Acute Perforations of the Sigmoid Colon Secondary to Diverticulitis H. Joseph Howe, MD, Little Rock, Arkansas Robert E. Casali, MD, Little Rock, Arkansas Kent C. Westbrook, MD, Little Rock, Arkansas Bernard W. Thompson, MD, Little Rock, Arkansas Raymond C. Read, MD, Little Rock, Arkansas
Numerous reports [l-12] have alluded to both the challenging problem of acute perforated sigmoid diverticulitis and the confusion surrounding the surgical treatment of the disease. There is uniformity of opinion in that excision of the sigmoid colon is the primary goal of therapy, but to accomplish this, controversy exists in choosing the procedure with the lowest morbidity and mortality. Presented with free perforation of colonic diverticula, the surgeon has several options: (1) exteriorization of the perforated segment; (2) a two stage approach-resection of the perforated segment with the formation of a colostomy closure (Figure 1); (3) a three stage approachcolostomy with or without drainage of the perforation, resection, and colostomy closure (Figure 2); or (4) resection of the perforative segment with primary end-to-end anastomosis. Smithwick [13,14] found the lowest morbidity and mortality with the “classic” three stage approach. Others [l&24] have not documented this and have found a higher morbidity and mortality from sepsis with the three stage approach; a proximal diverting colostomy has not given “protection” from sepsis in these situations. Therefore, resection of the diseased segment with a two stage approach began to be utilized to lessen the prolonged morbidity and septic course. Primary resection with end-to-end anastomosis as performed by Madden and Tan [26] has not been extensively performed and is fraught with hazard in these conditions. The present study is a retrospective analysis of our experience with the surgical diverticulitis.
management
of perforated
From the Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Reprint requests shoukl be addressed to H. Joseph Howe, MD. Department of Surgery. University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, Arkansas 72201. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1978.
184
Clinical Material and Methods From 1967 to 1977, a total of forty-one patients with documented perforation of the colon secondary to divertitular disease were treated at the University of Arkansas Medical Center and the Little Rock Veterans Administration Hospital. There were twenty-nine males and twelve females with a mean age of 54.1 years. No patient had a preceding history of granulomatous bowel disease, collagen vascular disease, or steroid therapy. All underwent emergency operations based on clinical findings. Operative Procedures. A three stage procedure, consisting of a colostomy and drainage and secondary resection of the involved segment with later closure of the colostomy, was used in twenty-one instances. (Figure 2.) Primary resection of the involved segment of sigmoid colon with adjacent mesentery, end colostomy, and closure of the rectum (Hartmann procedure) was carried out in seventeen patients. (Figure 1.) In two, primary resection and anastomosis were carried out, whereas exteriorization was carried out in one and simple closure in another. (Table I.) Results
The three stage and two stage groups are compared in Table II. Most of the two stage procedures were performed in the last four years of the study. Mortality. One patient in each group died from progressive sepsis. Our mortality compares favorably with that of others, as seen in Table III. Morbidity. Thirteen of twenty-one patients in the three stage group and two of seventeen in the two stage group required additional operative procedures. There were a total of twenty-one additional operative procedures in the three stage group. Of this group, five of the additional procedures were to drain intraperitoneal abscesses and the remainder were wound-related problems. Only two patients required
additional operative procedures in the two stage group, which were to drain abscesses in the distal pouch.
The American Journal of Surgery
Sigmoid Perforations
Figure 1. Hartmann procedure: resection of perforated segment of colon, oversewing of rectum, and end colostomy.
The morbidity was high in both groups, being 71 per cent in the three stage group and 37 per cent in the Hartmann group. The major morbidity was due to wound infections in both groups, as seen in Table IV. The cumulative hospital stay was 36.1 days in the two stage group and 59.3 days in the three stage group. Comments
Wichern [25] classified acute perforations of the colon secondary to diverticulitis into the following groups: (1) free perforation with diffuse peritonitis; (2) perforation outside the mesentery walled off by adjacent structures with localized peritonitis and pericolic abscess formation; and (3) perforation into the leaves of the sigmoid mesentery with mesocolic abscess formation. The frequency of free perforation varies, depending upon the series examined. All cases
Figure 2. Initial procedure of three stage procedure: right transverse diverting colostomy w/th drainage of colon/c perforation.
of diverticulitis are included in some reports, thus lowering the incidence of perforative diverticulitis considerably. In other series, this complication is reported relative only to the patients with diverticular disease who were operated on. Thus, the published incidence of free perforation with diffuse peritonitis varies from 1 per cent to as high as 17 per cent, with most series showing a figure around 2 per cent [26-281. Emergency surgical treatment for acute free perforation is mandatory, but controversy exists as to the best procedure to perform. Classically, this problem has been treated by the three stage approach. Utilizing this technic, patient mortality has ranged from 5 to 30 per cent [1,26]. Therefore, various authors have suggested that resection be utilized to lower operative morbidity and mortality. Proponents of primary resection or exteriorization state
TABLE II TABLE I
Results
Type6 of Operation Performed (1967-1977) Number
Colostomy, resection, colostomy closure Primary resection with colostomy and subsequent anastomosis (Hartmann procedure) Primary resection and anastomosis Exteriorization of the involved segment without resection or colostomy Simple closure of perforation
Volume 137, February 1979
21 17
2 1 1
Mortality Morbidity Cumulative hospital stay Number requiring additional surgical procedure (laparotomy) Number of additional operative procedures
Hartmann Group
3 Stage
1(6.2%) 6 (37%) 36.1 days 2
1(5%) 15 (71%) 59.3 days 13
2
Croup
21
Howe
et al
TABLE III
Mortality After Operation for Free Perforation with Generalized Peritonitis (collected serles) Colostomy and Drainage No. of Patients Deaths
Author Belding Staunton Large Madden Smiley Watkins and Oliver Localio and Stahl Roxburgh, Dawson, and Yeo Ryan Byrne and Garick Whelan, Furcinitti, and Lavarreda Miller and Wichem Rodkey and Welch
5
2
6 16
2 10
7
0
4 4 1 5
13 14 9 16
Total
28 (32.7%)
86
that excision of the perforated segment results in removal of the continuing source of peritoneal contamination. Some criticisms of the classic three stage approach are as follows: (1) Without resection, the septic focus remains in the abdomen. (2) Defunctioning the segment of colon does not necessarily result in subsidence of the diverticulitis. (3) Excision of the involved segment does not seem to promote extension of infection to the retroperitoneal tissues, as believed in the past. (4) Survivors from the initial catastrophy usually have to undergo prolonged hospitalization and several operations, with the usual hazards of these operations. Primary resection and anastomosis as advocated by Madden and Tan [26] has failed to gain widespread acceptance due to the danger of anastomotic leakage. The Hartmann procedure, on the other hand, has gained acceptance due to the feasibility and safety of the procedure. Watkins and Oliver [S] confirmed that resection versus staged procedures significantly lowered the mortality from
TABLE IV
Complications
wound Infection Dehiscence Hernia Abscess Subphrenic Pelvic Pericolostomy Hartmann pouch Stoma1 necrosis Renal failure
188
Hartmann Group
3 stage Group
3 0 0
11 2 5
0 0 0 2 2 1
1 1 2 0 0 0
Resection without Anastomosis No. of Patients Deaths
5
Resection and Anastomosis No. of Patients Deaths 4
0
13 7
2 1
0
3 7 3 17
0 0 0 2
4 5
1 1
6 10 2 5 1
44
4 (9.1%)
50
1 5 (10%)
30 to 7 per cent. It would appear that, with few exceptions, most agree that the treatment of choice for free perforation and generalized peritonitis is resection. The proximal colon is brought out as an end colostomy, and the upper part of the rectum is closed as a blind pouch. (Figure 1.) In our series, patients with this procedure had lower morbidity. Excision of the perforated segment was curative in that they (with the exception of 2 patients) required only two total operations for complete rehabilitation as compared to four operations per patient in the three stage group. The cumulative hospital stay and cost were therefore less in the two stage group. In our series there were two patients who had a problem with the distal segment. In one a small bowel fistula developed to the distal segment and in another an abscess developed. Both had been closed with an automatic stapler. Inverting sutures may eliminate this problem. In view of the varied circumstances in which diverticulitis presents, no single operation is applicable to all patients with diverticulitis. Evaluation of surgical procedures for diverticulitis would be more meaningful if specific pathologic manifestations for which they are used were more carefully defined. Exteriorization has been used by some, but while admitting certain advantages, it is rare to be able to perform this procedure due to the short, thickened mesentery and adhesions seen in perforated diverticulitis. It is recognized that from any small series of cases, absolute conclusions are scarcely justified. However, it would seem apparent from the data at hand that once surgery becomes necessary, resection should be the ultimate goal, and therefore, the indications for the classic three stage approach should be reevaluated.
The Ame&an Journal of Surgery
Sigmoid Perforations
Summary Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.
References 1. Localio SA, Stahl WM: Diverticular disease of the alimentary tract. I. The colon. Curr Probl Surg Chicago, Year Book Medical, December 1967. 2. Rugtiv G: Diverticulitis: selective surgical management. Am JSurg 130: 219, 1975. 3. Colcock BP: Recent experiences in the surgical treatment of diverticulitis. Surg Gyneco/ Obstet 121: 63, 1965. 4. Classen JN: Surgical treatment of acute diverticulitis by staged procedures. Ann Surg 164: 562, 1976. 5. Garnjobst W: Further criteria for anastomosis in diverticulitis of the sigmoid colon. Am J Surg 120: 264, 1970. 6. Staunton MD: Treatment of perforated diverticulitis coli. Br Med J 1: 916. 1962. 7. Large JM: Treatment of perforated diverticulitis. Lancet 1: 413, 1964. 6. Watkins GL, Oliver GA: Management of perforated sigmoid diverticulitis with diffusing peritonitis. Arch Surg 92: 924, 1966. 9. Ryan P: Emergency resection and anastomosis for perforated sigmoid diverticulitis. 8r J Surg 45: 611, 1956. 10. Byrne JJ, Garick L: Surgical treatment of diverticulitis. Am J Surg 121: 379, 1971. 11. Boyden AM: The surgical treatment of diverticulitis of the colon. Ann Surg 132: 94, 1950. 12. Sweatman AC: The surgical management of diverticular disease of the colon complicated by perforation. Surg Gyneco/ Obstet 144: 47, 1977. 13. Smithwick RH: Surgical treatment of diverticulitisof the sigrnoid. Am J Surg 99: 192, 1960. 14. Smithwick RH: Experiences with the surgical management of diverticulitis of the sigmoid. Ann Surg 115: 969, 1942. 15. Himal HS: Management of perforating diverticulitis of the colon. Surg Gynecol Obstet 144: 225, 1977. 16. Rodkey GV. Welch CE: Surgical management of colonic diverticulitis with free perforation or abscess formation. Am J Surg 117: 265, 1969. 17. Graves HA: Surgical management of perforated diverticulitis of the colon. Am Surg 39: 142, 1973. 18. Marsh J: One hundred consecutive operations for diverticulitis of the colon. South Med J 68: 133, 1975. 19. Levy SB: Surgical treatment of diverticular disease of the colon.
Volume 137, February 1979
Ann Surg 166: 947, 1967. 20. Labow SB: The Hartmann procedure in the treatment of divertitular disease. Dis Co/on Rectum 16: 392, 1973. 2 1. Laimon H: Hartmann resection for acute diverticulitis. Rev Surg 31: 1. 1974. 22. Botsford Tw: Mortality of the suraical treatment of diverticulitis. Am JSurg 121: 762, 1971. 23. Smiley DF: Perforated sigmoid diverticulitis with spreading peritonitis. Am J Surg 111: 431, 1966. 24. Nahrwold DL: Diverticulitis with perforation into the peritoneal cavity. Ann Surg 185: 80. 1977. 25. Wichern WA: Perforated sigmoid diverticulitis. Am J Surg 121: 536. 1971. 26. Madden JL. Tan PY: Primary resection and anastomosis in the treatment of perforated lesions of the colon with abscess or diffusing peritonitis. Surg Gyneco/ Obstet 113: 646, 1961. 27. Brown DB: Diverticulitis disease of the colon. Br J Surg 47: 485, 1960. 28. Colcock BP: Surgical management of complicated diverticulitis. N Engl J A&d 259: 520, 1958.
Discussion Cyril Costello (St. Louis, MO): Three years ago the cases of appendicitis in pregnant women were reviewed at our hospital, which has a large obstetric service. One of the residents who did that work reported findings almost identical to those presented herein. There was no maternal loss. We lost one baby, and that was in a patient who had a retrouterine perforation and an abscess that was missed. Claude H. Organ (Omaha, NB): I think it was the late Lawrence Fallas from Henry Ford Hospital who said that in the presence of abdominal pain it is always appendicitis against the field. I think that is true here, as it so often is in many other age groups. Axiomatically, if one diagnoses the common things, one will be commonly right, and if one diagnoses the rare things, one will rarely be correct. This paper makes three points that are pertinent. First, there are a lot of things that interfere with the diagnosis of acute appendicitis, of which pregnancy is one, and certainly sex, age, trauma, and perhaps more than anything else, laboratory work. The figures that were shown here regarding rebound tenderness and muscle guarding in the right lower quadrant are sine que non for the diagnosis of acute appendicitis. Second, the myth that acute appendicitis in pregnancy has a very hazardous effect on the pregnancy of the mother and child has been refuted, and certainly the absence of maternal mortality here and the increased sensitivity in our ability to monitor the fetus has made appendectomy in this particular disease-if one calls pregnancy a “disease”-manageable. Third, the recurring theme is coming back to us time and time again, when all else fails, as an extreme last resort, one might examine the patient. Albert0 Gomez (Phoenix, AZ): A muscle-splitting incision over the point of maximum tenderness should provide excellent exposure. In case of a difficult diagnosis; you can always use a midline incision.
187
Numerous reports [l-12] have alluded to both the challenging problem of acute perforated sigmoid diverticulitis and the confusion surrounding the surgical treatment of the disease. There is uniformity of opinion in that excision of the sigmoid colon is the primary goal of therapy, but to accomplish this, controversy exists in choosing the procedure with the lowest morbidity and mortality. Presented with free perforation of colonic diverticula, the surgeon has several options: (1) exteriorization of the perforated segment; (2) a two stage approach-resection of the perforated segment with the formation of a colostomy closure (Figure 1); (3) a three stage approachcolostomy with or without drainage of the perforation, resection, and colostomy closure (Figure 2); or (4) resection of the perforative segment with primary end-to-end anastomosis. Smithwick [13,14] found the lowest morbidity and mortality with the “classic” three stage approach. Others [l&24] have not documented this and have found a higher morbidity and mortality from sepsis with the three stage approach; a proximal diverting colostomy has not given “protection” from sepsis in these situations. Therefore, resection of the diseased segment with a two stage approach began to be utilized to lessen the prolonged morbidity and septic course. Primary resection with end-to-end anastomosis as performed by Madden and Tan [26] has not been extensively performed and is fraught with hazard in these conditions. The present study is a retrospective analysis of our experience with the surgical diverticulitis.
management
of perforated
From the Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Reprint requests shoukl be addressed to H. Joseph Howe, MD. Department of Surgery. University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, Arkansas 72201. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1978.
184
Clinical Material and Methods From 1967 to 1977, a total of forty-one patients with documented perforation of the colon secondary to divertitular disease were treated at the University of Arkansas Medical Center and the Little Rock Veterans Administration Hospital. There were twenty-nine males and twelve females with a mean age of 54.1 years. No patient had a preceding history of granulomatous bowel disease, collagen vascular disease, or steroid therapy. All underwent emergency operations based on clinical findings. Operative Procedures. A three stage procedure, consisting of a colostomy and drainage and secondary resection of the involved segment with later closure of the colostomy, was used in twenty-one instances. (Figure 2.) Primary resection of the involved segment of sigmoid colon with adjacent mesentery, end colostomy, and closure of the rectum (Hartmann procedure) was carried out in seventeen patients. (Figure 1.) In two, primary resection and anastomosis were carried out, whereas exteriorization was carried out in one and simple closure in another. (Table I.) Results
The three stage and two stage groups are compared in Table II. Most of the two stage procedures were performed in the last four years of the study. Mortality. One patient in each group died from progressive sepsis. Our mortality compares favorably with that of others, as seen in Table III. Morbidity. Thirteen of twenty-one patients in the three stage group and two of seventeen in the two stage group required additional operative procedures. There were a total of twenty-one additional operative procedures in the three stage group. Of this group, five of the additional procedures were to drain intraperitoneal abscesses and the remainder were wound-related problems. Only two patients required
additional operative procedures in the two stage group, which were to drain abscesses in the distal pouch.
The American Journal of Surgery
Sigmoid Perforations
Figure 1. Hartmann procedure: resection of perforated segment of colon, oversewing of rectum, and end colostomy.
The morbidity was high in both groups, being 71 per cent in the three stage group and 37 per cent in the Hartmann group. The major morbidity was due to wound infections in both groups, as seen in Table IV. The cumulative hospital stay was 36.1 days in the two stage group and 59.3 days in the three stage group. Comments
Wichern [25] classified acute perforations of the colon secondary to diverticulitis into the following groups: (1) free perforation with diffuse peritonitis; (2) perforation outside the mesentery walled off by adjacent structures with localized peritonitis and pericolic abscess formation; and (3) perforation into the leaves of the sigmoid mesentery with mesocolic abscess formation. The frequency of free perforation varies, depending upon the series examined. All cases
Figure 2. Initial procedure of three stage procedure: right transverse diverting colostomy w/th drainage of colon/c perforation.
of diverticulitis are included in some reports, thus lowering the incidence of perforative diverticulitis considerably. In other series, this complication is reported relative only to the patients with diverticular disease who were operated on. Thus, the published incidence of free perforation with diffuse peritonitis varies from 1 per cent to as high as 17 per cent, with most series showing a figure around 2 per cent [26-281. Emergency surgical treatment for acute free perforation is mandatory, but controversy exists as to the best procedure to perform. Classically, this problem has been treated by the three stage approach. Utilizing this technic, patient mortality has ranged from 5 to 30 per cent [1,26]. Therefore, various authors have suggested that resection be utilized to lower operative morbidity and mortality. Proponents of primary resection or exteriorization state
TABLE II TABLE I
Results
Type6 of Operation Performed (1967-1977) Number
Colostomy, resection, colostomy closure Primary resection with colostomy and subsequent anastomosis (Hartmann procedure) Primary resection and anastomosis Exteriorization of the involved segment without resection or colostomy Simple closure of perforation
Volume 137, February 1979
21 17
2 1 1
Mortality Morbidity Cumulative hospital stay Number requiring additional surgical procedure (laparotomy) Number of additional operative procedures
Hartmann Group
3 Stage
1(6.2%) 6 (37%) 36.1 days 2
1(5%) 15 (71%) 59.3 days 13
2
Croup
21
Howe
et al
TABLE III
Mortality After Operation for Free Perforation with Generalized Peritonitis (collected serles) Colostomy and Drainage No. of Patients Deaths
Author Belding Staunton Large Madden Smiley Watkins and Oliver Localio and Stahl Roxburgh, Dawson, and Yeo Ryan Byrne and Garick Whelan, Furcinitti, and Lavarreda Miller and Wichem Rodkey and Welch
5
2
6 16
2 10
7
0
4 4 1 5
13 14 9 16
Total
28 (32.7%)
86
that excision of the perforated segment results in removal of the continuing source of peritoneal contamination. Some criticisms of the classic three stage approach are as follows: (1) Without resection, the septic focus remains in the abdomen. (2) Defunctioning the segment of colon does not necessarily result in subsidence of the diverticulitis. (3) Excision of the involved segment does not seem to promote extension of infection to the retroperitoneal tissues, as believed in the past. (4) Survivors from the initial catastrophy usually have to undergo prolonged hospitalization and several operations, with the usual hazards of these operations. Primary resection and anastomosis as advocated by Madden and Tan [26] has failed to gain widespread acceptance due to the danger of anastomotic leakage. The Hartmann procedure, on the other hand, has gained acceptance due to the feasibility and safety of the procedure. Watkins and Oliver [S] confirmed that resection versus staged procedures significantly lowered the mortality from
TABLE IV
Complications
wound Infection Dehiscence Hernia Abscess Subphrenic Pelvic Pericolostomy Hartmann pouch Stoma1 necrosis Renal failure
188
Hartmann Group
3 stage Group
3 0 0
11 2 5
0 0 0 2 2 1
1 1 2 0 0 0
Resection without Anastomosis No. of Patients Deaths
5
Resection and Anastomosis No. of Patients Deaths 4
0
13 7
2 1
0
3 7 3 17
0 0 0 2
4 5
1 1
6 10 2 5 1
44
4 (9.1%)
50
1 5 (10%)
30 to 7 per cent. It would appear that, with few exceptions, most agree that the treatment of choice for free perforation and generalized peritonitis is resection. The proximal colon is brought out as an end colostomy, and the upper part of the rectum is closed as a blind pouch. (Figure 1.) In our series, patients with this procedure had lower morbidity. Excision of the perforated segment was curative in that they (with the exception of 2 patients) required only two total operations for complete rehabilitation as compared to four operations per patient in the three stage group. The cumulative hospital stay and cost were therefore less in the two stage group. In our series there were two patients who had a problem with the distal segment. In one a small bowel fistula developed to the distal segment and in another an abscess developed. Both had been closed with an automatic stapler. Inverting sutures may eliminate this problem. In view of the varied circumstances in which diverticulitis presents, no single operation is applicable to all patients with diverticulitis. Evaluation of surgical procedures for diverticulitis would be more meaningful if specific pathologic manifestations for which they are used were more carefully defined. Exteriorization has been used by some, but while admitting certain advantages, it is rare to be able to perform this procedure due to the short, thickened mesentery and adhesions seen in perforated diverticulitis. It is recognized that from any small series of cases, absolute conclusions are scarcely justified. However, it would seem apparent from the data at hand that once surgery becomes necessary, resection should be the ultimate goal, and therefore, the indications for the classic three stage approach should be reevaluated.
The Ame&an Journal of Surgery
Sigmoid Perforations
Summary Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.
References 1. Localio SA, Stahl WM: Diverticular disease of the alimentary tract. I. The colon. Curr Probl Surg Chicago, Year Book Medical, December 1967. 2. Rugtiv G: Diverticulitis: selective surgical management. Am JSurg 130: 219, 1975. 3. Colcock BP: Recent experiences in the surgical treatment of diverticulitis. Surg Gyneco/ Obstet 121: 63, 1965. 4. Classen JN: Surgical treatment of acute diverticulitis by staged procedures. Ann Surg 164: 562, 1976. 5. Garnjobst W: Further criteria for anastomosis in diverticulitis of the sigmoid colon. Am J Surg 120: 264, 1970. 6. Staunton MD: Treatment of perforated diverticulitis coli. Br Med J 1: 916. 1962. 7. Large JM: Treatment of perforated diverticulitis. Lancet 1: 413, 1964. 6. Watkins GL, Oliver GA: Management of perforated sigmoid diverticulitis with diffusing peritonitis. Arch Surg 92: 924, 1966. 9. Ryan P: Emergency resection and anastomosis for perforated sigmoid diverticulitis. 8r J Surg 45: 611, 1956. 10. Byrne JJ, Garick L: Surgical treatment of diverticulitis. Am J Surg 121: 379, 1971. 11. Boyden AM: The surgical treatment of diverticulitis of the colon. Ann Surg 132: 94, 1950. 12. Sweatman AC: The surgical management of diverticular disease of the colon complicated by perforation. Surg Gyneco/ Obstet 144: 47, 1977. 13. Smithwick RH: Surgical treatment of diverticulitisof the sigrnoid. Am J Surg 99: 192, 1960. 14. Smithwick RH: Experiences with the surgical management of diverticulitis of the sigmoid. Ann Surg 115: 969, 1942. 15. Himal HS: Management of perforating diverticulitis of the colon. Surg Gynecol Obstet 144: 225, 1977. 16. Rodkey GV. Welch CE: Surgical management of colonic diverticulitis with free perforation or abscess formation. Am J Surg 117: 265, 1969. 17. Graves HA: Surgical management of perforated diverticulitis of the colon. Am Surg 39: 142, 1973. 18. Marsh J: One hundred consecutive operations for diverticulitis of the colon. South Med J 68: 133, 1975. 19. Levy SB: Surgical treatment of diverticular disease of the colon.
Volume 137, February 1979
Ann Surg 166: 947, 1967. 20. Labow SB: The Hartmann procedure in the treatment of divertitular disease. Dis Co/on Rectum 16: 392, 1973. 2 1. Laimon H: Hartmann resection for acute diverticulitis. Rev Surg 31: 1. 1974. 22. Botsford Tw: Mortality of the suraical treatment of diverticulitis. Am JSurg 121: 762, 1971. 23. Smiley DF: Perforated sigmoid diverticulitis with spreading peritonitis. Am J Surg 111: 431, 1966. 24. Nahrwold DL: Diverticulitis with perforation into the peritoneal cavity. Ann Surg 185: 80. 1977. 25. Wichern WA: Perforated sigmoid diverticulitis. Am J Surg 121: 536. 1971. 26. Madden JL. Tan PY: Primary resection and anastomosis in the treatment of perforated lesions of the colon with abscess or diffusing peritonitis. Surg Gyneco/ Obstet 113: 646, 1961. 27. Brown DB: Diverticulitis disease of the colon. Br J Surg 47: 485, 1960. 28. Colcock BP: Surgical management of complicated diverticulitis. N Engl J A&d 259: 520, 1958.
Discussion Cyril Costello (St. Louis, MO): Three years ago the cases of appendicitis in pregnant women were reviewed at our hospital, which has a large obstetric service. One of the residents who did that work reported findings almost identical to those presented herein. There was no maternal loss. We lost one baby, and that was in a patient who had a retrouterine perforation and an abscess that was missed. Claude H. Organ (Omaha, NB): I think it was the late Lawrence Fallas from Henry Ford Hospital who said that in the presence of abdominal pain it is always appendicitis against the field. I think that is true here, as it so often is in many other age groups. Axiomatically, if one diagnoses the common things, one will be commonly right, and if one diagnoses the rare things, one will rarely be correct. This paper makes three points that are pertinent. First, there are a lot of things that interfere with the diagnosis of acute appendicitis, of which pregnancy is one, and certainly sex, age, trauma, and perhaps more than anything else, laboratory work. The figures that were shown here regarding rebound tenderness and muscle guarding in the right lower quadrant are sine que non for the diagnosis of acute appendicitis. Second, the myth that acute appendicitis in pregnancy has a very hazardous effect on the pregnancy of the mother and child has been refuted, and certainly the absence of maternal mortality here and the increased sensitivity in our ability to monitor the fetus has made appendectomy in this particular disease-if one calls pregnancy a “disease”-manageable. Third, the recurring theme is coming back to us time and time again, when all else fails, as an extreme last resort, one might examine the patient. Albert0 Gomez (Phoenix, AZ): A muscle-splitting incision over the point of maximum tenderness should provide excellent exposure. In case of a difficult diagnosis; you can always use a midline incision.
187
