp; S3, > or = 10 mm polyp; S4, cancer; S5, diverticular stricture) for each examination. Strategies were compared to the reference standard using kappa statistic, interpretation times using paired t-test, learning curves using logistic regression and Pearson's correlation coefficient. Of 303 examinations, 69 (23%) were abnormal. CAD-assisted radiographers detected 17/17 (100%) cancers, 21/28 (72%) polyps > or = 10 mm and 42/60 (70%) 6-9 mm polyps. The overall agreement between radiographers and the reference management strategy was good (kappa 0.72; CI: 0.65, 0.78) with agreement for S1 strategy in 189/211 (90%) exams; S2 in 19/27 (70%); S3 in 12/19 (63%); S4 in 17/17 (100%); S5 in 5/6 (83%). The mean interpretation time was 17 min (SD = 11) compared with 8 min (SD = 3.5) for radiologists. There was no learning curve for recording correct strategies (OR 0.88; p = 0.12) but a significant reduction in interpretation times, mean 14 and 31 min (last/first 50 exams; -0.46; p < 0.001). Routine CTC interpretation by radiographers is effective for initial triage of patients with cancer, but independent reporting is currently not recommended.

BT05 MODERN MANAGEMENT OF COLONIC DIVERTICULITIS IN THE OBESE

Colonic diverticulitis is a dietary disorder of the ageing Western population associated with a low intake of oral fibre. Symptoms develop in only 10% of patients and overall only 1% of patients experience a complication. CT scan is the investigation of choice, although CT fails to predict clinical outcomes in many cases. Uncomplicated diverticulitis is reliably managed by antibiotics in the great majority of cases. So much so that enthusiasm for elective surgical resection after two documented attacks is waning, particularly in the high risk patient i.e. obese. Complicated diverticulitis (abscess, peritonitis, fistulae, stricture or bleeding) that fails conservative management is traditionally treated by open Hartmann's rectosigmoidectomy. Alternatives to laparoscopy are particularly helpful in the obese where large incisions cause significant problems with pain management, patient mobilisation and wound breakdown with hernia. Endoscopic management of acute diverticular bleeding and stricture with obstruction is well described. Radiological management of diverticular abscess is widely available Laparoscopic washout for purulent peritonitis is new whilst laparoscopic resection for faecal peritonitis is proven. Technical aspects of colonic diverticular surgery in the obese will be discussed and our experiences with laparoscopic, colonoscopic and radiological management complicated diverticulitis will be presented.