World J. Surg. 16, 149, 1992
World Journal of Surgery © 1992by the Soei(~t¢~ lnternatinrial¢ de Chirurgie
To the Editor We read with interest Schmit and coworkers experience with 16 cases of cecal diverticulitis, "Cecal Diverticulitis: A Continuing Diagnostic Dilemma" (World J. Surg. •5:367, 1991). The diagnosis of cecal diverticulitis, despite good contrast studies of the large bowel, can be difficult and even at operation the appearances may conflict with an otherwise convincing pre-operative diagnosis, as illustrated by our recent experience. A 55 year old man presented with a short history of right sided abdominal pain and pneumaturia. A double contrast barium enema (Fig. 1) suggested isolated cecal diverticular disease or metachronous pathology in the cecum and sigmoid colon. At operation a large mass, firmly adherent to the bladder, Was treated by radical right hemicolectomy in continuity with a partial cystectomy. Though the liver was free of disease, we thought the prognosis appalling until the histology reminded us of the pre-operative differential diagnosis. Although we had not
planned to treat this rare complication of cecal diverticulitis (ceco-vesical fistula) conservatively, we believe that the cornerstone in the management of most, if not all, cases of cecal diverticular disease is operative, as suggested by the authors and Veidenheimer in his commentary. In addition, as there is a history of repeated attacks of pain in 30% to 50% of patients [1, 2], only excision will remove the underlying cause. B.M. Stephenson, F.R.C.S. D.E. Sturdy, M.S., F.R.C.S. Royal Gwent Hospital Newport, Great Britain
References 1. Arrington, P., Judd, C.S.: Cecal diverticulitis. Am. J. Surg. 42:56, 1981 2. Mealy, K.: Solitary' cecal diverticula presenting with right iliac fossa pain. Br. J. Hosp. Med+ 4•:284, 1989
Reply Cecal diverticulitis complicated by the development of a cecalvesical fistula is indeed a rare phenomenon, but this report nonetheless illustrates the dilemma the surgeon must act upon at celiotomy in the majority of these cases. Whereas initial nonoperative treatment of the uncomplicated left colonic diverticular phlegmon is the standard of care, distinguishing right sided diverticulitis from appendicitis is made nearly impossible by the lack of helpful physical signs or specific radiologic findings. The surgeon is therefore confronted with this pathology via a transverse right lower quadrant incision. Over twothirds of patients with histologically proven cecal diverticular disease will have a cecal phlegmon present at the time of exploration, which is very difficult to distiguish from a neoplastic process while in situ. Our experience with 16 patients presenting with this pathologic entity dictates that at laparotomy, an excisional approach is the safest therapy. When the diverticulum is recognizable and involves a small percentage of cecal circumference, diverticulectomy or partial cecectomy should suffice; when the phlegmon involves a large part of the cecum, usually as a result of a contained perforation, a partial colectomy up to uninflamed margins followed by primary anastomosis has proven to be a safe and effective option.
Fig. I. Double contrast bariumenema illustrating cecal diverticular disease. From Stephenson, B.M., Farouk, R., Sturdy, D.E.: Caecoveslcal fistula secondary to diverticulitis. Br. J. Urol. 66:102, 1990.
Paul J. Schmit, M.D. Department of Surgery U C L A School of Medicine Los Angeles, California, U.S.A.
World Journal of Surgery © 1992by the Soei(~t¢~ lnternatinrial¢ de Chirurgie
To the Editor We read with interest Schmit and coworkers experience with 16 cases of cecal diverticulitis, "Cecal Diverticulitis: A Continuing Diagnostic Dilemma" (World J. Surg. •5:367, 1991). The diagnosis of cecal diverticulitis, despite good contrast studies of the large bowel, can be difficult and even at operation the appearances may conflict with an otherwise convincing pre-operative diagnosis, as illustrated by our recent experience. A 55 year old man presented with a short history of right sided abdominal pain and pneumaturia. A double contrast barium enema (Fig. 1) suggested isolated cecal diverticular disease or metachronous pathology in the cecum and sigmoid colon. At operation a large mass, firmly adherent to the bladder, Was treated by radical right hemicolectomy in continuity with a partial cystectomy. Though the liver was free of disease, we thought the prognosis appalling until the histology reminded us of the pre-operative differential diagnosis. Although we had not
planned to treat this rare complication of cecal diverticulitis (ceco-vesical fistula) conservatively, we believe that the cornerstone in the management of most, if not all, cases of cecal diverticular disease is operative, as suggested by the authors and Veidenheimer in his commentary. In addition, as there is a history of repeated attacks of pain in 30% to 50% of patients [1, 2], only excision will remove the underlying cause. B.M. Stephenson, F.R.C.S. D.E. Sturdy, M.S., F.R.C.S. Royal Gwent Hospital Newport, Great Britain
References 1. Arrington, P., Judd, C.S.: Cecal diverticulitis. Am. J. Surg. 42:56, 1981 2. Mealy, K.: Solitary' cecal diverticula presenting with right iliac fossa pain. Br. J. Hosp. Med+ 4•:284, 1989
Reply Cecal diverticulitis complicated by the development of a cecalvesical fistula is indeed a rare phenomenon, but this report nonetheless illustrates the dilemma the surgeon must act upon at celiotomy in the majority of these cases. Whereas initial nonoperative treatment of the uncomplicated left colonic diverticular phlegmon is the standard of care, distinguishing right sided diverticulitis from appendicitis is made nearly impossible by the lack of helpful physical signs or specific radiologic findings. The surgeon is therefore confronted with this pathology via a transverse right lower quadrant incision. Over twothirds of patients with histologically proven cecal diverticular disease will have a cecal phlegmon present at the time of exploration, which is very difficult to distiguish from a neoplastic process while in situ. Our experience with 16 patients presenting with this pathologic entity dictates that at laparotomy, an excisional approach is the safest therapy. When the diverticulum is recognizable and involves a small percentage of cecal circumference, diverticulectomy or partial cecectomy should suffice; when the phlegmon involves a large part of the cecum, usually as a result of a contained perforation, a partial colectomy up to uninflamed margins followed by primary anastomosis has proven to be a safe and effective option.
Fig. I. Double contrast bariumenema illustrating cecal diverticular disease. From Stephenson, B.M., Farouk, R., Sturdy, D.E.: Caecoveslcal fistula secondary to diverticulitis. Br. J. Urol. 66:102, 1990.
Paul J. Schmit, M.D. Department of Surgery U C L A School of Medicine Los Angeles, California, U.S.A.
