It is usually sufficient to remove only the most severely affected segment; however, the proximal margin of resection

should be in an area of pliable colon without hypertrophy or inflammation [137]. Not all of the diverticula-bearing colon must be removed. Usually a sigmoid colectomy will suffice; however, occasionally the proximal resection margin must extend well into the descending colon or to the left transverse colon. Distally, the margin of resection should be where the taenia coli splay out STI571 nmr onto the upper rectum. After sigmoid colectomy for diverticulitis, an important predictor of recurrent diverticulitis is a colosigmoid rather than a colorectal anastomosis [156, 157]. When a colectomy for diverticular disease is performed, a laparoscopic approach is appropriate in selected patients (Recommendation 1 B). Laparoscopic colectomy may have advantages over open laparotomy, including less pain, smaller scar, and shorter recovery [137]. There is no increase in early or late complications [158, 159]. Cost and outcome are comparable to open resection [160]. Laparoscopic surgery learn more is acceptable in the elderly [161] and seems to be safe in selected patients with complicated disease [162]. Urgent operation is

required for patients with diffuse peritonitis or for those who fail non-operative management of acute diverticulitis (Recommendation 1 B). If a patient presents with severe or diffuse peritonitis, emergency colon resection is necessary. Also, if sepsis does not improve with inpatient conservative treatment of acute diverticulitis or after percutaneous drainage, surgery is indicated [137]. Immunosuppressed or immunocompromised patients are more likely to present with perforation or fail BKM120 purchase medical management, so a lower threshold for urgent or elective surgery should apply to them [163]. The source control of diffuse peritonitis is discussed cAMP together in the next topic of large bowel perforations. Large bowel perforations No practice guideline has been proposed for the source control of large bowel perforation. Causes

of large bowel perforations include (1) penetrating foreign body perforation, (2) extrinsic bowel obstruction, (3) intrinsic bowel obstruction, (4) direct loss of bowel wall integrity without foreign body perforation, (5) intestinal ischemia, and (6) infection. The principles of source control include: control of the site of perforation, evacuation of contamination, debridement of necrotic tissue, and re-establishment of functional anatomy. Many patients who have large bowel perforations develop sepsis with accompanying hemodynamic compromise, hypothermia, acidosis, and a coagulopathy [164]. These patients require rapid resuscitation and rapid surgery. The standard approach is known as damage control surgery.