Surgical Management of Right Colon Diverticulitis S. S. Ngoi, M.B.B.S., F.R.C.S., J. Chia, M.B.B.S., F.R.C.S., M. Y. Goh, M.B.B.S., F.R.C.S., E. Sim, M.B.B.S., F.R.C.S., A. Rauff, M.B.B.S., M.S., F.R.C.S. From the Department of Surgery, National University Hospital, Singapore, Singapore The infrequent occurrence of right colon diverticulitis in the developed West has led to a controversy in the management of this disease. In Singapore, we continued to avoid colectomy whenever possible because this disease is usually nonprogressive. We reviewed 68 patients treated by conservative surgery to evaluate the effectiveness of this treatment policy. Almost 70 percent of our patients were below 40 years of age, and the clinical presentation was indistinguishable from acute appendicitis. Diverticulectomy was done only for inflamed and perforated diverticula (25 cases), while the nonperforated diverticulum was left alone (40 cases). The inflammation invariably responded to antibiotic therapy. Only three patients had colonic resection since a malignant neoplasm could not be excluded. There were no adverse sequelae over a mean follow-up period of three and onehalf years, except for one patient who had recurrent attacks of right colon diverticulitis necessitating colectomy. With this policy of management we encountered no mortality, and morbidity was acceptable. [Key words: Right colon diverticulitis; Conservative surgery; diverticulectomy] Ngoi SS, ChiaJ, Goh MY, Sire E, RauffA. Surgical management of right colon diverticulitis. Dis Colon Rectum 1992;35:799-802.
ions differ w h e n a positive p r e o p e r a t i v e or intraoperative diagnosis is made. 5-s Based on an earlier study, w e c o n t i n u e to avoid c o l e c t o m y w h e n e v e r possible for this nonlethal condition. 9 O u r preferred m e t h o d of t r e a t m e n t for p e r f o r a t e d i n f l a m e d diverticula is local excision, c h o o s i n g to leave the n o n p e r f o r a t e d i n f l a m e d diverticulum alone. We report our results a c h i e v e d with this conservative management. MATERIALS AND
METHODS
The records of 68 patients with acute right c o l o n diverticulitis w h o u n d e r w e n t surgery at the Dep a r t m e n t of Surgery, National University of Singapore, f r o m January 1981 to January 1990 w e r e reviewed. From these records, we extracted data on clinical presentation, physical findings, laboratory investigations, surgical p r o c e d u r e s , and eventual o u t c o m e . Preoperative b r o a d - s p e c t r u m antibiotics against Gram-negative o r g a n i s m s w e r e given to all patients and c o n t i n u e d for three to s e v e n days after surgery. All patients u n d e r w e n t surgery on a p r e o p e r a t i v e diagnosis of acute appendicitis, and the a p p r o a c h to the a p p e n d i x and cecal region was t h r o u g h a gridiron incision. The policy of m a n a g e m e n t in the d e p a r t m e n t was to p e r f o r m an a p p e n d e c t o m y f o l l o w e d by div e r t i c u l e c t o m y if a p e r f o r a t e d diverticulum was e n c o u n t e r e d . If the i n f l a m e d diverticulum was not perforated, it was not resected. In cases w h e r e a mass was p r e s e n t and could b e dissected f r o m the i n f l a m e d diverticulum, colonic resection was not carried out.
he incidence of diverticular disease in Singap o r e is increasing as a c o n s e q u e n c e of rapid u r b a n d e v e l o p m e n t and c h a n g i n g dietary patterns. A barium e n e m a study a m o n g Singaporean patients r e c e n t l y r e v e a l e d the i n c i d e n c e of diverticulosis to b e close to 20 percent, a figure c o m p a r a b l e to that in the West. Interestingly, there is a u n i q u e predilection for disease to occur in the right colon, a situation peculiar to the Orient. >4 Consequently, m o r e cases of right c o l o n diverticulitis are s e e n in these communities. The extent of local surgical t r e a t m e n t for right c o l o n diverticulitis r e m a i n s controversial. Most w o u l d agree that a mass lesion indistinguishable f r o m a n e o p l a s m n e e d s resection. H o w e v e r , opin-
T
RESULTS Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991. Address reprint requests to Dr, Ngoi: Department of Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 0511, Singapore. 799
T h e r e w e r e 36 m a l e s and 32 f e m a l e s in the study group. Their ages r a n g e d f r o m 20 to 85 years, with a m e a n of 37.9 years. The majority of the patients w e r e u n d e r the age of 40 years (69 p e r c e n t ) .
800
NGOI E T AL
Clinical Features All 68 patients had right iliac fossa pain or discomfort as the main presenting complaint. Tenderness and guarding over the right iliac fossa was present on physical examination, and the site of maximal tenderness was noted to be lateral to McBurney's point. Fever was present in over half of these patients, but none exceeded 38.5~ A raised leukocyte count was seen in two-thirds. In five patients (7.3 percent), a tender mass in the right iliac fossa was clearly present at preoperative examination. The duration of symptoms was short, with a mean of 2.1 days (range, one to seven days). Preoperative radiologic studies were not performed routinely, and endoscopic examination was not done. No additional effort was made to distinguish acute appendicitis from cecal diverticulitis preoperatively (Table 1).
Surgical Procedures The most common procedure was an appendectomy with or without drainage depending on the presence of pus or purulent exudates in the right paracolic gutter (40 patients) (Table 2). Surgery Table 1. Clinical Characteristics of Patients with Right Colon Diverticuiitis Age Range Mean Percent > 40 years Sex distribution Male/female ratio Signs and symptoms Right lilac fossa pain Right lilac fossa tenderness/ guarding Fever Diarrhea Right iliac fossa mass Nausea and vomiting Total white count > 12 x 103
20-85 years 37.9 years 31 36:32 68/68 (100%) 68/68 (100%)
Dis Colon Rectum, August 1992
was approached through a gridiron incision, and this was extended laterally and/or medially when necessary to gain more access. In 25 patients who had an inflamed and perforated diverticulum, diverticulectomy was performed. The pus was aspirated, and the healthy edges of the colon were closed primarily in two layers of interrupted sutures (Fig. 1). tn most cases, the inflamed diverticulum was surrounded by a mass of inflamed fatty tissue, which could be dissected away. Three patients with an inflammatory mass (noted preoperatively) needed a right hemicolectomy because the attending surgeon found it difficult to separate the inflamed fatty tissue covering from the diverticulum to determine the nature of the underlying lesion and was unable to exclude a malignant tumor (Figs. 2 and 3). The mean duration of hospital stay for the latter two groups of patients was similar (7.9 days). The mean duration of hospital stay for patients who received only appendectomy and antibiotic therapy was shorter (5.5 days), although not significantly. Morbidity and Mortality There was no mortality in this study. The overall morbidity rate was 19.1 percent (eight cases), consisting mainly of wound infection (Table 3). Wound infection was largely subcutaneous and was treated by daily dressing and secondary suture. One patient each developed a cecal fistula and a liver abscess. This was from the group of patients who had appendectomy and drainage only. Both of these complications resolved on conservative treatment without serious sequelae. Complete wound dehiscence, anastomotic leakage, intraper-
40/68 (58.8%) 12/68 (17.6%) 5/68 (7,3%) 5/68 (7.3%) 43/68 (63.2%)
Table 2. Hospital Stay Procedures Simple appendectomy _+drainage Appendectomy + diverticulectomy Right hemicolectomy
Number
Mean Hospital Stay (days)
40
5.5
25
7.9
3
7.9
Figure 1. Primary repair after diverticulectomy for an inflamed, perforated cecal diverticulum (arrow).
Vol. 35, No. 8
TREATMENT OF RIGHT COLON DIVERTICULITIS
Figure 2. Postoperative specimen showing an inflammatory mass as a result of a perforated diverticulum, which was sealed off by the omentum. This was clinically difficult to separate because of dense adhesions. Table 3. Complications Complications Wound infection Liver abscess Cecal fistula Others* Total
801
Figure 3. Close-up view showing the perforated diverticulum with a track leading to the inflammatory mass. Histology confirmed the presence of a perforated diverticulum and no malignancy.
Follow-Up Number of Patients 8 1 1 3 13 (19.1%)
* Includes one patient with gastric stress ulcers and two patients with incisional hernia.
itoneal abscess, enteric fistulations, prolonged paralytic ileus, and ileal obstruction were not encountered. In one patient, upper gastrointestinal bleeding from stress ulcers occurred. This responded to conservative treatment. Two patients developed incisional hernia over the gridiron incision a few years later and required surgical repair.
The follow-up ranged from 12 months to 6 years, with a mean of 389 years. During this period, only one patient needed an elective right hemicolectomy for persistent symptoms of right colon diverticulitis. These consisted mainly of persistent right iliac fossa pain, which interfered with his work. There was complete relief of symptoms after the surgery. The remaining 64 patients (i. e., excluding those who had an emergency right hemicolectomy) were asymptomatic at the time of this report. DISCUSSION Experience with right colon diverticulitis in the developed West is scarce, and thus surgical management policies are still controversial. 5-8 The complications of right colon diverticulosis such as
802
NGOI E T AL
b l e e d i n g and inflammation are infrequent occurrences, unlike those of left-sided disease. 1~ The treatment for left-sided diverticular disease centers a r o u n d surgical resection, while right-sided lesions can be more conservatively managed. It has b e e n our practice to perform diverticulectomy only for perforated diverticula and to repair the defect primarily. In these y o u n g patients we have tried to avoid a major colectomy. A right c o l e c t o m y was carried out w h e n the possibility of a n e o p l a s m could not be excluded. Of five cases with a t e n d e r mass n o t e d preoperatively, in only two patients were we able to separate the inflamed fat to reveal the perforated diverticulum. In the inflamed nonperforated diverticulum (40 cases), no further therapy b e y o n d simple drainage of purulent fluid was done. The inflammation will invariably settle with antibiotic treatment. Supplemental a p p e n d e c t o m y is r e c o m m e n d e d to avoid confusion with appendicitis if s u b s e q u e n t attacks occur. It was very difficult in our series to make a correct preoperative diagnosis of right c o l o n diverticulitis. This is because the clinical presentation of this disease is very similar to that of acute appendicitis. In several r e p o r t e d series, the rate of correct diagnosis varies from 0 p e r c e n t to 24 percent. 5'8-12 Many authors have suggested that, in patients with right colon diverticulitis, the duration of symptoms was longer, nausea and vomiting o c c u r r e d less frequently, and the site of t e n d e r n e s s was lateral to McBurney's point, s'1~ Furthermore, the infrequent o c c u r r e n c e of right colon diverticulitis compared with acute appendicitis and the conseq u e n c e s of a higher morbidity from perforated appendicitis have swayed surgical policy toward intervention rather than conservative treatment. With the advent of video laparoscopy, differentiation of these two conditions is n o w facilitated. It will certainly change the course of s u b s e q u e n t surgical management. ~3 Our results s h o w that, in the vast majority of patients with right c o l o n diverticulitis, simple drainage and diverticulectomy for perforated diverticula have resulted in no mortality, minimal postoperative morbidity, and a short hospital stay. This disease is usually nonprogressive, unlike left
Dis Colon Rectum, August 1992
c o l o n diverticulitis. Differentiation from cancer of the right colon is not difficult in the majority of cases. Colonic resection may b e c o m e necessary in a few selected patients w h o continue to suffer r e p e a t e d attacks of right iliac fossa pain and in those in w h o m malignancy cannot be ruled out satisfactorily.
REFERENCES 1. Chia JG, Wilde CC, Chintana CW, Ngoi SS, Goh PM, Ong CL. Trends of diverticular disease of the large bowel in a newly developed country. Dis Colon Rectum 1991;34:498-501. 2. Sugihara K, Muto T, M0rioka Y, Asano A, Yamamoto T. Diverticular disease of the colon in Japan: a review of 615 cases. Dis Colon Rectum 1984;27:531-7. 3. Munakata A, Nakaji S, Yoshida Y, Han MC, Choi WK. Study on the diverticular disease of the colon in Korea. J Jpn Soc Colo-Proctol 1982;35:224-31. 4. Vajrabukka T, Saksornchai K, Jimakorn P. Diverticular disease of the colon in a far-eastern community. Dis Colon Rectum 1980;23:151-4. 5. Schmit PJ, Bennion RS, Thompson JE. Cecal diverticulitis: a continuing diagnostic dilemma. World J Surg 1991;15:367-71. 6. Fischer MG, Farkas AM. Diverticulitis of the cecum and ascending colon. Dis Colon Rectum 1984;27: 454-8. 7. Luoma A, Nagy A. Cecal diverticulitis. Can J Surg 1989;32:283. 8. Asch MJ, Markowitz AM. Cecal diverticulitis: report of 16 cases and a review of the literature. Surgery 1969;65:906-10. 9. Tan EC, Tung KH, Tan L, Wee A. Diverticulitis of caecum and ascending colon in Singapore. J R Coil Surg Edinb 1984;29:373-6. 10. Graham SM, Ballantyne GH. Cecal diverticulitis, a review of the American experience. Dis Colon Rectum 1987;30:821-6. 11. Wagner DE, Zollinger RW. Diverticulitis of the cecum and ascending colon. Arch Surg 1961;83: 435-41. 12. Arrington P, Judd CS. Cecal diverticulitis. Am J Surg 1981;142:56-9. 13. Sim E, Kum CK, ChiaJ, Goh P, RauffA. Laparoscopy: an effective tool in the prevention of normal appendicectomies. Am Surg 1991;57(Abstr 3):185.
ions differ w h e n a positive p r e o p e r a t i v e or intraoperative diagnosis is made. 5-s Based on an earlier study, w e c o n t i n u e to avoid c o l e c t o m y w h e n e v e r possible for this nonlethal condition. 9 O u r preferred m e t h o d of t r e a t m e n t for p e r f o r a t e d i n f l a m e d diverticula is local excision, c h o o s i n g to leave the n o n p e r f o r a t e d i n f l a m e d diverticulum alone. We report our results a c h i e v e d with this conservative management. MATERIALS AND
METHODS
The records of 68 patients with acute right c o l o n diverticulitis w h o u n d e r w e n t surgery at the Dep a r t m e n t of Surgery, National University of Singapore, f r o m January 1981 to January 1990 w e r e reviewed. From these records, we extracted data on clinical presentation, physical findings, laboratory investigations, surgical p r o c e d u r e s , and eventual o u t c o m e . Preoperative b r o a d - s p e c t r u m antibiotics against Gram-negative o r g a n i s m s w e r e given to all patients and c o n t i n u e d for three to s e v e n days after surgery. All patients u n d e r w e n t surgery on a p r e o p e r a t i v e diagnosis of acute appendicitis, and the a p p r o a c h to the a p p e n d i x and cecal region was t h r o u g h a gridiron incision. The policy of m a n a g e m e n t in the d e p a r t m e n t was to p e r f o r m an a p p e n d e c t o m y f o l l o w e d by div e r t i c u l e c t o m y if a p e r f o r a t e d diverticulum was e n c o u n t e r e d . If the i n f l a m e d diverticulum was not perforated, it was not resected. In cases w h e r e a mass was p r e s e n t and could b e dissected f r o m the i n f l a m e d diverticulum, colonic resection was not carried out.
he incidence of diverticular disease in Singap o r e is increasing as a c o n s e q u e n c e of rapid u r b a n d e v e l o p m e n t and c h a n g i n g dietary patterns. A barium e n e m a study a m o n g Singaporean patients r e c e n t l y r e v e a l e d the i n c i d e n c e of diverticulosis to b e close to 20 percent, a figure c o m p a r a b l e to that in the West. Interestingly, there is a u n i q u e predilection for disease to occur in the right colon, a situation peculiar to the Orient. >4 Consequently, m o r e cases of right c o l o n diverticulitis are s e e n in these communities. The extent of local surgical t r e a t m e n t for right c o l o n diverticulitis r e m a i n s controversial. Most w o u l d agree that a mass lesion indistinguishable f r o m a n e o p l a s m n e e d s resection. H o w e v e r , opin-
T
RESULTS Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991. Address reprint requests to Dr, Ngoi: Department of Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 0511, Singapore. 799
T h e r e w e r e 36 m a l e s and 32 f e m a l e s in the study group. Their ages r a n g e d f r o m 20 to 85 years, with a m e a n of 37.9 years. The majority of the patients w e r e u n d e r the age of 40 years (69 p e r c e n t ) .
800
NGOI E T AL
Clinical Features All 68 patients had right iliac fossa pain or discomfort as the main presenting complaint. Tenderness and guarding over the right iliac fossa was present on physical examination, and the site of maximal tenderness was noted to be lateral to McBurney's point. Fever was present in over half of these patients, but none exceeded 38.5~ A raised leukocyte count was seen in two-thirds. In five patients (7.3 percent), a tender mass in the right iliac fossa was clearly present at preoperative examination. The duration of symptoms was short, with a mean of 2.1 days (range, one to seven days). Preoperative radiologic studies were not performed routinely, and endoscopic examination was not done. No additional effort was made to distinguish acute appendicitis from cecal diverticulitis preoperatively (Table 1).
Surgical Procedures The most common procedure was an appendectomy with or without drainage depending on the presence of pus or purulent exudates in the right paracolic gutter (40 patients) (Table 2). Surgery Table 1. Clinical Characteristics of Patients with Right Colon Diverticuiitis Age Range Mean Percent > 40 years Sex distribution Male/female ratio Signs and symptoms Right lilac fossa pain Right lilac fossa tenderness/ guarding Fever Diarrhea Right iliac fossa mass Nausea and vomiting Total white count > 12 x 103
20-85 years 37.9 years 31 36:32 68/68 (100%) 68/68 (100%)
Dis Colon Rectum, August 1992
was approached through a gridiron incision, and this was extended laterally and/or medially when necessary to gain more access. In 25 patients who had an inflamed and perforated diverticulum, diverticulectomy was performed. The pus was aspirated, and the healthy edges of the colon were closed primarily in two layers of interrupted sutures (Fig. 1). tn most cases, the inflamed diverticulum was surrounded by a mass of inflamed fatty tissue, which could be dissected away. Three patients with an inflammatory mass (noted preoperatively) needed a right hemicolectomy because the attending surgeon found it difficult to separate the inflamed fatty tissue covering from the diverticulum to determine the nature of the underlying lesion and was unable to exclude a malignant tumor (Figs. 2 and 3). The mean duration of hospital stay for the latter two groups of patients was similar (7.9 days). The mean duration of hospital stay for patients who received only appendectomy and antibiotic therapy was shorter (5.5 days), although not significantly. Morbidity and Mortality There was no mortality in this study. The overall morbidity rate was 19.1 percent (eight cases), consisting mainly of wound infection (Table 3). Wound infection was largely subcutaneous and was treated by daily dressing and secondary suture. One patient each developed a cecal fistula and a liver abscess. This was from the group of patients who had appendectomy and drainage only. Both of these complications resolved on conservative treatment without serious sequelae. Complete wound dehiscence, anastomotic leakage, intraper-
40/68 (58.8%) 12/68 (17.6%) 5/68 (7,3%) 5/68 (7.3%) 43/68 (63.2%)
Table 2. Hospital Stay Procedures Simple appendectomy _+drainage Appendectomy + diverticulectomy Right hemicolectomy
Number
Mean Hospital Stay (days)
40
5.5
25
7.9
3
7.9
Figure 1. Primary repair after diverticulectomy for an inflamed, perforated cecal diverticulum (arrow).
Vol. 35, No. 8
TREATMENT OF RIGHT COLON DIVERTICULITIS
Figure 2. Postoperative specimen showing an inflammatory mass as a result of a perforated diverticulum, which was sealed off by the omentum. This was clinically difficult to separate because of dense adhesions. Table 3. Complications Complications Wound infection Liver abscess Cecal fistula Others* Total
801
Figure 3. Close-up view showing the perforated diverticulum with a track leading to the inflammatory mass. Histology confirmed the presence of a perforated diverticulum and no malignancy.
Follow-Up Number of Patients 8 1 1 3 13 (19.1%)
* Includes one patient with gastric stress ulcers and two patients with incisional hernia.
itoneal abscess, enteric fistulations, prolonged paralytic ileus, and ileal obstruction were not encountered. In one patient, upper gastrointestinal bleeding from stress ulcers occurred. This responded to conservative treatment. Two patients developed incisional hernia over the gridiron incision a few years later and required surgical repair.
The follow-up ranged from 12 months to 6 years, with a mean of 389 years. During this period, only one patient needed an elective right hemicolectomy for persistent symptoms of right colon diverticulitis. These consisted mainly of persistent right iliac fossa pain, which interfered with his work. There was complete relief of symptoms after the surgery. The remaining 64 patients (i. e., excluding those who had an emergency right hemicolectomy) were asymptomatic at the time of this report. DISCUSSION Experience with right colon diverticulitis in the developed West is scarce, and thus surgical management policies are still controversial. 5-8 The complications of right colon diverticulosis such as
802
NGOI E T AL
b l e e d i n g and inflammation are infrequent occurrences, unlike those of left-sided disease. 1~ The treatment for left-sided diverticular disease centers a r o u n d surgical resection, while right-sided lesions can be more conservatively managed. It has b e e n our practice to perform diverticulectomy only for perforated diverticula and to repair the defect primarily. In these y o u n g patients we have tried to avoid a major colectomy. A right c o l e c t o m y was carried out w h e n the possibility of a n e o p l a s m could not be excluded. Of five cases with a t e n d e r mass n o t e d preoperatively, in only two patients were we able to separate the inflamed fat to reveal the perforated diverticulum. In the inflamed nonperforated diverticulum (40 cases), no further therapy b e y o n d simple drainage of purulent fluid was done. The inflammation will invariably settle with antibiotic treatment. Supplemental a p p e n d e c t o m y is r e c o m m e n d e d to avoid confusion with appendicitis if s u b s e q u e n t attacks occur. It was very difficult in our series to make a correct preoperative diagnosis of right c o l o n diverticulitis. This is because the clinical presentation of this disease is very similar to that of acute appendicitis. In several r e p o r t e d series, the rate of correct diagnosis varies from 0 p e r c e n t to 24 percent. 5'8-12 Many authors have suggested that, in patients with right colon diverticulitis, the duration of symptoms was longer, nausea and vomiting o c c u r r e d less frequently, and the site of t e n d e r n e s s was lateral to McBurney's point, s'1~ Furthermore, the infrequent o c c u r r e n c e of right colon diverticulitis compared with acute appendicitis and the conseq u e n c e s of a higher morbidity from perforated appendicitis have swayed surgical policy toward intervention rather than conservative treatment. With the advent of video laparoscopy, differentiation of these two conditions is n o w facilitated. It will certainly change the course of s u b s e q u e n t surgical management. ~3 Our results s h o w that, in the vast majority of patients with right c o l o n diverticulitis, simple drainage and diverticulectomy for perforated diverticula have resulted in no mortality, minimal postoperative morbidity, and a short hospital stay. This disease is usually nonprogressive, unlike left
Dis Colon Rectum, August 1992
c o l o n diverticulitis. Differentiation from cancer of the right colon is not difficult in the majority of cases. Colonic resection may b e c o m e necessary in a few selected patients w h o continue to suffer r e p e a t e d attacks of right iliac fossa pain and in those in w h o m malignancy cannot be ruled out satisfactorily.
REFERENCES 1. Chia JG, Wilde CC, Chintana CW, Ngoi SS, Goh PM, Ong CL. Trends of diverticular disease of the large bowel in a newly developed country. Dis Colon Rectum 1991;34:498-501. 2. Sugihara K, Muto T, M0rioka Y, Asano A, Yamamoto T. Diverticular disease of the colon in Japan: a review of 615 cases. Dis Colon Rectum 1984;27:531-7. 3. Munakata A, Nakaji S, Yoshida Y, Han MC, Choi WK. Study on the diverticular disease of the colon in Korea. J Jpn Soc Colo-Proctol 1982;35:224-31. 4. Vajrabukka T, Saksornchai K, Jimakorn P. Diverticular disease of the colon in a far-eastern community. Dis Colon Rectum 1980;23:151-4. 5. Schmit PJ, Bennion RS, Thompson JE. Cecal diverticulitis: a continuing diagnostic dilemma. World J Surg 1991;15:367-71. 6. Fischer MG, Farkas AM. Diverticulitis of the cecum and ascending colon. Dis Colon Rectum 1984;27: 454-8. 7. Luoma A, Nagy A. Cecal diverticulitis. Can J Surg 1989;32:283. 8. Asch MJ, Markowitz AM. Cecal diverticulitis: report of 16 cases and a review of the literature. Surgery 1969;65:906-10. 9. Tan EC, Tung KH, Tan L, Wee A. Diverticulitis of caecum and ascending colon in Singapore. J R Coil Surg Edinb 1984;29:373-6. 10. Graham SM, Ballantyne GH. Cecal diverticulitis, a review of the American experience. Dis Colon Rectum 1987;30:821-6. 11. Wagner DE, Zollinger RW. Diverticulitis of the cecum and ascending colon. Arch Surg 1961;83: 435-41. 12. Arrington P, Judd CS. Cecal diverticulitis. Am J Surg 1981;142:56-9. 13. Sim E, Kum CK, ChiaJ, Goh P, RauffA. Laparoscopy: an effective tool in the prevention of normal appendicectomies. Am Surg 1991;57(Abstr 3):185.
