Diverticulitis with Perforation into the Peritoneal Cavity DAVID L. NAHRWOLD, M.D., WILLIAM E. DEMUTH, M.D.
Sigmoid diverticulitis with free perforation or perforation through the mesentery results in generalized peritonitis. Emergency surgical treatment is mandatory, but the most efficacious procedure has not been clearly established. Ten consecutive patients were treated by removal of the perforated sigmoid colon, temporary end colostomy and peritoneal toilet. All but one patient survived the initial procedure, and there were only four minor complications. The preoperative diagnosis was correct in 8 of the 10 patients. Analysis of the preoperative clinical findings revealed that a decision in favor of immediate operation was not difficult. The predominant clinical manifestations were severe abdominal pain and tenderness, fever, and elevation of the white blood cell count. The most reliable diagnostic finding was localization of the area of maximum tenderness to the left lower quadrant and suprapubic areas. While it is not applicable for all the pathologic manifestations of diverticulitis, sigmoid colectomy, temporary end colostomy and peritoneal toilet is efficacious therapy in perforative diverticulitis with free communication between the colonic lumen and the peritoneal cavity.
From the Department of Surgery, College of Medicine, The Pennsylvania State University, and The Milton S. Hershey Medical Center, Hershey, Pennsylvania
cedures for diverticulitis would be more meaningful if the specific pathologic manifestations for which they are used were more carefully defined. Correlation of the clinical findings with the various pathologic manifestations of diverticulitis might also be useful to establish the indications for and the timing of a given surgical procedure. Accordingly, this is the report of our experience with ten consecutive patients who had perforative sigmoid diverticulitis with free communication between the lumen of the colon and the peritoneal cavity and purulent peritonitis. They were treated by removal of the D IVERTICULITIS iS one of the few clinical entities for perforated colon and temporary end colostomy. which a standard method of surgical treatment has Historical Data not evolved. Numerous operations have been used, including primary resection and anastomosis,6 exteriorizaEight of the 10 patients were women. The age range tion,5 colostomy with or without drainage, followed by was from 34 to 82 years, with a mean of 58 years. resection with or without concomitant colostomy closThe chief complaint at the time of admission was abure,3'7'10 and resection with temporary colostomy. 1'7 dominal pain in 9 patients and vomiting in one. Pain was The pathologic findings in diverticulitis vary according also the first symptom of the illness in 7 patients; in the to the extent of disease and the rapidity with which the remaining 3 the first symptoms were dysuria, vomiting and disease progresses. Thus, diverticulitis may result in free weakness. A summary of the symptomatology is shown in perforation, local inflammatory changes in the pericolonic Table 1. The interval between onset of the first symptom fat or mesentery, mesenteric abscess, fistula formation and admission to the hospital ranged from 6 hours to 7 and a variety of other pathologic findings. days, and the mean interval was 60 hours. We believe that no single operation is applicable to all Characteristics of the pain were analyzed because it of Evaluation prosurgical with diverticulitis. was present in all 10 patients. It was described as genpatients eralized throughout the abdomen in 3 patients, and localized to the left lower quadrant in 5, the right lower Submitted for publication April 26, 1976. in one. Five All correspondence: David L. Nahrwold, M.D., Department of quadrant in one, and the suprapubic area Surgery, The Milton S. Hershey Medical Center, Hershey, Pennsylvania patients described the pain as constant, one as intermittent and cramping, and 4 as constant with a cramping 17033. 80
VOl. 185 . NO. I
DIVERTICULITIS WITH PERFORATION
TABLE 1. Symptomatology
TABLE 2. Significant Concomitant Disease
Symptom
Number of Patients
Disease
Number of Patients
Abdominal pain Anorexia Weakness Nausea and vomiting Dysuria Fever Chills
10 7 7 6 4 3 1
Hypertension Rheumatic heart disease Glaucoma Asthma (steroids) Parkinson's disease Rheumatoid arthritis (steroids) Diabetes (ketoacidosis)
2 I I I 1 I I
peritoneal cavity and two also had feces scattered throughout the abdomen. The perforation was directly through the antimesenteric wall of the sigmoid colon in 5 patients and through the mesentery into the peritoneal cavity in 5. Cultures of the pus grew a variety of gramnegative organisms in all but one patient. In all patients the involved portion of the sigmoid and its mesocolon, including the perforation, was excised. The length of colon removed ranged from 9 to 38 cm and averaged 18 cm. The proximal colon was brought through the abdominal wall in the left lower quadrant as a colostomy. The distal bowel was closed in 3 layers in 7 patients, closed around a catheter in two, and brought through the wound as a mucocutaneous fistula in one patient. Penrose drains were placed in the pelvis in 5 patients. Prior to closure the peritoneum was thoroughly Physical Examination and Laboratory Findings debrided and the peritoneal cavity was irrigated with Six of the 10 patients were obese. Mean weight of the copious amounts of saline solution. All patients received parenteral antibiotics, which were begun no later than at entire group, predominantly women, was 155 pounds. Pulse rate at the time of admission ranged from 64 to 134 the commencement of operation. per minute. The mean was 96 per minute. All but one of Results the patients were febrile on admission. The mean temperAll patients survived except an 82-year-old woman who ature was 38.30. The physical findings on abdominal examination are developed multiple intra-abdominal abscesses and eventushown in Table 3. All patients had abdominal tender- ally died of sepsis 5 weeks after operation. Complicaness in the lower portion of the abdomen, but the area tions in the survivors included two wound infections, an of maximum tenderness was in the right lower quadrant episode of paroxysmal atrial tachycardia in the patient in two patients. The manifestations of peritonitis, re- with rheumatic heart disease and a pleural effusion which bound and percussion tenderness, were absent in two pa- required thoracentesis. The mean length of the entire hostients, and two other patients had normal bowel sounds. pitalization was 21 days.
component. The pain was very severe in 8 patients, moderate in one, and mild in one. The mean interval between the last bowel movement and the time of admission was 23.5 hours, and the range was one to 72 hours. A history of previous treatment for various manifestations of diverticular disease was obtained in 7 of the 10 patients. All 7 had been treated within 4 years of admission and two of these had required a previous hospitalization. Four patients had either undergone previous cholecystectomy for cholelithiasis or were known to have gallstones. Eight of the 10 patients were receiving therapy for concomitant illnesses (Table 2). Two were being treated with steroids, and the diabetic patient was admitted in severe ketoacidosis.
The white blood cell count was elevated in all but one patient, but the differential count was shifted to the left in all patients. Mean WBC was 17,050/mm3. Plain abdominal x-rays were normal in three patients, but the remaining 7 had findings consistent with either ileus or intestinal obstruction. Free air was identified in only two patients.
Operative Findings and Treatment The correct preoperative diagnosis was made in all but two patients, who were thought to have acute appendicitis because of the location of their pain and the area of maximum tenderness. All patients had free pus within the
TABLE 3. Findings on Abdominal Examination Number of Patients
Findings
10
Tenderness to palpation Area of maximum tenderness Left lower quadrant Right lower quadrant
7 2 I
Suprapubic area Rebound and percussion tenderness Abdominal distention Bowel sounds Absent Decreased Normal
8
5
4 4 2
82
NAHRWOLD AND DEMUTH
Reanastomosis was carried out in all surviving patients an average of 16 weeks after colostomy. One elderly patient died suddenly of a myocardial infarction during an otherwise uncomplicated postoperative course. There were no other complications. All survivors have remained well during an average followup period of 30 months. Discussion The primary problem in caring for diverticulitis patients is to determine whether immediate surgical therapy is necessary. Most surgeons would agree that patients with diverticulitis who have free communication between the lumen of the colon and the peritoneal cavity should have immediate operation. The clinical data derived from our patients provide information which may be helpful in making the decision to operate. The main symptom in all our patients was abdominal pain. In all but two patients the severity of the pain was sufficient to suggest that an acute abdominal catastrophe had occurred. The other symptoms elicited in the history were rather non-specific and were of little value in establishing the diagnosis. Although the mean interval between the onset of symptoms and admission was 60 hours, 9 of the 10 patients had a bowel movement within 24 hours of admission. Thus, the frequent references to increasing constipation as a clinical manifestation of diverticulitis was not supported by our study. On abdominal palpation there was sufficient tenderness to suggest that a serious problem existed in all patients. While localization of the pain by history was not especially helpful in establishing the site of disease, localization of the area of maximum tenderness to the left lower quadrant or suprapubic area basically established the diagnosis of diverticulitis in 8 patients. Although localization of tenderness to the right lower quadrant led to the erroneous diagnosis of acute appendicitis in two patients, the decision to operate was unaffected. The presence of peritonitis was obvious from the findings of rebound and percussion tenderness in all but two patients. Other physical findings, including the presence or absence of bowel sounds, were of little help in making a specific diagnosis or in determining the need for operation. The presence of a mass in the left lower quadrant, frequently cited as a diagnostic aid, was not detected in any of our patients, probably because most of them were obese or had marked muscle guarding. Thus, the absence of a mass should not be taken as evidence against the diagnosis of diverticulitis. Fever and elevated white blood cell count, present in all but one patient, made it obvious that the abdominal process was inflammatory. X-rays were helpful only in the two patients in whom there was free subdiaphragmatic air. The incidence of free air was 39% in patients reported by Graves et al.4
Ann. Surg. * January 1977
This study suggests that a decision in favor of immediate operation can be made with little difficulty on the basis of clinical findings. Severe abdominal pain, marked rebound and percussion tenderness, fever and white blood cell count elevation are diagnostic of an acute infectious abdominal process which requires surgical treatment. When these findings are present and the maximum area of tenderness is in the lower left quadrant or the suprapubic area, perforated sigmoid diverticulitis is the most likely diagnosis. Our choice of resection and temporary end-sigmoid colostomy as therapy for perforated diverticulitis with free communication between the colonic lumen and the peritoneal cavity is based on several principles. Resection of the colon eliminates the possibility of subsequent peritoneal contamination from the perforation. Removal of the inflamed colon and its mesentery adjacent the perforation eliminates these tissues as a possible focus for continued intraabdominal sepsis. These principles have been employed successfully for many years in the treatment of free perforations of the appendix and gallbladder by appendectomy and cholecystectomy, respectively. While there have been reports of successful treatment by primary resection and anastomosis, we do not feel that colonic anastomosis in a grossly contaminated field is wise because of the possibility of suture line leakage and the potential lethality of this complication. However, there is no question that primary resection and anastomosis may be applicable in some diverticulitis patients with small mesocolic abscesses in which there is no free communication between the colonic lumen and the peritoneal cavity. In our patients there were no problems attributable to the methods used to manage the distal rectosigmoid stump. In most patients the inflammatory process in the colon extended down to the rectosigmoid area and the distal segment was not long enough to establish a separate stoma. Closure of the defunctionalized rectosigmoid in three layers at the peritoneal reflection was simple and effective. Closure around a tube brought through the abdominal wall did not seem to offer any advantage. Identification of the rectosigmoid stump at the time of reanastomosis was not difficult and we were surprised at the ease with which colostomy closure could be done. The outcome after resection was unaffected by the presence or absence of pelvic drains. Canter and Shorb have emphasized that diverticulitis patients who are receiving long-term steroid therapy are more likely to have free perforation or spreading peritonitis.2 This was the case in two of our patients. Altemeier and his associates found that 23 percent of their diverticulitis patients were diabetic.8 Routine testing of the urine for glucose in the emergency department led to the diagnosis of diabetic ketoacidosis in one of our pa-
Vol. 185 . No.
DIVERTICULITIS WITH PERFORATION
tients who had no history of previous manifestations of diabetes. Identification of this problem and adequate preoperative therapy probably prevented a fatal outcome. Our experience and the experience of others' 4'7'9 suggest that removal of the perforated and infected sigmoid colon, temporary end colostomy and peritoneal toilet is an efficacious method of treatment of diverticulitis patients who have free communication between the colonic lumen and the peritoneal cavity. References 1. Botsford, T. W., Zollinger, R. M., Jr. and Hicks, R.: Mortality of the Surgical Treatment of Diverticulitis. Am. J. Surg., 121:702, 1971. 2. Canter, J. W. and Shorb, P. E., Jr.: Acute Perforation of Colonic Diverticula Associated with Prolonged Adrenocorticosteroid Therapy. Am. J. Surg., 121:48, 1971.
83
3. Giffen, J. M., Butcher, H. R., Jr. and Ackerman, L. V.: Surgical Management of Colonic Diverticulitis. Arch. Surg., 94:619, 1967. 4. Graves, H. A., Jr., Franklin, R. M., Robbins, L. B., II, and Sawyers, J. L.: Surgical Management of Perforated Diverticulitis of the Colon. Am. Surg., 39:142, 1973. 5. Linder, J. M. and Hoffman, S.: Exteriorization in the Surgical Management of Acute Free Perforation in Diverticulitis of the Sigmoid Colon. Surg. Gynecol. Obstet., 114:755, 1962. 6. Madden, J. L.: Primary Resection and Anastomosis in the Treatment of Perforated Lesions of the Colon. Am. Surg., 31: 781, 1965. 7. Miller, D. W., Jr. and Wichern, W. A., Jr.: Perforated Sigmoid Diverticulitis. Appraisal of Primary Versus Delayed Resection. Am. J. Surg., 121:536, 1971. 8. Schowengerdt, C. G., Hedges, G. R., Yaw, P. B. and Altemeier, W. A.: Diverticulosis, Diverticulitis, and Diabetes. Arch. Surg., 98:500, 1969. 9. Smiley, D. F.: Perforated Sigmoid Diverticulitis with Spreading Peritonitis. Am. J. Surg., 111:431, 1966. 10. Smithwick, R. H.: Surgical Treatment of Diverticulitis of the Sigmoid. Am. J. Surg., 99:192, 1960.
Sigmoid diverticulitis with free perforation or perforation through the mesentery results in generalized peritonitis. Emergency surgical treatment is mandatory, but the most efficacious procedure has not been clearly established. Ten consecutive patients were treated by removal of the perforated sigmoid colon, temporary end colostomy and peritoneal toilet. All but one patient survived the initial procedure, and there were only four minor complications. The preoperative diagnosis was correct in 8 of the 10 patients. Analysis of the preoperative clinical findings revealed that a decision in favor of immediate operation was not difficult. The predominant clinical manifestations were severe abdominal pain and tenderness, fever, and elevation of the white blood cell count. The most reliable diagnostic finding was localization of the area of maximum tenderness to the left lower quadrant and suprapubic areas. While it is not applicable for all the pathologic manifestations of diverticulitis, sigmoid colectomy, temporary end colostomy and peritoneal toilet is efficacious therapy in perforative diverticulitis with free communication between the colonic lumen and the peritoneal cavity.
From the Department of Surgery, College of Medicine, The Pennsylvania State University, and The Milton S. Hershey Medical Center, Hershey, Pennsylvania
cedures for diverticulitis would be more meaningful if the specific pathologic manifestations for which they are used were more carefully defined. Correlation of the clinical findings with the various pathologic manifestations of diverticulitis might also be useful to establish the indications for and the timing of a given surgical procedure. Accordingly, this is the report of our experience with ten consecutive patients who had perforative sigmoid diverticulitis with free communication between the lumen of the colon and the peritoneal cavity and purulent peritonitis. They were treated by removal of the D IVERTICULITIS iS one of the few clinical entities for perforated colon and temporary end colostomy. which a standard method of surgical treatment has Historical Data not evolved. Numerous operations have been used, including primary resection and anastomosis,6 exteriorizaEight of the 10 patients were women. The age range tion,5 colostomy with or without drainage, followed by was from 34 to 82 years, with a mean of 58 years. resection with or without concomitant colostomy closThe chief complaint at the time of admission was abure,3'7'10 and resection with temporary colostomy. 1'7 dominal pain in 9 patients and vomiting in one. Pain was The pathologic findings in diverticulitis vary according also the first symptom of the illness in 7 patients; in the to the extent of disease and the rapidity with which the remaining 3 the first symptoms were dysuria, vomiting and disease progresses. Thus, diverticulitis may result in free weakness. A summary of the symptomatology is shown in perforation, local inflammatory changes in the pericolonic Table 1. The interval between onset of the first symptom fat or mesentery, mesenteric abscess, fistula formation and admission to the hospital ranged from 6 hours to 7 and a variety of other pathologic findings. days, and the mean interval was 60 hours. We believe that no single operation is applicable to all Characteristics of the pain were analyzed because it of Evaluation prosurgical with diverticulitis. was present in all 10 patients. It was described as genpatients eralized throughout the abdomen in 3 patients, and localized to the left lower quadrant in 5, the right lower Submitted for publication April 26, 1976. in one. Five All correspondence: David L. Nahrwold, M.D., Department of quadrant in one, and the suprapubic area Surgery, The Milton S. Hershey Medical Center, Hershey, Pennsylvania patients described the pain as constant, one as intermittent and cramping, and 4 as constant with a cramping 17033. 80
VOl. 185 . NO. I
DIVERTICULITIS WITH PERFORATION
TABLE 1. Symptomatology
TABLE 2. Significant Concomitant Disease
Symptom
Number of Patients
Disease
Number of Patients
Abdominal pain Anorexia Weakness Nausea and vomiting Dysuria Fever Chills
10 7 7 6 4 3 1
Hypertension Rheumatic heart disease Glaucoma Asthma (steroids) Parkinson's disease Rheumatoid arthritis (steroids) Diabetes (ketoacidosis)
2 I I I 1 I I
peritoneal cavity and two also had feces scattered throughout the abdomen. The perforation was directly through the antimesenteric wall of the sigmoid colon in 5 patients and through the mesentery into the peritoneal cavity in 5. Cultures of the pus grew a variety of gramnegative organisms in all but one patient. In all patients the involved portion of the sigmoid and its mesocolon, including the perforation, was excised. The length of colon removed ranged from 9 to 38 cm and averaged 18 cm. The proximal colon was brought through the abdominal wall in the left lower quadrant as a colostomy. The distal bowel was closed in 3 layers in 7 patients, closed around a catheter in two, and brought through the wound as a mucocutaneous fistula in one patient. Penrose drains were placed in the pelvis in 5 patients. Prior to closure the peritoneum was thoroughly Physical Examination and Laboratory Findings debrided and the peritoneal cavity was irrigated with Six of the 10 patients were obese. Mean weight of the copious amounts of saline solution. All patients received parenteral antibiotics, which were begun no later than at entire group, predominantly women, was 155 pounds. Pulse rate at the time of admission ranged from 64 to 134 the commencement of operation. per minute. The mean was 96 per minute. All but one of Results the patients were febrile on admission. The mean temperAll patients survived except an 82-year-old woman who ature was 38.30. The physical findings on abdominal examination are developed multiple intra-abdominal abscesses and eventushown in Table 3. All patients had abdominal tender- ally died of sepsis 5 weeks after operation. Complicaness in the lower portion of the abdomen, but the area tions in the survivors included two wound infections, an of maximum tenderness was in the right lower quadrant episode of paroxysmal atrial tachycardia in the patient in two patients. The manifestations of peritonitis, re- with rheumatic heart disease and a pleural effusion which bound and percussion tenderness, were absent in two pa- required thoracentesis. The mean length of the entire hostients, and two other patients had normal bowel sounds. pitalization was 21 days.
component. The pain was very severe in 8 patients, moderate in one, and mild in one. The mean interval between the last bowel movement and the time of admission was 23.5 hours, and the range was one to 72 hours. A history of previous treatment for various manifestations of diverticular disease was obtained in 7 of the 10 patients. All 7 had been treated within 4 years of admission and two of these had required a previous hospitalization. Four patients had either undergone previous cholecystectomy for cholelithiasis or were known to have gallstones. Eight of the 10 patients were receiving therapy for concomitant illnesses (Table 2). Two were being treated with steroids, and the diabetic patient was admitted in severe ketoacidosis.
The white blood cell count was elevated in all but one patient, but the differential count was shifted to the left in all patients. Mean WBC was 17,050/mm3. Plain abdominal x-rays were normal in three patients, but the remaining 7 had findings consistent with either ileus or intestinal obstruction. Free air was identified in only two patients.
Operative Findings and Treatment The correct preoperative diagnosis was made in all but two patients, who were thought to have acute appendicitis because of the location of their pain and the area of maximum tenderness. All patients had free pus within the
TABLE 3. Findings on Abdominal Examination Number of Patients
Findings
10
Tenderness to palpation Area of maximum tenderness Left lower quadrant Right lower quadrant
7 2 I
Suprapubic area Rebound and percussion tenderness Abdominal distention Bowel sounds Absent Decreased Normal
8
5
4 4 2
82
NAHRWOLD AND DEMUTH
Reanastomosis was carried out in all surviving patients an average of 16 weeks after colostomy. One elderly patient died suddenly of a myocardial infarction during an otherwise uncomplicated postoperative course. There were no other complications. All survivors have remained well during an average followup period of 30 months. Discussion The primary problem in caring for diverticulitis patients is to determine whether immediate surgical therapy is necessary. Most surgeons would agree that patients with diverticulitis who have free communication between the lumen of the colon and the peritoneal cavity should have immediate operation. The clinical data derived from our patients provide information which may be helpful in making the decision to operate. The main symptom in all our patients was abdominal pain. In all but two patients the severity of the pain was sufficient to suggest that an acute abdominal catastrophe had occurred. The other symptoms elicited in the history were rather non-specific and were of little value in establishing the diagnosis. Although the mean interval between the onset of symptoms and admission was 60 hours, 9 of the 10 patients had a bowel movement within 24 hours of admission. Thus, the frequent references to increasing constipation as a clinical manifestation of diverticulitis was not supported by our study. On abdominal palpation there was sufficient tenderness to suggest that a serious problem existed in all patients. While localization of the pain by history was not especially helpful in establishing the site of disease, localization of the area of maximum tenderness to the left lower quadrant or suprapubic area basically established the diagnosis of diverticulitis in 8 patients. Although localization of tenderness to the right lower quadrant led to the erroneous diagnosis of acute appendicitis in two patients, the decision to operate was unaffected. The presence of peritonitis was obvious from the findings of rebound and percussion tenderness in all but two patients. Other physical findings, including the presence or absence of bowel sounds, were of little help in making a specific diagnosis or in determining the need for operation. The presence of a mass in the left lower quadrant, frequently cited as a diagnostic aid, was not detected in any of our patients, probably because most of them were obese or had marked muscle guarding. Thus, the absence of a mass should not be taken as evidence against the diagnosis of diverticulitis. Fever and elevated white blood cell count, present in all but one patient, made it obvious that the abdominal process was inflammatory. X-rays were helpful only in the two patients in whom there was free subdiaphragmatic air. The incidence of free air was 39% in patients reported by Graves et al.4
Ann. Surg. * January 1977
This study suggests that a decision in favor of immediate operation can be made with little difficulty on the basis of clinical findings. Severe abdominal pain, marked rebound and percussion tenderness, fever and white blood cell count elevation are diagnostic of an acute infectious abdominal process which requires surgical treatment. When these findings are present and the maximum area of tenderness is in the lower left quadrant or the suprapubic area, perforated sigmoid diverticulitis is the most likely diagnosis. Our choice of resection and temporary end-sigmoid colostomy as therapy for perforated diverticulitis with free communication between the colonic lumen and the peritoneal cavity is based on several principles. Resection of the colon eliminates the possibility of subsequent peritoneal contamination from the perforation. Removal of the inflamed colon and its mesentery adjacent the perforation eliminates these tissues as a possible focus for continued intraabdominal sepsis. These principles have been employed successfully for many years in the treatment of free perforations of the appendix and gallbladder by appendectomy and cholecystectomy, respectively. While there have been reports of successful treatment by primary resection and anastomosis, we do not feel that colonic anastomosis in a grossly contaminated field is wise because of the possibility of suture line leakage and the potential lethality of this complication. However, there is no question that primary resection and anastomosis may be applicable in some diverticulitis patients with small mesocolic abscesses in which there is no free communication between the colonic lumen and the peritoneal cavity. In our patients there were no problems attributable to the methods used to manage the distal rectosigmoid stump. In most patients the inflammatory process in the colon extended down to the rectosigmoid area and the distal segment was not long enough to establish a separate stoma. Closure of the defunctionalized rectosigmoid in three layers at the peritoneal reflection was simple and effective. Closure around a tube brought through the abdominal wall did not seem to offer any advantage. Identification of the rectosigmoid stump at the time of reanastomosis was not difficult and we were surprised at the ease with which colostomy closure could be done. The outcome after resection was unaffected by the presence or absence of pelvic drains. Canter and Shorb have emphasized that diverticulitis patients who are receiving long-term steroid therapy are more likely to have free perforation or spreading peritonitis.2 This was the case in two of our patients. Altemeier and his associates found that 23 percent of their diverticulitis patients were diabetic.8 Routine testing of the urine for glucose in the emergency department led to the diagnosis of diabetic ketoacidosis in one of our pa-
Vol. 185 . No.
DIVERTICULITIS WITH PERFORATION
tients who had no history of previous manifestations of diabetes. Identification of this problem and adequate preoperative therapy probably prevented a fatal outcome. Our experience and the experience of others' 4'7'9 suggest that removal of the perforated and infected sigmoid colon, temporary end colostomy and peritoneal toilet is an efficacious method of treatment of diverticulitis patients who have free communication between the colonic lumen and the peritoneal cavity. References 1. Botsford, T. W., Zollinger, R. M., Jr. and Hicks, R.: Mortality of the Surgical Treatment of Diverticulitis. Am. J. Surg., 121:702, 1971. 2. Canter, J. W. and Shorb, P. E., Jr.: Acute Perforation of Colonic Diverticula Associated with Prolonged Adrenocorticosteroid Therapy. Am. J. Surg., 121:48, 1971.
83
3. Giffen, J. M., Butcher, H. R., Jr. and Ackerman, L. V.: Surgical Management of Colonic Diverticulitis. Arch. Surg., 94:619, 1967. 4. Graves, H. A., Jr., Franklin, R. M., Robbins, L. B., II, and Sawyers, J. L.: Surgical Management of Perforated Diverticulitis of the Colon. Am. Surg., 39:142, 1973. 5. Linder, J. M. and Hoffman, S.: Exteriorization in the Surgical Management of Acute Free Perforation in Diverticulitis of the Sigmoid Colon. Surg. Gynecol. Obstet., 114:755, 1962. 6. Madden, J. L.: Primary Resection and Anastomosis in the Treatment of Perforated Lesions of the Colon. Am. Surg., 31: 781, 1965. 7. Miller, D. W., Jr. and Wichern, W. A., Jr.: Perforated Sigmoid Diverticulitis. Appraisal of Primary Versus Delayed Resection. Am. J. Surg., 121:536, 1971. 8. Schowengerdt, C. G., Hedges, G. R., Yaw, P. B. and Altemeier, W. A.: Diverticulosis, Diverticulitis, and Diabetes. Arch. Surg., 98:500, 1969. 9. Smiley, D. F.: Perforated Sigmoid Diverticulitis with Spreading Peritonitis. Am. J. Surg., 111:431, 1966. 10. Smithwick, R. H.: Surgical Treatment of Diverticulitis of the Sigmoid. Am. J. Surg., 99:192, 1960.
