-
日消外会誌 10(5):554~ 575,1977年
DIVERTICULAR DISEASE OF THE COLON.
PATHOGENETICAL,PATHOPHYSIOLOGICAL,
RADIOLOGICAL AND SURGICAL ASPECTS.
Dept.Of Ceneral Surgery(Head: Prof.Dr.B.L6hr)and
DcPt.of Radiology(Head: Prof.Dr.H.Cremllel).
Univeriity of Kiel,D‐23 Kiel,Fed.RcP.Cemany.
v o n L O h r , B . , T h i e d c , A . a n d P o s e r H .
IEltrOduction
100 ycars ago diverticu10sis Ofthc large intestine was
known(CruVellier,1849;IIabcrshon)
1857)but waS hardly considered a source oF
disease.Graser(1899)waS the arst to make
extcnsivc anato■lical studies oF divcrticu10sis and callcd thc
mucOus lnembranc protrusions
PscudOiverticula. In recent decades an increase orthis largc
intestinal abnOrmality has been
notcd, frequently accompanicd by comPlicatiOns; the condition is
known as diverticular
discasc(Vcga, 1976). Besides radiologic analysis,cttnical
symptoms play a prcdominant
rolc in thc diagnOsis of this discasc(Goulard and Hampton,
1954;Wolf et al. 1956).
If the assumption is corrcct that changing nutritional habits
are a mttOr factOr in the
pathogcncsis or diverticalar formatiOn(ParkS,1975),then the
advent of lnOdcrnizcd mcthOd
of fbod proccssing in cOuntries such as」apan,where thc discasc
has been relativcly unknown
until now,will undOubtcdly be accompanied by a risc in
divcrticulaF diSease,silnilar tO that
obscrvcd in Europc and the U.S.A. in recent years.
EPidemiology
CIassen(1973)reported that by 1980 the U.S.A.is cxPcctcd tO have
7.4 million peoPic
with diverticulosis,a nfth oF whom(abOut l.4 million)will ShOw
symptoms of the disease and
about 300,000(a largc numbcrl)will rCquire surgical
intervcntiOn(Table l)・ According
to Strohmcycr(1976)the flgurcs arc cxpcctcd to be 2.5
1nillion,450,000 and 100,000 rcspcctivcly
Tablc l. EPidcmiology U.S.A.却 cderal Republic oF Ccrmany(Figurcs
in millions).
-
1977年 9月 97(555)
fOr the Federal Republic of Germany.These ngures alone testify
to the importance of exact
analysis or all prOg■ostic, diagnostic, pathophysioloぶcal and
therapeutical criteria of this
disease.Today it is not suttcient that the surgeon intcrvene
only the cases with complica‐
tiOns,rather he shOuld participate in the carly stagesゃvith
consideration of pathOgenetilal and
Pathophysi010gical aspects for treatmcnt.He is,thercFOre,■ ot
only resPonsible for therapy
in the later stages,but shOuld also be consulted at the onset of
the discase. The rbllowing dis‐
cussion concerning the pathogenesis of diVerticular discase will
substantiate this宙 ewpoint.
Pathogenesis
Thl PathOgenesis of divertcu10sis is deterIIllned by scveral
clos1ly rclatcd processes which
can be classined as social,bio10事 cal,COlonic wali and
intraluminary factors(TablC 2)。
The social FactOrs inciudc advancing age and nutritional habitst
ヽヽ「idh incrcasing age,
c h a n g e s o c c u r i n t h e w a l 1 0 f t h e c o 1 0 n w
h i c h e n a b l e p r o t r u s i 。ぃ t O b r e a k t h r o u g h
t h e m u s c u l a r
wall wlth simultaneously increased muscular tonusc Stelzncr and
Liersf(1976)called this a
“Inyostatic cOntraction'' as opposed to llbrosed contracture
after atrophy of musclcs and
Table 2. systCmatic and rclatonshiP Of pathological factors in
d市erdculosis.
臼 なo l o = 1 ●● l r a c t o ■3 - B r e C t p 0 3 t u r e i n w a
l X i n g a n d B 4 t t i n , _ _ _ _ _ 一 十 一 十 一 … …
Reduc ti。こ 。F con■ ective ti33せ e and increasc of rat tissue due
to_― ――一‐‐――
世範・Hいよい ま貫督:f塩盟r主化支正電王艦tu盟:貫劇i:l。lrp孟:岳i:i:::::盤l::iabi:と
'i::岳l::1::程:i]tR真二1丁:工ど11:左重
Changed aliectional fl。ャol bibo3 vessels vith age
tho,lzontal→ver●lcal), 1
Morphologl● al increase or the intranural nerve ,loxus‐ ―――一 ―一
―‐――――く‐- 1 1
n ch。liner.lc Pharma空____す =」●xus throughi b)bile acと ds and
salts と _.|
| ,
! |Ooprostagょ 3 (●xt●コded contact ,lth nerve plcxus and
musculature)
pharllicocherlically illduced contracturc brought about by drug
poisoning or changcs in
iOnic cOncentration. Because of high inncr pressurc, mucous
lnembranc is fOrced outward
through the brcaches in the muscular wall forn工 ng so―called
Pseudodivtrticula.
Buritttt et al。(1972)claiins that changed nutridOnal
habits,i.e.low intake of roughag● ,
play a signincant rolc as a predisposing factOr. Foods low in
cellulose― lacking llber一―
pass through the bOwcis at a much slower rate than foods with
high bulk content(ParkS,1974).
This s10w passage leads to spastic c010nic musculaturc and thus
to increased intter presstrc
(StelZner and hcrse,1976).On the othcr hand bulky a stOol with
much undigested material
reqlllrcs shorter passagc tiine and as a rcsult inner prcssure
is gready reduced.
/ n 6「V e
l n t i a l u m i n a r v f a c t o r s 丁
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98(556) 日消外会誌 10巻 5号
Whether an erect,sitting,or walking Posture is acmally a factor
as Becker(1976)Postulat_
es,Inust remain questionablc since it is possible to induce
diverticulosis in anilnals throguh
appropriate diet (HodgSOn, 1972).
C e r t a i n l y t h c g r e a t e s t n u m b c r o f m u t u
a l l y r e l a t e d F a c t o r s o r g i n a t e i n t h e c O l
i n i c w a l l
itself(Table 2). According toヽ 江orson(1963)and MOrson and
Dawson(1974)changes occur
in the musde structurc.]略 imarily there is shortening of thc
10ngitudinal taenia and scc‐
ondarily a thickcnlng of thc circular l■uscle layer(Williams,
1967). By illing up the left
sidc of the colon with silicOne foam,Hughes(1969a,b)Was able to
obtain a threc_dimensional
Tablc 3. Frequency of ambulatory patients(n=319)with
diVcrticulo雨 s
in 1976(givcn in pcrcentagcs).
0‐9 10-19 20‐ 29 30‐ 39 40と 49 50‐ 59 60‐ 69 70‐ 79 80‐ 89
DECADES
vicw oF the altered colonic anatOmy and thereby secured evidencc
supporting this Opinion.
Comparative hist010gical sttdies have cOnflrmed the
abnormalitics in thc muscics and nette
plexus(Bccker,1976).Thc anatomical alteratons are accompanicd
functiOnally by the
fOrmatio■ of``segmental high pressure chambers''as described by
ReifFerscheid(1967).TheSe
are fOrmed by extrclne hausttation and lead to high segmcntal
pressure which Parks and
Connel(1969)were ablc to demonstrate by open‐ end
catheterization, Slack (1962)and
Reirersheid(1967)drew particular attention to changcs in the
vascular course which occur
with advancing age and are simultaneously accompanied by a
reduction of connective tissue.
0‐9 10-19 20‐ 29 30‐ 39 40と 49 50‐ 59 60‐ 69
-
1977年 9月 99(557)
Fig. 1. Radiographic demOnstration oF the relati。 ■ship between
a diverticulum
and vessel. ヽ[icroscOpic evaluation,
We havc developed a special radiO10gic exalnination techniquc
whereby it is pOssiblc to show
血e formatiOn oF diverticula On the vasuclar breaches in the
muscular wall(See Fig.1).
Whetter the mOrphological increase in the intamural plexes
observed by Becker and
Brunner(1974)is a primary or secondary phenOme■ on remains
undecided.Functonally,it
has been established,however,that increased irritatOn in the
circular colonic musclcs in the
diverdcular intesdne is due to physio10gical and
Pharinalcoogical substances(Paintcr and
Truelove,1964).
An increase in frequency and a rise in the intensity of pressure
waves aRer itteCtiOrls of
morphine and prostlgmine were observed through a combination oF
pressure measurements
and cineradiOgraphy. The greatest pressure occured again in
the``segmental high Pressurc
chamber''.
A silnilar stimulating efFec,Inay be attributed to bile acids
and salts,espec1411y through
relatively high cOncentradon a■ d extended cOntact,both of WhiCh
are caus,d by c6prOstasis.
OF cOurse, the numcrous factOrs leading to diverticular
formatiOn shOuld be not con‐
sidcred by themselves.The formation oF diverticula is brought
abOut through the coincidcnce
oF severzll predisposing factors. This must also be considered
with regards to the resPectiVe
ch01cc Of treatment ― whether conservative or operatte一 ―.
PathophysiO10gy and Anatomy
Thc relationshiP between pathophysio10gical and anatOnlical
abnomalities in the in‐
-
100(558)
営苫81:虚「→
Fig。 3. Histological dcmonstration of a complete
diverticulum.
日消外会魅 10巻 5号
1ドCOH'LEII(I NTRAHLIRAL)3:VERTiCutA
(HORF山OLCG:CAL CORRELAr:旺 OF D:VER‐
IV:DEHCE OF CCHPLET=D8唯 R7:●叫A〕
F,sruLA'ORは H備 ,COVERED'こ RFORAr'OR
S:::itlgsuう/
Fig。 4. IEstological dclnOnstration of an incom―
plcte diverticdum with signs of intramural
inflammation.
Fig. 2, Schcmatic morpho10gy or dverdcular for mations,
COHPLETI D:VERIiCULい
FREE PERFORA7:0出
(ES,EC:ALLY lH'SE6MEttT札 いに出PRESSuRE Cは 的ERゆ 予 :CuLAR D:SEASE H
Tl10ur RAD:OLCCiC
testianl、vall cxplains the clinical progress oF diverticular
discasc. As can be scen froIIl the
sttdies oF Schreiber et al。
(1966),ReifFerschcid(1967)Schumpelick and Koch(1974),there
are various forms Of diverticula which exhibit distinctly
difFercnt prognostic signincancc(see
F i g . 2 ) .
Completc diverticuia are mucouS Inembrane prolapses with a
serosal coating and arc,
sttictly dcaned,not truc divcrdcula but so‐ called Graser
pscudodivcrticula(1899);truc diver‐
-
1977年 9月 101(559)
tcula protrude thrOugh a■ layers or the intesinal wall(sce
Fig。3).ComPlete dive=卓 Cula
are lnostly responsible fOr free perforatiOns which are often
due to pressure necrosis caused by
Fccal stOnes of their early stages accompa航ed by simultaneous
increase in intraluminary pres‐
sure. Sccondly,ulceratons lcad to the erOsion oF larger vessels
in the neck arca resulting in
massive bleeding which cannOt stop of its own accord because oF
the relatively wide lumen
(scc Fig, 2).
Incomple,c Or intramural diverticula,a sccond tyPc oF
diverticular formation,are often
T‐shaped invaぶnatiOns of the large intesunal mucous membrane
which cOmmunicates with
thc intesdnes by way of a vcry narrow lumen.Unlikc thc
cOmplete,transmural divcrdcula,
they are shcathed with a strong layer Ofmuscle. According to
Schumpelick and Koch(1974),
rtteCted epithelial cdls,fecal rcmains and leukocytes arc FOund
in the lumen where they arc
highly predisposing to infcctiOn, Already in the early stages of
development, lymphocyte
patches can be identifled on the base,a10ng with perifbcal
swelling of the surrounding muscles
and mucous lnembrane abnOrmattties. In later stages,in which
mOst of the cottplete diver―
tiClla arc still fully frec oF infectiOn,■licrOabscesses may be
found in the surrounding area
(Fig.4).The results are oedematic swelling oF the intestinal
walls and eliminaton issures
軸ath lnicroscOPic b100d clots in thc vcnous drainage vessels.
Thc surrounding tissuc bccomes
scarrcd and then llbrosclerotic leading 3o conttaction of thc
walls and IInally to stenOsis. Cov―
ered perloratiOns Or flstula FOrlnations are frequent and thcre
is ofte■occult hemorrhttng in
the lumen. Incomplete diverticula are predisposers and as such
arc the anatolnical_patho‐
logical cOrrelates of perisigmoiditis. If diverticular discasc
is brought abOut as the result of
incOmplete diverticula,then it must be underst00d that complete
recovery is hardly possiblc,
rather the discase will continue to progress.
酌胡価 ogic Diagnods
A re工able diagnosis of tle disease and its cOmplicatons tt
largcly dependent on radiology.
The preferred method Presents the large intesine by means of thc
mralm6_technique(Welin
and Welin,1976)which iS based on the work of the Kiel surgeon
A,W.Fischer(1925).In
our opinion,Other techniques arc inadcquatc and may icad to
faise interpretations. Examplcs
are given in Figs. 5-10.
Especially important FOr the surgcon is thc Preoperativc
difFercntiaton betwccn diver―
ticu10sis and diverticular disease with their complicatiOns.
D市 erticulosis is usually fOund in segments of thc sigmOid and
desccnding regioIIs of the
colon.This is a typical conditiOn in the Fedcral Rcpublic Of
Ccrmany,comprising ncarly
60%of the cases.PrOnOunccd sPasdcity and lack of clastcity in
the afFected segment宙th
rclatively g00d ne対bilitt in the neighboring large intestinal
region is tyPical ror d市erticular
-
102(560)
Fig. 5. Doublc cOntrast study oF thc c。 10■ with
thc Malln6‐ tcchniquc. Settncntal divcrticulosis
in tlle siも_.Oid area.
Fig. 7. Dcmonstration oF incomplctc divcrticula
(→)by doublc contrast techniquc.
日消外会議 1 0巻 5号
Fig.6.GRASER(● )diVCrticula in thc caccumand ttcending co10n
innammatory rcaction on
thc tip or thc cacc― .
Fig.8. X‐ ray,divcrticulum (=〉 )With an inFcc‐
tcd hcad and stcnOsis oF thc neck.
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1977年 9月
Fig.9t X_rays covcrCd PCrfOration(P)・
103(561)
Fig. 10. X‐ray, typical peric。lic rcactおn behvecn
postcrior rectal wall(→ )and OS Sacrum(中 ).
discasc Of thc lert colon(Fig.5).Thc diSease seldom involves thc
caecum (Fig.6). RadiO‐
logic dcmOnstration of incompletc divcrticula is only possible
through careFul employment
oF the Malm6o‐ tethniquc(Fig.7).
Inflammatory deterllination of the diverticular head and
stcnosis oF the ndck can be
shown by radi010gy and thus provides ew■ dencc oF diverticular
alteratiOns caused by inna.1_
mation(Fig.8)。 Covered PerForatiOns are among thc serious
complicatons(Fig。 9)・ If the
tissuc surrounding the largc intestine becOmes inna.llncd during
this diseasc,retrorcctal widcn―
ing of thc area rcsults as soon as thc spreading reactiOn
rcaches the sitttna‐ rectum‐ aFea(Fig.
10).Normally,the distance betwccn the sacrum and thc posterior
rectal wall should not
CXCCCd l CII;if this distance widcns cOnsiderable,it is a
typical reaction of the surrounding
area during advanced diverticualr discase of this intestinal
segment. This can be visualized
by X_ray.
It is OFten dil■cult to difFerentiatc bctween infectcd stenosis
at thc base OF divcrticula
and carcinomatoid stcnosis. A proccdurc that wc havc
dcveloped(ThiCde et al. 1977)can
bc of grcat help in making clear, rettable diagnoses. Our
proccdurc involves pin‐ pointcd
coloscopicrradioloJc dCmonstration oF the large intestine.A
tri―iOdizcd contrast mcdium,
Conray 80 for cxamplc,is ittected thrOugh an exible
coloscopc.This allows demonstration
OF thc stenosed iarge intestinal segmcnt without its bcing
overshadOwed. An example can
dcmonstrate this. Thc scgment which has been cxtremely altered
by diverticular disease
silnulatcs a complctc tumOrous stenosis. The spccial, combinadon
exa■ lination technique
-
104(562) 日消外会議 1 0巻 5号
oF a sigmOid stcnosis inFig. 11. COmbincd cO10scOpic‐ radiologic
dcmonstration
diverticular discttc in 4 phascs.
indicated a stcnosis causcd by diverticular diseasc(Fig. 11).
Thc OpCrativc data cOnflrmcd
this. C010scOpy alonc PIays but a IIlinor role in the diagnOsis
Ofdivcrticula. Oniy thc lcOaliza‐
tion and morphO10gy or a beginning divcrticular neck can bc
deter■ lined cndoscopically.
Radiolog■ c Evaluation
An cvaluation OF dOublc cOntrast studies oFthe colon carried Out
on a total of 319 patients
in 1976 rcvcaled somc notcworthy data On diverticuair disease,
Tablc 3 shO、 γs thc rclativc
frequency of this discasc according to dccadcs OFlifc. い
、ltl10ugh we lbund no instanccs in the
flrst and second dccases,thcrc was a steady risc from thc third
to thc ninth dccades,incrcasing
to 63%oF all paticnts examined.Thc numbcr ofcascs was relativc
10w;ncvertheless,it seems
to us that these ngures arc still representative rbr thc
PopulatiOn of our countty as a whole.
The evaluation also yicldcd sOme exact data cOnccrning the
localizatiOn of divcrticula. In
a total of l16 patients、vith divcrticulosis or diverticular
discasc, diverticula FOrmtions 、vcrc
distributed throughout the colon as f01lows(sCe
Fig.12):57.8%wcre FOund in the sigmOid
and descending colon(a), 16.40/。in the transversc and thc icft
sidc Of the c010n togcther(b),
8.6%in thC Cntire largc intcstinc(c)and 6。9%in thC ascending
colo■(d)・A cOmbined
appearence in thc ascending,dcsccnding and sigmOid colon was
IOund in 60/。. Furthcr 10cali‐
zations or colnbinations were very rare,
-
1977年 9月 105(563)
Fig. 12. Diagram shOMng the radiologically dctcHnined frequency
oF thc
localisation oF di▼erticu10sis.
CompHcat:bns
Comphcations arc diagnOsed by clinical,Iaboratory tcchnical and
particularly by radio‐
10gical criteria.In di、crticular discase,complications Occur
which we difFercntiate primarily
as not acutc or acutely dangerous to lifc(Table
4),TumOrs,stenosis,subilcus,cOvered Pcr―
fOratiOns,abscesses,istulas,and occult hemorrhattng are nOt
considered mortally dangerous
and maybe tteated Operattely or evcn conservatively. On the
cOntrary,ユcus,free perfora
出抽
-
Table 4. 軌 mplicatiOns or divcrticdar disease.
106(5643 日消外会議 10巻 5号
Pr■mary not
Tur10rs
Stenos13
Suじlle」 o
ユocal perょ t。■ltis
・rrozea pelvと 。“
(DEUCIER et al. ■ 974)
Absceao● o
PAstulag
Occult bleedin宮
"elective operationl'
or conservative
treatment
Acutely dangereus to llfe
Masolve bleeding
t'energency operaticnl'
。r conservative treatment,
vith later "elective
oPeratと on■
tiOn with fecal peritonits,c010nic wall phlegmon and massive
bleeding can usually be contr
0 1 l c d O n l y b y e m c r g c n c y s u r g e r y . H o w e
v e r , i n t h c c a s e s o f m a s s i v e b l c c d i n g , o n
e s h o u l d
always irstattempt a Proccdurin which the intestine is washed
out with an ice‐cold sattne solut
ion tO which l翌ampulcs Suprareniぃhave been addcd pcr 1000
ml.I■90%ofthe cases the
hemorrhaging wili stop and recurrcnce can be prcvented by
electivc operative interventi‐
On aftcrsclective diagnosis has been carried out. According to
Taylor and EPstein(1969),
blcedin grecurs in 20判 % of the cases aFter purely coぬ ervatte
trcatment.
In cases with complications,radiography is the mOst imPortant
exaHunation techniquc,
whether thrOugh tOtal abdolninal view by perforations with free
air in pcritoneal cavity,Or
as a dOuble‐cOntrast cnema with a tribiodized contrast
substance,c.g. Urovision一 ,tO disciose
thc prcscnce oftumors,stenosis,covcrcd PcrfOratiOns or astulas.
on the contrary,angiography
had bccn a disappointmentin discerning between carcinomas and
stenosis ofthe sigmOid rcgion
caused by diverticula. E)ifFerendatiOn through vascular
demOnsttation is nOt possible preo‐
perativcly. At best, angiOgraphy can bc a diagnostic aid in
10calizing hcavy diverticular
h c m O r r h a g i n g a n d c n a b l c s p r e o p c r a t 市e
l o c a l i z a t i o n O f t h e s O u r c e o f b l e e d i n g i
n 3 t 1 5 0 % o f
thc cascs,Only,howcver,in patients with massive
blccdingI(HcuCk,1976),
-
1977年 9月 107(565)
Swぶ cal AsPects
Wc have classifled thc hOsPitalizcd cases at thc Kicl Clinic
frO■ l thc last 14 ycars into 3
stages oF deve10pmcnt fro■ l the standPoint oF clinica1
0bservation. This classincation is, in
our opinion, the best lncthod OF shOwing the thcrapcutical
aspccts;it is clearly dill■ cd and
undcrstandable (irablc 5).
The statistics fbr thc years 1963-1976 are prcscntcd in thc
tablc as wcll as thc symptoms
in perccntages. Tablc 6 gives a diagram Of thc stagc oF scverity
corrcsponding to thc agc of
Table 5. HOspitalizcd paticnts ゃ vith diverticulosis and
diverticdar discase 1963-1976.
Criteria for classiflcatiOn of thc clinical stagcs.
Cllnical Stages CPiteria forcll■ lcal classlllcatと on
Symptong/Findings
withっ ut
cllnical symptoms
with or ▼ lthout
radょ ologic evidence
with
cll■ lcal sytnptons
dlgestive dirficultieo 57
co14c and tenesmu3 54
occult bl● eding 20
,1●rt appendicitis■ 24
palpable tumors iS
atenoこ と3 10
●ompllcatと on3 WhiCh are
acutely dangeroua to
llre
rr●● perrorati。 ■ 82
419us 0
mag8と Ve bleedと ng 9
Tablc 6. Dcgrcc oF severity accOrding toi:agC`
20-29 30‐39 50‐59 60‐69
口 Stagc I □ stage II Z st"c III
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108(566) 日消外会議 10巻 5号
the hOsPitalized PatientS・ Stage III was not observed bcfore age
40; arter 40 therc was a
rise in frcqucncy incrcasing with advancing age.
The Opcrativc proccdurc dcpcnds on whethcr the paticnt has a
comPliCated or an uncoHl―
plicated form of the disease. While the uncomplicated
diverticular disease is usually trcated
by one‐stagc―rcsection,this proccdurc is cOnsidered too risky
fbr the treatlnent ofthc complicated
fOrm fOr which variOus Othcr mcthOds are moresuitabic(Summary by
Parks,1976).
Therc arc several methods oF muiti‐ stage‐resection which can be
applied sclectlvely ac‐
cording to thc symptOms and thc clinical and anatomical
conditio■ of thc paticnt. The three‐
stagc‐proccdurc OF SchiOfttr(1・ Step=colostomyttdrainage of the
pcritoneal ca宙 ty;2.step=
rcscction;3.stcp=closurc ofthc cO10stOmy;Baumgartel at
al.1972)is acCOmpanied by a high
mortality rate(Smiley,1966;Hcbcrer et al。 1974).Thc SOurce
ofinfection continucs tt cOn‐
taminatc thc surrounding arca in spitc of recal eliコ
nination(Dcucher et al,1974).
The twO_stage‐ incOntinuity_resection ( こヽこ1ler and WVichern,
1971)with CXCision of thc
diseased scgmcnt can bc applicd in several modiflcations. In thc
Proccdure according to
在ヽikulicz,thc PrOxilnal and distal sigmoid loops are scwn to the
left underside of the abdomen
in double―abrrci forln. In thc sccond Step, the two largc
intestinal loops are rdoined,
In Hartinann's resection the proxil■ al sigmOid ioop becomes a
tcr■ linal anus and thc
distal sigmoid loop is intraperitoneally closed.
The prOccudre is the samc in the rescction dcscribcd by Cuicke
with the cxception that
thc sigmOid ioop is extraperitOneally closed.
Thesc opcrative prOccudres are advantageous since the reiativcly
brief operatng tilne
increases the chances oF surw■ val even in severly ill, older
patients. Parimary resccdon wi‐
th prOtectivc c01ostomy (ヽ 空adden, 1965) should Only be
attcmpted on younger patie―
nts in relativcly good gencral condition, as it requires ionger
opcratng tine which involvcs
additional ttsks fOr the patient. Here again the colostomy must
bc closed in second step.
Tablc 7. Therapcutical procedurc in 213 paticnts(1963-1976)
hosPitalized.
one atage l mult4‐ ●●88e
W
唖
“
H
″
-
1977年 9月 109(567)
The therapeutic prOcedures carried Out on 213 patients in Kiel
during the years frOm 1963
to 1976 are given according to clinical stage in Table 7.
All persOns in Stage l cither rece市ed no special trcatmcnt or
wcrc trcatcd conservat持 ely,
that is by diet control. Nearly halr Of the patients in Stage II
undcrwcnt surgery9 with Onc―
stage―rcsecton bcing the predOHlinatly elected course. The 22
patients in Stage III, thOse
w i t h m O r t a l l y d a n g c r o u s c o m p l i c a t i O
n s , w c r e t r e a t e d b y v a r i o u s m l t h o d S i t h e
p r o c e d u r c w a s
dictated by local indings and above ali by the gencral cOndition
of thc individual patients.
In almOst all cases Opcrative measurcs wcre undertakcn(alSO in a
case witt heavy hemOrrhaging
whilc another such casc was treated conscrvativcly)・ ThC
patients recci宙ng only a colostOmy
and drainage dicd of thcrapeutically resistant fecal
peritonitis, A multi‐stage operattvc Pro‐
cedure had been indicatcd.Duc to thc higL rick ractors,we have
seldom performcd Onc‐
stagc―rcsection during thc last 5 years. We have found the two‐
stageaprocedure to bc mOrc
Facorable,preFerring the inc6ntnuity resection of the Hartt1lann
type. The lower l■ ortality
ratc as well as shorter hOspitalizatO五一-55 days for the
two‐stage as opposcd to 83 days(at
that time)fOr the thrce_stage‐ method―一 speaks FOr the two―
stage―rcscction.
Our primary hOspital mOrtalitt rate Was,at that time,about
6.5%;in 3.2%,i.e・ tWO
patents,suturc insuttciency was thc cause of death. Thc prilnary
l■ ortattty rate of patients
in Stagc III is rathcr dismal. In 7 0f ll cases, therapeutic
resistant Fccal peritonitis w益
rcsPonsible fOr dcath. The ability tO cOntrol this factor is
exceptional even tody. There
is a chance orsurvival only ifthe til■ e betwcen pcrforation and
operation is shOrt. Thc simab
tion is hOpeless if 3-4 hours have elapscd since perfOration.
Neither tOnscrvative nor Opcrative
therapy are sumcient to check a negiccted Fecal pcritonitis.
Longaterコ n Observations of Conservative Versus Operative
Therapy
Thc high mObilitt Ofthc wOrking populatiOn in thc Fcderal
Rcpublic of Oermany makes
it dil■cult to Observe development ovcr longer periods of til■
c; many patients could not bc
traced 5 ycars or inore after hosPitalizatiOn. ThereFOre,thc
IIgures glvcn in table 3 may only
be understood as tendcncies,that is,they are not truly
representative.
Ofthe 14 paticnts who werc classifled in Stage l and who did nOt
undcrgo surgery,9 still
sho、vcd Stage l sttptoms 5 years iater,while 5,that is l,3,had
Progrcsscd to Stage II. Thc
tendency oF group II Patients is impress市 ei Of 20 coIIservat市
ely trcatcd cases,18 had rc―
m a i n e d s t a t i O n a r y , 1 . c . b y e x a c t e x a m
n a t o n o f t h e i r c a s c h i s t o r i e s t h e y c O n d m
e d t o s h O w
symptoIIs oF Stagc II. Two paticnts,however,had died in the
lneantimc of frec perforatiOn,
f0110wed by consecutivc peritonitis and had, thereFOrc,
progressed to Stage III. The largc
mttOritiy OfPatientsin Stage II who had been oPcrativcly treated
showed fcw Or no symptoms
oF thc disease 5 ycars later. This was also truc ofthc Fcw
patentsin Stage III whOm we wcrc
-
110(568) 日 消外会議 10巻 5号
Table 8. Long‐term obscwations. Conscrvativc thcraPy versus
cPeratiVC treatment.
01■nical atag● at rol■ o▼_up examinatと onS years iater
Cau80 0f aeath
tive
I1 18
111 2 (death) 2 1ec■1 0erl―tOniti3
n 口 14
I completely 12rr●. 。r
2
III operative I comPletelyfree oIsymptoms
II
able to trace.
Thc 10ng―tern■rcsults of our cOIIserVatively treatcd Patients
were quite good,that is,■o
detcrioration Of the discasc in 77%.ImprOVement was achieved in
90%of thC patients
rccciving operative treatment.In comparison,statistics collected
by ReifFcrschcid(1976)
showcd good long― term results after resection in 98.5% (762
cases),while only 66.5% (992
cascs)of thC COnservatively trcated grouP were described as
good.
Myotomy
Myottmy of the sigmoid intestine in thc early stages has recendy
been proPagated as
a new techniquc. ■ ■lis tcchniquc was dcve10ped by Reilly(1965,
1966, 1975)who rCferred
tO it as iongitudinal lnyotomy. The scParatiOn OFthe l■ uscles
is supposcd to lead to reductOn
OF prcssure in thc s准 軍noid colon. In thc Original procedure,
hOwcvcr, Only thc thickened
circular ibers betwcen the taenia were
scParated(Akobviantz,1974;Fig。13).The mCthOd
is controversial becausc thc mortalitt rate lies at
5%(ParkS,1974)j and the intraluIIllnal
pressure rcduction rcmains efFective for only about 3 years.
After that tilne there is a rccur‐
rcncc of the Original conditiOn(Smith and Ruckley,1971;Prasad
and Daniel,1971)unleSS
paraysmpatholytics and a high cellulose diet are prescribed,
Thc transverse myotomy method,which has gained current
popularitiy(HOdgSon,1973;
K y r l e , 1 9 7 6 ) , a n d t h e s o m e w h a t s i m i l a
r l y c v a l u a t e d m c t h o d O f s p i r a l m y o t o m y (
P a r k S , 1 9 7 4 )
can bc documented only by a Few short― tcrm observations as no
long‐ term data arc available
at this til■c.
Colottc Fistulas in Diverticular ELsease
Thc therapeutic approach to divcrticular cottnc istulas deservcs
sPcCial attention(COICOCk
-
1977年 9月 111(569)
Fig. 13. Cuidc tO antillescntcric inicsiOn
REILLY from AKOVBIANTZ(1974).
of 10nitudinal myotomy accordng to
Fig. 14. Schematic IIstula Fomation in diwcrticular discasc.
and Stahmann,1972;KraFt_Kinz and Prexl,1976).General
rccommendatiOns can only
be arrived at through collectiVc statistics.Neighboring organs
in which d持 erticular istulas
have been known to devcloP are ShOWn in Fig.14 and Table 9.
Fistulas appcar in about 15%
of the cases to bc operatcd. Fig. 14 and table 9 demOnstrate the
difFerent Flstula fOrmatiOns,
-
112(570) 日消外会誌 10巻 5号
Tablc 9. Appcarancc and trcament oF colonic nstulas in
diverticdar dsease。 278 paticnts
Out of a total of 1840 had Prcoperativc nstulas.
Local12ation Prequency (■ ‐ 2'8
without absccag fomation i vith abB● ●as romat■ on
145 口 0■ .2 名
■lvayatwo‐or thre● ―
stage‐ reeectio■
90 ‐ 32.4 ■
37 ‐ 13.3 拓 tvo‐stage― re8●Ctと0■
■ ‐ 0,4岳
4 ‐ ■ ,4 略
1 ‐ 0,4,
two‐atage resection
CollcctiVe atatisticsi COLCOCK a. STAM「 lANN 1972〔 n ‐ lSS5),
DEUCHER et al. ■ 974 (■ ‐ ■52),
XRAFT,XINZ a. PREXL 1976 (n ‐ 52)ぅ OWn Cagea く n ‐ ●1)
their Frequency and therapeutic trcatinent, The variOus
possibilities are listed according
to decreasing frcquencyi colo,vesical,colo― cutancous,colo‐
entric and colo‐colic,colo‐uretheral,
colo‐uterine and colo‐vaginal istulas. 980/。 are fOund in thc
flrst three catcgories; thc last
3 are very rare as thc collect市 c statistics for 278 cascs
indicates(Table 9).
Thc mode of surgery is still essentially determined by the
cxisting abscess fOrmations.
When abscesses arc still in evidence,a multi‐ stage‐procedurc is
called for;a one‐ stagc‐rcscc‐
tion may be considered only if nstulas are present betwcen the
large intestine and the bladder
or the skin, and if the absccsseS are no longer in evidence.
IntracPeradVe Coコ nl抗ned Evaluadon ofthe Resected Segnent
For a11■ost a year now we have bccn analyzing each resccted
large intcstinai scgment
intraopcratively by mcans Of a cOmbined techniquc.A mucous
membrane demOnstratiOn
is achieved with Barotrast and simuitaneously,a vascular
ittect10n is carried out.Up to
now wc have been ablc to collcct some remarkable facts about
diverticular disease. The
c x c e l l e n t X ―r a y s o b t a i n e d t h r O u g h t h i
s t e c h n i q u e a r c e v a l u a t e d l t t c r o s c o P i C
a l l y s s o m c o f t h e
capillarics may evcn bc cvaluatcd by this method.
SOme oF thc data we havc acquircd can be documentcd by a Few
examplcs. To our
knowledge,such exaFninations have not been reported beFOre in
the literature. The questiOn
of whcther incomplete diverticula are still present at the edge
of the reseltiOn can be clarined
intraOperattely by rmcroscopic evaluation of the X― rays;if
necessary,these pathogenically
crucial incomplete diverticula can then be resccted immediately
in order to achicvc radical
surgcry(sce Fig.15). IncOmplCte diverticula do not cxceed the
intesdnal wall lttvcau. Signs
-
1977年 9月 113(571)
Fig。 15. Demonstration
航 croscopic cvaluation
oF small incomplete divcrticula througll X‐ ray and
(台 ).
十卓,!1,ll,
p
Fig. 16-17. アヽascular ittcctiOn .vith Barotrast and doublc
contrast tcchnique.
Fig.16.ComParativc dcmonstration oF the mesenteric vcssds. a)No
inaammatory changes,
the vcsscls arc still elastic and sOFt. b)VeSSels altcrcd by
infection in diverdcular disease.
OFinfectiOn are indicatcd on the divcrticular neck,causing
abnormalities in thc area. ‐ Further
information about the innammatory inv01vement in the mesentcry
can be obtalned by radio‐
logy. Figs,16a)and b)are eXCInplary: The d市 erdcular disease
illusttated in Fig.16a)is
stll conined tO the wall oF the colon. The lnesenteric vessels
show■ O inaal_atory changes
and are stili elastic and sOrt, Fig。 16b)shoWS the vcssels in a
l■ esentery which have been al‐
-
114(572)
Fig。 17. Comparative demonstration of
づ Divcrticular disease.
日消外会お 1 0巻 5号
an intesdne sttment・
b)CrOhn'3disase・
tered by infectiOn in a case OF scttental diverdcular disease Of
thc cO10n. Irregularites and
stenosation Of the vessel walls can be recottzed・ Su●h
exa■unations are a great aid in un‐
derstanding the tendency of diverdcular dsease to spread一
―begininng in the cO10nic wall
and encroaching secOndarily on the mesentery,DILrendatOn from
Other innammatory
intestinal disacases is also possible with this technique. A
cOmparative demOnstration doc―
unents this imprcs競 義 。 (Fig。17a and b)。 17a)shOWS a specimen
fron diverdcular disease
and 17b)an intesdne infected with CrOhn's discase. Arteriove■
Ous ancurysms,in Pardcular,
are ttpica■y10cated in the intestinal wall itser during Crohn's
dsease.The mesentcry
vessels,however,show a difFerent kind oF abnomalitt when
afFected by diⅥ 3rticular disease.
Tre■ こs■■ContenPOrary Treament Ofコ にvcHttcular Dに sease
The abundance oF pathO10gical‐anatOmical,radiological and
functbnal data(Graser,
1898; Schrciber, 1965; Parks, 1969; Hcberer et al. 1970; Bccker
a.Brunner, 1974; Hcuck,
1974;Ottettann,1974;Becker,1976;Stelzner,1976 and odlers)has
cOnsiderably inllucnced
the atitude towards diverdcular discase.Our own studies(Thiede
et al.1975)as wen as
t h o s e o f K i i ―c d e a n d P r O s s ( 1 9 7 4 ) h a v e S
h O W n d l a t t h e p 五m a r y m o r t a l i t y o f S t a g e I
I I
Patents can be as h確 出 as 50%。 SurttCal techniques can not
substantially reduce dtts high
death ratlj since the patients succumb to thlrapeutcally
resistant complicatお ns of the discase.
In view Ofthesc Facts,two demands lnust be lnade ofthe
conservatve and operative therapists:
1. When Possible,the occurence oF dtterticular comlications must
be prevented through
d i c t a n d m e d i c a l t r e a t m e n t . T h i s c a n b
e a c c o m p l おh e d b y t h e c o I I s t a n t P r e S C r i b
i n g o F w h e a t
bran and foods high in cdlulose as laxaミ 弱 e.g.Agiolax―
(BrOdripp and HumPhreys,1976;
Sche工erer, 19765 Strohmeycr, 1976).
2, Close cooperation btteen the intettl and surglcal
gsatroentcrologists shOuld begln
声
|
-
1977年 9月 115(573D
at the Onset of the discase in order that rcsectiOn can be
perrOrlned as early as necessary(IIol‐
lender et al.1974)。 It has not yet bccn established tthether the
myOtOmy procedurc(Reilly,
1971)and itS modincations in thc carly stages are of
tllerapcutical signiflcancc, since long‐
term observatiOns are not available(Dcucher, 1976).
Summary
Thc recent sharp incrcase itt the number of PcOPlc with
divcrticular disease,pardcularly
in thc Western industrial natiOns,necessitates the analysis
Ofall cpidemiO10gical,pathOgenetical,
anatolnical,and PathOphysio10gical paramctcrs of thc disease.A
number of mutually realted
pathOgenetic factOrs, classiIIcd as sOcial, biOiOgical, cO10nic
wall and intralulninary9 arc re‐
spollsiblc fOr the appearancc Of this diseasc.PathophysiO10gy
cOnsiderably inaucnces the
prognOsis, PredOHlinant dccisive factors in thc diagnosis are
radiological demOnstra工 on
(e,g・dOuble―tOntrast study oF the co10n)and Cilnical symptolns.
Subtle X― ray diagnosis alsO
assists in the acquisitiOn of information abOut thc rclativc
frcqucncy and locattzation Of the
oFthc divcrticula. 正 )istributiOn intO thrcc clinical stages is
based on therapeutica1 0bsettation.
Opcrating techniques are standardized tOdy and as is shOwn in
this study, can be applied
difFcrentially in Stagcs II and III. FOr patients in Stage
II,prilnary resectiOn is the``elected"
proccdure,whilc Stage III usually calls lbr muld― stagc
resectiOns,the incOntinuity resection
Of thc Hartlnann typc being the preferred lnethOd. Becausc of
poor prog4osis in cases with
complicatiOns,rcsection shOuld be carried out in thc carly
stages of the discase;inllalnmatory
inv01vement caused by incOmplete d市 erdcula also spcaks for
carly rescction. Insuttcient
data are availablc tO cvaluate the vahOus myotomy techniques, C。
10nic nstulas, which
appear in about 15% Of the Cases Or divcrticular diseasc,requre
a multistage operational
p r o c e d u r e i n t h c m t t O r i t y O f t t e c a s e s
. c O m b i n c d i n t r a O p e r a t v e e v a l u a t i O n o f
t h e r e s c c t e d
segmcnt is advantageous in dcterming the achieved Operat市 e
radicalness,csPCCially regard‐
ing the pathogenetically imPOrtant incomplete diverticula. This
procedure is alsO an aid
in bringing to light ncw aspccts cOncerning the gcnesis and
sprcad oF divcrticular discase.
Ltterat■■re
Akovciantz,A.: Dic MyotOmic in der BChandlung der
Kolondivertikulosc tttd diVCrtikulitis in:Kolondiver‐
titulitis, RcifFcrschdd, M.Thicme, Snttgart(1974.)
Baumgartcl,F.,Krcmcr.K.and Schrciber.H.W.: Spezidlc Chirurtte
ttr dc Praxia,Thicme‐ Stuttgart(1972).Beckcr, V.: PatholOgisch
anatOmishcc Aspcktc zur Entstchung von Divcrtikein und ihrcn
Komplikationen.
Langenbccks Arch.Chir.3442(1976)401.
Beckcr,v.and Brunncr,H.P.:
Divcrtikulosc,Divcrtiklditis.PathOgcnesc und Patholgoischc Anato■
lic in t Kolon‐diverttkulits.Hrsg.Rci強 ミchcid,M.stuttgarし
ThicIIIC(1974).
Bttdrゃ P,A.J,M.and Humphreys,D.M.: Diverticular discase: Thrcc
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Painter,N.S.: EfFect of dietary f■ ber。■stools and the transit
times andits roe
in the cunsation Of disease. Lancet 1972 11, 1403.
Ciを、ANscn,]4ヽ[., Divcrtikcl des Damcs.In: L.Dcmling(cd):
Klinische CastrOenterologle,斑 .I Stuttgart:
-
116(574) 日消外会お 10巻 5号
Thicme 1973.
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175 (1972) 838.
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Cr a s c r , E . : U b e r m u l t i p l e F a l s c h c D a m d
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741.
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divcrticulitis.Am.J.Roentgenol.72(1954)213.
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Hebcrer,C。 ,HofFmaIIn,K.Bary,S.V.and Naran。 ,H.: zur oPcrativen
TheraPie dcr Dickdamdivertikulids.
1ヽ工nch.medo Wschr. 116(1974)1075.
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342(1976)4j21.
Hodgson,」 .: An interim report in prOducdon oF colon divertictda
in the rabbit.GUT 13(1972)802.
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CUT 10(1969a)336.
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-
1977年 9月117(575)
Parks,T.G.and Connel,A.ヽ 1.: Motility studics in diverticular
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Par臨 ,T.C.and Connd,A.M.: Modlity sttdies in dverticular
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