Brief

Report

The

Use

of

WAIS-III

in

Adults

with

HFA

and

Asperger

Syndrome

The

WAIS

III

was

administered

to

adults

with

high

functioning

autism

-LRB-

HFA

-RRB-

and

adults

with

Asperger

syndrome

Differences

between

Verbal

Intelligence

-LRB-

VIQ

-RRB-

and

Performance

Intelligence

-LRB-

PIQ

-RRB-

were

not

found

Processing

Speed

problems

in

people

with

HFA

appeared

At

the

subtest

level

the

Asperger

syndrome

group

performed

weak

on

Digit

Span

Comprehension

and

Block

Design

were

relative

strengths

In

the

HFA

group

performance

on

Digit-Symbol

Coding

and

Symbol

Search

was

relatively

poor

Strengths

were

found

on

Information

and

Matrix

Reasoning

The

results

suggest

that

the

VIQ-PIQ

difference

can

not

distinguish

between

HFA

and

Asperger

syndrome

WAIS

III

Factor

Scale

and

Subtest

patterning

provides

a

more

valid

indicator

Introduction

Over

the

past

few

years

interest

in

HFA

and

Asperger

syndrome

in

adults

with

normal

intelligence

has

increased

markedly

However

not

much

is

known

about

the

cognitive

profiles

of

these

groups

Only

a

few

studies

exist

about

adults

who

function

relatively

well

in

society

and

have

been

diagnosed

late

in

life

-LRB-

Howlin

Vermeulen

-RRB-

The

present

study

aims

to

assess

the

cognitive

profiles

of

this

relatively

well-functioning

subgroup

by

means

of

the

Wechsler

Intelligence

Scale

III

-LRB-

WAIS

III

Wechsler

-RRB-

In

WAIS

III

the

intelligence

pattern

is

described

at

three

levels

The

first

level

contains

Performance

Intelligence

and

Verbal

Intelligence

The

second

level

consists

of

the

four

factor

scales

Verbal

Comprehension

Perceptual

Organization

Freedom

from

Distractibility

and

Processing

Speed

The

third

level

contains

the

subtests

The

following

paragraphs

summarizes

research

on

the

intelligence

profiles

of

adults

with

the

autistic

disorder

or

Asperger

syndrome

on

the

basis

of

these

three

levels

The

Performance

IQ

-LRB-

PIQ

-RRB-

Verbal

IQ

-LRB-

VIQ

-RRB-

dichotomy

has

been

incorrectly

used

for

years

to

underpin

the

diagnosis

of

autistic

disorder

or

Asperger

syndrome

It

is

questionable

whether

the

two

constructs

should

even

be

applied

in

general

because

research

did

not

support

the

construct

validity

of

the

VIQ-PIQ

dichotomy

-LRB-

Taub

-RRB-

For

adults

with

HFA

studies

on

WAIS-R

have

yielded

contradictory

results

-LRB-

Minshew

et

al.

Siegel

et

al.

Vermeulen

-RRB-

which

may

reflect

the

validity

problems

of

the

VIQ-PIQ

dichotomy

-LRB-

Arnau

and

Thompson

Taub

-RRB-

The

factor

scale

level

is

of

great

importance

in

assessing

cognitive

abilities

because

factor

analytic

studies

indicate

that

the

factor

scales

give

the

best

estimates

of

the

four

factors

underlying

intelligence

-LRB-

Arnau

and

Thompson

Ryan

and

Paolo

-RRB-

No

studies

have

been

performed

on

WAIS-III

profiles

for

adults

with

HFA

or

Asperger

syndrome

as

far

as

we

know

Therefore

no

information

is

available

on

the

results

of

factor

scales

in

these

groups

This

leads

to

the

conclusion

that

the

most

important

factors

of

the

intelligence

pattern

for

adults

with

HFA

or

Asperger

syndrome

are

still

unknown

On

subtest

level

some

studies

on

WAIS

or

WAIS-R

found

low

Comprehension

versus

high

Block

Design

scores

-LRB-

Goldstein

et

al.

Rumsey

and

Hamburger

-RRB-

A

relatively

high

variability

between

the

subtests

scores

in

adults

with

HFA

has

also

been

reported

-LRB-

Siegel

et

al.

-RRB-

In

summary

research

shows

that

among

adults

with

HFA

or

Asperger

syndrome

results

of

VIQ-PIQ

differences

vary

and

may

be

influenced

by

the

validity

problems

of

the

VIQ-PIQ

dichotomy

The

factor

scale

scores

and

the

subtest

patterns

provide

a

better

representation

of

the

intelligence

pattern

Aims

of

the

Present

Study

The

present

study

aims

to

acquire

insight

into

the

WAIS

III

profiles

of

normal

intelligent

adults

with

HFA

and

Asperger

syndrome

Profiles

in

the

total

group

and

differences

between

the

two

diagnostic

groups

will

be

examined

Methods

Procedure

All

participants

were

recruited

from

the

GGZ

-LRB-

Mental

Health

Center

-RRB-

Eindhoven

and

Oost-Brabant

The

participants

met

the

criteria

for

Asperger

syndrome

or

HFA

Participants

with

relevant

neurodevelopmental

conditions

and

genetic

conditions

were

excluded

as

were

institutionalized

patients

and

patients

with

a

Full

Scale

IQ

below

Subjects

The

mean

Full

Scale

IQ

of

the

participants

was

individual

scores

varied

between

and

-LRB-

see

Table

-RRB-

Table

of

participantsIQ

and

ageMSDRange

Full

scale

Mean

Autistic

Asperger

Gender

Education

Lower/middle

Higher

Employment

status

Employed

or

Current

living

circumstances

Lives

with

Lives

independently

Sheltered

Lives

with

parents

All

individuals

ranged

in

age

from

to

years

The

mean

age

was

Of

all

participants

finished

higher

education

and

individuals

had

work

participants

lived

together

with

a

partner

The

relatively

large

number

of

participants

who

had

a

relationship

worked

and

were

well

educated

emphasizes

the

relatively

high

level

of

functioning

in

this

group

Assessment

of

Disorder

Hetero-anamnestic

information

was

gathered

using

the

Dutch

version

of

the

Autistic

Disorder

Diagnostic

Interview

revised

version

-LRB-

ADI-R

Lord

et

al.

-RRB-

administered

by

psychologists

who

were

officially

trained

in

the

administration

and

scoring

of

the

instrument

To

gather

anamnestic

information

a

semi-structured

interview

was

used

to

assess

presence

of

the

DSM-IV

criteria

of

HFA

and

Asperger

syndrome

-LRB-

APA

-RRB-

Because

of

the

controversial

nature

of

the

DSM-IV

criteria

-LRB-

Ghaziuddin

et

al.

Mayes

et

al.

-RRB-

additional

questions

were

used

to

differentiate

between

HFA

and

Asperger

syndrome

based

on

the

diagnostic

criteria

of

Gillberg

and

Gillberg

-LRB-

-RRB-

and

-LRB-

WHO

-RRB-

Assessment

of

Intelligence

The

intelligence

profile

was

assessed

using

the

Dutch

translation

of

the

WAIS

III

-LRB-

Wechsler

-RRB-

The

WAIS-III

has

excellent

psychometric

properties

-LRB-

Sattler

and

Ryan

-RRB-

and

has

been

validated

for

the

Dutch

population

-LRB-

Wechsler

-RRB-

Results

Analyses

were

done

at

the

three

WAIS-III

levels

VIQ

versus

PIQ

the

four

factor

scales

and

all

subtests

Preliminary

analysis

included

checks

for

normality

linearity

influential

data

points

and

assumptions

of

repeated

measures

No

serious

deviations

were

found

T-tests

showed

that

both

diagnosis

groups

were

comparable

in

education

and

work

status

as

well

as

in

gender

distribution

Differences

Between

WAIS

III

VIQ

and

PIQ

Differences

between

VIQ

and

PIQ

for

all

participants

and

both

diagnostic

groups

were

analyzed

by

means

of

paired

t-tests

No

statistically

significant

effects

were

found

for

any

of

the

investigated

groups

-LRB-

see

Table

-RRB-

Table

and

PIQ

differences

in

the

total

group

and

in

diagnostic

groupsVIQPIQMean

difference

nMSDMSDTotal

Autistic

Differences

Between

Factor

Scale

Scores

Factor

Scale

profiles

were

studied

within

the

total

group

and

between

the

two

diagnostic

subgroups

by

means

of

repeated

measures

analysis

of

variance

Mauchly

's

test

indicated

that

the

assumption

of

sphericity

was

not

met

Therefore

the

degrees

of

freedom

were

corrected

using

the

Huynh

Feldt

correction

-LRB-

ε

-RRB-

Post-hoc

comparisons

using

the

Sidak

adjustment

for

multiple

comparisons

showed

that

the

main

effect

of

the

WAIS

III

Factor

Scale

was

statistically

significant

-LRB-

F

-LRB-

-RRB-

p

-RRB-

An

interaction

effect

of

differences

in

Factor

Scale

mean

by

diagnostic

group

was

also

found

-LRB-

F

-LRB-

-RRB-

p

-RRB-

To

find

out

which

differences

in

WAIS

III

Factor

Scale

means

added

to

the

significant

main

effect

post

hoc

pairwise

comparisons

were

done

This

showed

that

the

main

effect

in

the

total

group

can

be

attributed

to

Processing

Speed

being

significantly

lower

than

Verbal

Comprehension

-LRB-

p

-RRB-

and

Perceptual

Organization

-LRB-

p

-RRB-

Post

hoc

pairwise

comparisons

were

done

for

the

two

diagnostic

groups

to

analyse

the

within

group

effect

In

the

Asperger

group

no

significant

differences

in

Factor

Scale

mean

scores

were

found

The

HFA

group

however

showed

a

significant

lower

Processing

Speed

compared

to

Verbal

Comprehension

-LRB-

p

-RRB-

Perceptual

Organization

-LRB-

p

-RRB-

and

Freedom

from

Distractibility

-LRB-

p

-RRB-

-LRB-

see

Table

-RRB-

Table

scale

scores

for

the

total

group

and

the

diagnostic

groupsFactor

scaleMSDNVerbal

comprehensionAutistic

Asperger

Perceptual

organizationAutistic

Asperger

Freedom

from

distractibilityAutistic

Asperger

Processing

speedAutistic

Asperger

p

Differences

Between

WAIS

III

Subtest

Scores

The

Subtest

profiles

were

explored

within

the

total

group

and

between

the

two

diagnostic

subgroups

by

means

of

a

repeated

measures

analysis

of

variance

The

assumption

of

sphericity

was

not

met

Therefore

the

degrees

of

freedom

were

corrected

using

the

Huynh

Feldt

correction

-LRB-

ε

-RRB-

Post-hoc

comparisons

were

performed

using

the

Sidak

adjustment

for

multiple

comparisons

The

results

-LRB-

see

Table

-RRB-

showed

a

significant

main

effect

of

the

type

of

Subtest

-LRB-

F

-LRB-

-RRB-

p

-RRB-

Table

standardized

subtest

scores

for

the

total

groupSubtest

scores

Digit

Picture

Block

Matrix

Picture

Symbol

Object

p

An

interaction

effect

of

Subtest

by

diagnosis

was

also

found

-LRB-

F

-LRB-

-RRB-

p

-RRB-

indicating

that

the

patterning

of

the

WAIS

III

subtest

mean

scores

for

the

two

diagnostic

groups

differs

Table

and

show

the

mean

Subtest

scores

and

standard

deviations

for

the

HFA

group

and

the

Asperger

syndrome

group

Table

standardized

subtest

scores

for

the

autistic

disorder

groupSubtest

Scores

Digit

Picture

Block

Matrix

Picture

Symbol

Object

p

Table

standardized

subtest

scores

for

the

Asperger

syndrome

groupSubtest

Digit

Picture

Block

Matrix

Picture

Symbol

Object

p

Post

hoc

pair

wise

comparisons

showed

that

the

main

effect

in

the

total

group

can

be

attributed

to

the

fact

that

Digit-Symbol

Coding

was

significantly

lower

than

Vocabulary

-LRB-

p

-RRB-

Arithmetic

-LRB-

p

-RRB-

Information

-LRB-

p

-RRB-

Comprehension

-LRB-

p

-RRB-

Block

Design

-LRB-

p

-RRB-

and

Matrix

Reasoning

-LRB-

p

-RRB-

Furthermore

Symbol

Search

was

lower

than

Information

-LRB-

p

-RRB-

and

Comprehension

-LRB-

p

-RRB-

Post

hoc

pair-wise

comparisons

were

also

performed

for

the

two

diagnostic

groups

to

analyze

the

within

group

effect

The

two

groups

showed

significant

differences

in

Subtest

scores

In

the

Asperger

syndrome

group

Digit

Span

was

lower

than

Comprehension

-LRB-

p

-RRB-

and

Block

Design

-LRB-

p

-RRB-

In

the

HFA

group

performance

was

significantly

higher

in

Information

compared

to

Digit-symbol

Coding

-LRB-

p

-RRB-

and

Symbol

Search

-LRB-

p

-RRB-

Furthermore

Digit-Symbol

Coding

was

lower

than

Matrix

Reasoning

-LRB-

p

-RRB-

Discussion

WAIS

VIQ

Versus

PIQ

No

significant

differences

were

found

between

VIQ

and

PIQ

in

the

total

group

nor

in

the

two

diagnostic

subgroups

The

results

are

in

line

with

factor

analytic

studies

showing

that

the

VIQ-PIQ

dichotomy

is

not

valid

for

general

populations

-LRB-

Arnau

and

Thompson

Taub

-RRB-

WAIS

III

Factor

Scale

Level

The

Asperger

syndrome

group

was

characterized

by

a

flat

Factor

Scale

profile

in

the

Asperger

syndrome

group

while

the

HFA

group

performed

significant

low

in

Processing

Speed

A

low

Processing

Speed

indicates

problems

in

speed

of

processing

visual

information

-LRB-

Wechsler

-RRB-

Adults

with

HFA

apparently

need

more

time

than

other

people

to

process

and

integrate

visual

information

and

to

act

on

this

information

The

Processing

Speed

performance

of

the

HFA

group

might

be

influenced

by

problems

with

top-down

processing

and

ignoring

irrelevant

details

which

are

characteristic

of

people

with

HFA

-LRB-

Happé

Shah

and

Frith

-RRB-

In

order

to

maintain

an

overview

of

what

they

are

doing

they

work

slowly

WAIS

III

Subtest

Level

Analyses

showed

different

Subtest

patterns

in

the

HFA

and

the

Asperger

syndrome

groups

The

HFA

group

performed

significantly

low

in

Digit-Symbol

Coding

and

Symbol

Search

These

two

subtests

together

form

the

Processing

Speed

Factor

The

low

scores

for

these

subtests

represent

the

problems

in

speed

of

processing

visual

information

as

described

in

the

preceding

paragraph

The

HFA

group

showed

significantly

high

performance

in

Information

and

Matrix

Reasoning

High

scores

for

Information

are

in

line

with

the

fact

that

people

with

autism

usually

acquire

much

factual

knowledge

-LRB-

Happé

-RRB-

Matrix

Reasoning

taps

nonverbal

perceptual

reasoning

Matrix

Reasoning

is

the

only

Perceptual

Organization

subtest

without

a

time

limit

and

is

possibly

not

influenced

by

low

Processing

Speed

performance

scores

The

good

performance

of

the

HFA

group

can

probably

be

attributed

to

their

visual-spatial

strengths

-LRB-

Lincoln

et

al.

Tsatsanis

-RRB-

and

to

the

absence

of

a

time

limit

for

this

subtest

In

the

Asperger

group

scores

for

Digit

Span

were

relatively

low

Digit

Span

taps

working

memory

capabilities

-LRB-

Wechsler

-RRB-

which

can

been

defined

as

the

ability

to

hold

in

mind

past

states

of

the

environment

and

past

actions

while

currently

performing

an

action

-LRB-

Russell

-RRB-

People

with

autism

or

Asperger

syndrome

tend

to

store

information

in

details

instead

of

using

strategies

which

often

leads

to

problems

in

retaining

information

-LRB-

Happé

Minshew

et

al.

Tsatsanis

-RRB-

Low

Digit

Span

scores

in

the

Asperger

group

may

reflect

problems

in

applying

strategies

to

retain

information

The

Asperger

syndrome

group

performed

significantly

well

on

Comprehension

High

scores

on

Comprehension

in

this

group

seem

to

contradict

former

research

results

-LRB-

Klin

et

al.

Mayes

and

Calhoun

Siegel

et

al.

-RRB-

However

people

with

Asperger

syndrome

often

try

to

function

in

society

by

analyzing

social

situations

at

a

cognitive

level

which

has

been

described

as

using

an

explicit

theory

of

mind

-LRB-

Frith

and

Happé

-RRB-

A

extremely

well

developed

explicit

theory

of

mind

may

have

caused

the

Asperger

syndrome

group

to

have

such

high

scores

on

Comprehension

The

Asperger

Syndrome

group

also

performed

significantly

well

on

Block

Design

Strengths

in

Block

Design

have

often

been

reported

in

studies

of

people

with

HFA

or

Asperger

syndrome

-LRB-

Happé

Shah

and

Frith

-RRB-

This

has

been

attributed

to

strengths

in

processing

unconnected

stimuli

outside

a

meaningful

context

which

go

together

with

the

central

coherence

problems

seen

in

people

with

autistic

impairment

-LRB-

Shah

and

Frith

-RRB-

Conclusions

The

present

study

found

people

with

Asperger

syndrome

to

differ

significantly

from

people

with

HFA

in

WAIS

III

Factor

Scale

profiles

and

WAIS

III

Subtest

patterning

In

people

with

HFA

Processing

Speed

problems

were

found

Further

the

HFA

and

Asperger

syndrome

group

showed

different

subtest

patterns

The

present

study

supports

the

idea

that

HFA

and

Asperger

syndrome

can

be

differentiated

empirically

at

the

level

of

intellectual

functioning

This

lends

support

to

the

hypothesis

that

HFA

and

the

Asperger

syndrome

are

two

separate

disorders

O O O O O O O O O O O O B I O O O O O O O O O B I I O O O O O O O B I O O O O B O O O O O B O O O O O O O B I O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O B O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O B I O O O O O O O O O O B I O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O B I O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B I O O O O O

high functioning autism
asperger syndrome
intelligence
processing speed


First aid in acute stroke Objective First aid training is well established to teach the public how to recognize a medical emergency and take appropriate action . Though it is now handled as a high priority emergency stroke is not among the main topics of first aid . We investigated if first aid training may be useful for enhancing stroke awareness . Introduction First aid is a concept of first hands-on measures performed in a medical emergency by laypersons . The goal is to teach people how to recognize a medical emergency and start qualified action by providing measures of basic life support such as performing cardiopulmonary resuscitation . Other topics are injuries and burns , shock , unconsciousness or heart attack . In Germany first aid training is mainly offered by charity organizations like the German Red Cross , or the St. John Ambulance . There are various training programmess differing in length and depth of information . First aid training was effectively used to teach the public in new methods of life-saving therapy like automated external defibrillation -LSB- 1 -RSB- . Stroke or brain attack is not or only marginally included in first aid training . This is in contrast to the fact that management of acute stroke changed as it is now handled as a high priority emergency -LSB- 2 -RSB- . Limited knowledge of signs , symptoms and risk factors for stroke was noted as an important factor associated with delay of admission -LSB- 3 -- 5 -RSB- . To enhance awareness on stroke , various educational programmess have been initiated -LSB- 3 , 6 -- 8 -RSB- . The American Stroke Association 's Operation Stroke , a huge awareness campaign on stroke , the Coordinated Stroke Programme of Southwestern Ontario and King County 's Medic One at seattle are examples of continuous health education programmes using internet , designated courses and mass media . Regular first aid training was never used in a stroke information campaign though it is widely available and well accepted in many countries . In a prospective study we tried to test the hypothesis that stroke information integrated in first aid training will improve knowledge of laypersons . Additionally a concept of first action will increase motivation and acceptance will be quite high with participants . Methods Educational procedure A teaching sequence was created by stroke neurologists of the University of Erlangen together with senior instructors of the St. John Ambulance -LRB- Johanniter-Unfall-Hilfe -RRB- in Bavaria . Educational objectives of the session were clearly defined . The sequence was designed for a 15 to 20 minutes audiovisual presentation and provided information basically what stroke means and about stroke risk factors , warning signs and symptoms . Warning signs presented included sudden uni - or bilateral weakness or numbness , facial paresis , speech disturbance , blurred vision , trouble in walking , vertigo / dizziness , diplopia . Then a concept of first action to be taken in case of stroke was presented -LRB- Figure 1 shows a one-slide overview -RRB- . including check of vital signs and immediate activation of EMS . Fig. 1Concept of first action presented in the stroke lesson -LRB- originally presented in German -RRB- The teaching session was presented by first aid instructors integrated in regular first aid training programmes of 8 to 16 hours duration of the St. John Ambulance all over Bavaria . A small booklet was made for the first aid instructors to provide more detailed information about stroke . Data collection and analysis To investigate the effect of the teaching , all participants of designated courses were asked to fill out a questionnaire before the stroke lesson . At the end of the training program a similar questionnaire was presented slightly altered in structure and some questions . The overall length of the training courses differed as some courses were presented on a whole day schedule within one weekend while others offered one 90-minute teaching unit once weekly and were therefore scattered over a period of up to 6 weeks . Accordingly the time delay between the stroke lesson and the post-teaching questionnaire varied as well ranging from 1 to 28 days -LRB- mean 8.6 d -RRB- . Before teaching participants were asked to note in free text and explain what they think that a stroke is , to name signs and symptoms of stroke and to describe how they would act in case of witnessing stroke . Additionally sex , age and profession of participants was recorded as well as their previous information about stroke After the lesson we asked again for a definition of stroke and to list symptoms of stroke . Furthermore we asked how urgent they think that a stroke needs to get therapy . After all subjects were asked for their satisfaction with the training session , how they would rate their own interest in stroke and how they would rate the importance of stroke as a topic in first aid . Therefore a rating scale from 1 to 6 was given with 1 being the best , 6 the worst . Participants with any profession within health care were excluded from the analysis . The questionnaire was not offered in trainings for special groups such as in schools or nursing homes . Mean values were compared using paired t-tests while χ ² - statistics were used for proportions of nominal data . Results In 38 first aid training courses 532 participants -LRB- 86.6 % of 614 subjects attending the training -RRB- completed the questionnaire before and after training , 53.6 % of those were male , mean age was 28.6 years -LRB- + / − 11.1 y , range 15 -- 61 y -RRB- . Before training 28.4 % of all participants stated a correct description of stroke , another 32.7 % gave at least the brain as the location of the disease . The mean number of stroke symptoms named was 1.52 -LRB- ± 1.1 -RRB- , descriptions listed were mainly `` weakness '' , `` motor problems '' `` disturbance of consciousness '' or `` speech problems '' , 12.8 % of all respondents did not list at least one correct stroke symptom or warning sign , 40.7 % listed symptoms that are not typically suggestive of stroke -LRB- coded as incorrect -RRB- . The mean number of first aid measures named was 1.22 -LRB- ± 1.0 -RRB- . 78.7 % of respondents stated that they had any kind of information about stroke before the training . After the stroke lesson 69.9 % of the participants stated a correct description of stroke , and 20.3 % gave at least the brain as the location of the disease . Now the mean number of stroke symptoms named was 3.35 -LRB- ± 1.4 -RRB- . 58.5 % declared that in case of stroke urgent treatment is needed . See table 1 for an overview of key results . Table 1Key results from the questionnaire before and after receiving the stroke lessonn = 532before stroke lessonafter stroke lessonmean numberno . of stroke signs1 .523.35 p < 0.001 no . of first measures1 .22 not asked % of participantscorrect explanation what stroke means 28.469.9 p < 0.001 brain affected organ32 .720.3 p < 0.01 no/incorrect explanation38 .9 9.8 p < 0.01 > 4 symptoms listed 2.628.4 p < 0.001 no symptom listed12 .8 3.6 p < 0.001 `` immediate medical help required '' not asked58 .5 prior information about stroke78 .7 Most participants were satisfied with the stroke lesson as the mean value in the score -LRB- 1 = best to 6 = worst -RRB- was 1.76 -LRB- ± 0.6 -RRB- , interest in topics of stroke was rated high -LRB- mean 1.56 , ± 0,8 -RRB- . Stroke was regarded as an important topic for first aid training . -LRB- mean 1.57 , ± 0,9 -RRB- . The difference in mean number of symptoms named before and after the lesson was highly significant -LRB- p < 0.001 -RRB- , as well as the difference in percentage of participants giving a correct definition of stroke -LRB- p < 0.001 -RRB- and those naming more than 4 symptoms . In contrast the number of participants not listing at least one symptom and giving none or an incorrect definition of stroke was significantly reduced after the training . Discussion To our knowledge this is the first study published reporting about first aid training for public education on stroke . A teaching session was integrated in regular first aid training offered to the public by the St John Ambulance . From data of this pilot study the teaching session was very effective : Mean number of stroke symptoms and number of participants giving a correct description of stroke more than doubled . The difference in number of symptoms and portion of participants describing stroke symptoms correctly was highly significant . Nevertheless with a mean delay between teaching and retention test below 10 days these results show only the short-term effect and durability of the information remains unclear . From other studies in teaching medical skills to laypeople we know that knowledge is reduced by about 25 % over the first three months and may remain stable thereafter -LSB- 9 -RSB- . One year may be critical period for repetition of training -LSB- 10 -RSB- . However , participants showed also a high grade of satisfaction with the lesson and its presentation , and ranked importance of stroke as a topic quite high . As a consequence of these results the lesson is now integrated in every first aid training of the St. John Ambulance in Bavaria . Before this study there was no clear cut concept existing for first action in acute stroke . Despite the fact that calling EMS accelerates admission -LSB- 11 -RSB- the effect of all these actions performed by medical laypersons on stroke progression or outcome is not yet proven . However , it takes about 15 minutes from starting the call to arrival of EMS on scene -LSB- 12 -RSB- . During this time a bystander should be able to offer help to the patient . By presenting simple hands-on measures it is also emphasized that something can and must be done in case of acute stroke . The effect of various educational interventions was already demonstrated in previous studies -LSB- 3 , 6 -- 8 -RSB- . None of these studies handled information on stroke integrated in general health education campaigns such as routine first aid training . From our viewpoint integrating a stroke lesson in first aid training is not only effective but provides a number of advantages . First an integration makes it clear that stroke or brain attack is an important medical emergency as important as heart attack or trauma . Connecting brain attack with other medical emergencies also facilitates the demonstration of measures as they could be used for other situations as well and it might help to create a better understanding to stroke and its differences from other related diseases . We linked stroke to other related topics -LRB- e.g. `` head trauma '' -RRB- and formed a cluster of measures for `` all problems in the head '' as an effort towards integrative problem-based teaching which was shown to be superior to conventional lessons also in medical education -LSB- 13 -RSB- . Second , by using first aid training information on stroke this will reach large numbers of subjects not particularly interested in stroke or sometimes health education at all . According to their annual review the St. John Ambulance , England , issued a first aid training certificate to more than 500000 people in the year 2003 -LSB- 14 -RSB- , while the American Red Cross trained more than 11 million people in first aid -LSB- 15 -RSB- . In Germany within one year a driving license is issued to more than 800000 people mainly in the age of 16 to 21 . By legal regulations every one of them must have completed at least an 8 hour first aid training . So first aid training may especially reach younger people that are not interested in stroke awareness campaigns . Furthermore , given the large numbers of people reached , this method of education is extremely cheap . To summarize we found that a 15 minute presentation on stroke as a medical emergency improves stroke knowledge of participants in first aid training . Furthermore participants seem to appreciate getting information about stroke . Accordingly information on stroke or brain attack should be included in every first aid training thus reaching large numbers of subjects in many countries all over the world . Means of information may differ in their effectiveness -LSB- 8 , 16 -RSB- but the question is not whether education integrated in training programs may be more effective than mass media campaigns . Both methods of information will rather be complementary as they use different approaches and may reach different target groups . The goal is not to miss any single opportunity to send out the message about stroke as a medical emergency that needs immediate reaction by anyone who is next .

B I O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O B I O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B I O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

emergency medical service
healtheducation


Controversies

in

the

Surgical

Management

of

Sigmoid

Diverticulitis

The

timing

and

appropriateness

of

surgical

treatment

of

sigmoid

diverticular

disease

remain

a

topic

of

controversy

We

have

reviewed

the

current

literature

on

this

topic

focusing

on

issues

related

to

the

indications

and

types

of

surgery

Current

evidence

would

suggest

that

elective

surgery

for

diverticulitis

can

be

avoided

in

patients

with

uncomplicated

disease

regardless

of

the

number

of

recurrent

episodes

Furthermore

the

need

for

elective

surgey

should

not

be

influenced

by

the

age

of

the

patient

Operation

should

be

undertaken

in

patients

with

severe

attacks

as

determined

by

their

clinical

and

radiological

evaluation

Magnitude

of

the

Problem

Diverticular

disease

either

diverticulosis

or

diverticulitis

was

regarded

as

a

surgical

curiosity

in

the

surgery

but

over

the

past

years

its

prevalence

in

Western

countries

has

increased

dramatically

In

the

US

an

individual

's

risk

for

developing

diverticular

disease

approaches

by

age

Diverticulitis

defined

as

inflammation

and

infection

related

to

diverticula

occurs

in

to

of

patients

with

diverticulosis

and

is

one

of

the

most

common

indications

for

gastrointestinal

tract-related

hospitalizations

One

in

four

of

these

patients

presenting

with

diverticulitis

will

require

an

emergency

operation

because

of

perforation

peritonitis

or

systemic

complications

At

present

diverticulitis

is

the

associated

diagnosis

for

one

third

of

all

colostomies

and/or

colon

resections

As

such

diverticulitis

is

one

of

the

five

most

costly

gastrointestinal

disorders

affecting

the

US

population

Etiology

Colonic

diverticula

tend

to

develop

in

the

areas

of

weakness

in

the

colonic

wall

most

frequently

at

the

sites

of

penetration

of

the

wall

by

blood

vessels

These

outpouchings

of

mucosa

and

peritoneum

are

of

the

pulsion

type

and

are

thought

to

be

caused

by

an

increase

in

the

intraluminal

pressure

within

the

colonic

wall

in

affected

individuals

-LRB-

Fig.

-RRB-

Figure

images

of

diverticuli

Colonoscopy

can

be

rather

difficult

when

several

diverticula

are

encountered

because

of

increased

colonic

tortuosity

and

lack

of

distensibility

It

is

thought

that

a

low

intake

of

dietary

fiber

and

resultant

decrease

in

stool

bulk

predisposes

those

in

Western

societies

to

an

elevation

in

colonic

pressure

Some

authors

attribute

the

high

rate

of

diverticular

disease

to

the

development

of

the

roller

mills

during

the

last

half

of

the

century

causing

the

grains

to

be

crushed

so

effectively

as

to

nearly

eliminate

all

of

the

cellulose

from

the

Western

diet

Despite

significant

supporting

evidence

for

fiber

and

its

role

in

the

development

of

diverticulosis

no

study

to

date

has

demonstrated

that

a

high

fiber

diet

can

reverse

this

process

or

reduce

the

incidence

of

complications

in

cases

of

established

diverticulosis

In

addition

to

dietary

intake

other

factors

have

been

implicated

in

the

development

of

diverticular

disease

Most

studies

report

that

diverticular

disease

is

more

common

in

the

elderly

especially

elderly

women

and

in

patients

who

smoke

cigarettes

or

drink

alcohol

Sigmoid

colon

specimens

from

patients

with

diverticulosis

have

been

found

to

have

increased

in

vitro

sensitivity

to

acetylcholine

as

well

as

reduced

smooth

muscle

choline

acetyltransferase

activity

and

upregulation

of

smooth

muscle

muscarinic

receptors

The

significance

of

these

biochemical

characteristics

still

needs

to

be

elucidated

but

the

differences

suggest

that

there

are

underlying

physiological

abnormalities

that

may

predispose

to

the

development

and

progression

of

diverticular

disease

Clinical

Presentation

and

Evaluation

The

clinical

presentations

of

diverticular

disease

range

from

asymptomatic

diverticulosis

diverticulosis

with

periodic

spasmodic

abdominal

pain

and

bloating

diverticulosis

with

hemorrhage

and

finally

diverticulitis

Although

diverticula

can

occur

in

any

portion

of

the

colon

this

review

will

only

focus

on

sigmoid

diverticulitis

by

far

the

most

common

site

for

this

disease

process

Most

patients

with

diverticulitis

present

with

symptoms

of

left

lower

quadrant

abdominal

pain

fever

and

leukocytosis

-LRB-

Table

-RRB-

Additional

symptoms

of

acute

sigmoid

diverticulitis

may

include

nausea

vomiting

change

in

bowel

habits

urinary

frequency

and/or

dysuria

In

cases

of

clear-cut

diverticulitis

based

upon

the

clinical

picture

one

can

manage

the

patient

without

any

imaging

studies

In

many

cases

especially

in

those

with

severe

symptoms

and

potential

complicated

diverticulitis

computed

tomography

-LRB-

CT

-RRB-

scanning

should

probably

be

performed

The

value

of

CT

scanning

is

the

ability

to

confirm

the

diagnosis

and

confidently

stratify

the

severity

of

the

disease

process

differentiating

mild

localized

inflammation

from

advanced

inflammation

with

abscess

formation

and/or

distant

extension

Table

Symptoms

of

DiverticulitisSymptomsFrequency

-LRB-

-RRB-

Left

lower

quadrant

Before

the

advent

of

CT

the

contrast

enema

was

the

primary

tool

in

the

evaluation

of

colonic

diverticular

disease

However

CT

scans

have

largely

replaced

barium

enema

as

the

preferred

imaging

modality

to

evaluate

patients

with

suspected

diverticulitis

The

use

of

CT

scanning

has

been

justified

by

several

studies

from

the

radiological

literature

demonstrating

a

high

sensitivity

-LRB-

-RRB-

and

specificity

-LRB-

-RRB-

for

diverticulitis

-LRB-

Fig.

-RRB-

Contrast

enema

on

the

other

hand

has

a

sensitivity

of

only

and

a

specificity

of

for

diverticulitis

Figure

Computed

tomography

scan

images

of

a

patient

who

presented

with

uncomplicated

diverticulitis

that

was

subsequently

treated

successfully

with

antibiotics

Note

the

thickening

of

the

sigmoid

colon

yet

the

lack

of

any

extraluminal

fluid

or

air

b

Computed

tomography

scan

images

of

a

patient

who

presented

with

complicated

diverticulitis

and

an

extraluminal

fluid

collection

that

did

not

resolve

with

attempted

CT-guided

drainage

an

required

an

eventual

sigmoid

colectomy

Classification

There

are

two

commonly

utilized

classifications

of

diverticulitis

The

European

Association

for

Endoscopic

Surgeons

developed

a

classification

scheme

based

upon

the

severity

of

its

clinical

presentation

In

this

system

diverticulitis

is

divided

into

symptomatic

uncomplicated

disease

recurrent

symptomatic

disease

and

complicated

disease

-LRB-

Table

-RRB-

Table

Classification

of

Diverticulitis

-LRB-

Adapted

from

Kohler

et

al.

-RRB-

GradeClinical

DescriptionSymptomsISymptomatic

uncomplicated

diseaseFever

crampy

abdominal

pain

CT

evidence

of

diverticulitisIIRecurrent

symptomatic

diseaseRecurrence

of

aboveIIIComplicated

diseaseHemorrhageAbscessPhlegmonPerforationPurulent

and

fecal

peritonitisStrictureFistulaObstruction

Another

classification

system

was

developed

by

Hinchey

et

al.

and

is

used

to

describe

the

stages

of

complicated

diverticulitis

-LRB-

Table

-RRB-

This

scheme

allows

for

good

communication

among

surgeons

when

it

comes

to

describing

the

various

degrees

of

diverticular

perforation

ranging

from

a

localized

perforation

with

a

small

abscess

to

generalized

fecal

peritonitis

Clearly

the

proper

surgical

approach

will

vary

depending

upon

the

Hinchey

stage

Table

Classification

of

Complicated

Diverticulitis

-LRB-

Adapted

from

Hinchey

et

al.

-RRB-

StageDescriptionIPericolic

or

mesenteric

abscessIIWalled

off

pelvic

abscessIIIGeneralized

purulent

peritonitisIVGeneralized

fecal

peritonitis

We

will

refer

to

both

of

these

classifications

when

discussing

the

appropriate

management

of

this

disease

Yet

another

classification

developed

by

Ambrosetti

et

al.

is

based

upon

the

CT

findings

The

criteria

of

Ambrosetti

et

al.

are

being

increasingly

utilized

to

stratify

patients

into

optimal

pathways

for

management

-LRB-

Table

-RRB-

Thus

patients

with

mild

disease

are

likely

to

be

successfully

managed

with

intravenous

antibiotics

whereas

percutaneous

drainage

and

surgery

is

generally

indicated

for

cases

of

complicated

diverticulitis

Table

's

CT

Staging

of

Diverticulitis

-LRB-

Adapted

from

Ambrosetti

et

al.

-RRB-

Mild

DiverticulitisSevere

DiverticulitisLocalized

sigmoid

wall

thickening

-LRB-

mm

-RRB-

AbscessInflammation

of

pericolic

fatExtraluminal

airExtraluminal

contrast

Management

of

Complicated

Diverticulitis

Surgical

intervention

is

rarely

indicated

in

cases

of

acute

diverticulitis

because

most

of

these

cases

will

resolve

with

appropriate

antibiotic

management

Operations

are

reserved

for

cases

of

complicated

diverticulitis

i.e.

patients

with

perforation

and

peritonitis

abscess

formation

fistula

or

obstruction

Although

this

may

seem

clear-cut

decisions

regarding

if

and

when

to

operate

patients

with

diverticulitis

remain

a

topic

of

significant

debate

Operation

is

clearly

indicated

when

the

patient

presents

with

perforation

and

diffuse

peritonitis

whether

it

is

purulent

or

feculent

-LRB-

Hinchey

stages

III

and

IV

-RRB-

However

the

ideal

surgical

procedure

in

such

cases

of

perforation

remains

a

matter

of

debate

The

possible

operations

advocated

range

from

a

simple

washout

of

the

abdomen

with

drainage

as

described

in

a

few

case

reports

from

Scotland

and

France

to

primary

resection

with

a

Hartmann

pouch

primary

resection

with

anastomosis

diverting

ileostomy

and

finally

a

primary

resection

with

anastomosis

and

no

temporary

stoma

Of

these

American

surgeons

are

most

likely

to

perform

the

Hartmann

procedure

which

has

been

advocated

as

the

standard

of

care

for

perforated

diverticulitis

The

Hartmann

's

resection

has

proven

to

be

a

safe

and

effective

approach

and

is

based

upon

the

idea

that

an

anastomosis

in

the

setting

of

acute

infection/inflammation

is

dangerous

and

associated

with

a

high

rate

of

suture

line

breakdown

A

simple

washout

without

resection

would

not

be

considered

an

appropriate

approach

because

ongoing

infection/inflammation

of

the

involved

bowel

is

likely

to

occur

There

is

a

paucity

of

data

to

support

a

minimalist

simple

washout

approach

there

are

only

case

reports

in

the

literature

describing

the

technique

and

its

results

On

the

other

hand

the

practice

of

routine

stomas

in

operations

for

acute

diverticulitis

may

not

be

justified

Belmonte

et

al.

looked

at

consecutive

patients

treated

for

acute

diverticular

disease

at

the

University

of

Minnesota

both

urgently

and

electively

Of

these

had

a

primary

anastomosis

most

of

them

without

diversion

They

found

that

primary

anastomosis

was

quite

safe

with

an

overall

leak

rate

Interestingly

of

these

leaks

were

in

their

subset

of

patients

with

Hinchey

stage

IV

diverticulitis

a

group

that

comprised

of

their

total

study

population

A

systematic

literature

review

of

studies

comparing

a

Hartmann

's

procedure

to

a

primary

resection

with

anastomosis

for

perforated

diverticulitis

found

reported

cases

of

primary

anastomoses

The

reported

mortality

and

morbidity

in

the

patients

with

an

anastomosis

was

the

same

as

in

the

patients

who

underwent

the

Hartmann

's

procedure

These

data

suggest

that

in

a

select

group

of

patients

undergoing

surgery

in

the

acute

stage

of

diverticulitis

an

anastomosis

is

probably

safe

even

in

the

milieu

of

feculent

peritonitis

These

data

are

intriguing

but

must

be

viewed

with

caution

especially

in

the

case

of

a

very

sick

or

toxic

patient

with

multiorgan

system

failure

and/or

shock

In

the

absence

of

randomized

controlled

studies

we

still

recommend

the

Hartmann

's

procedure

in

patients

with

significant

purulent

or

feculent

peritonitis

and

those

patients

with

any

instability

related

to

the

systemic

effects

of

sepsis

However

in

a

patient

who

is

clinically

stable

a

primary

anastomosis

at

the

first

operation

can

be

performed

even

in

the

setting

of

perforation

-LRB-

Fig.

-RRB-

Figure

specimen

of

the

sigmoid

colon

that

was

resected

from

a

patient

who

presented

with

freely

perforated

diverticulitis

-LRB-

Hinchey

III

-RRB-

Proximal

margin

extends

to

the

area

where

the

diverticuli

end

and

the

distal

margin

is

at

the

rectum

Mention

should

be

made

of

the

meticulous

surgical

technique

that

must

be

used

in

this

situation

The

splenic

flexure

of

the

colon

may

need

to

be

mobilized

to

ensure

a

tension-free

anastomosis

One

should

imagine

the

rectum

collapsing

back

into

the

pelvis

with

the

patient

standing

upright

when

deciding

on

whether

the

bowel

ends

are

truly

free

of

tension

The

margins

of

resection

must

be

clearly

viable

with

regard

to

vascularity

Finally

it

may

be

best

to

avoid

the

crossed

staple

lines

inherent

to

the

double-stapled

technique

Either

a

double

pursestring

technique

with

a

stapled

end-to-end

anastomosis

or

a

standard

handsewn

anastomosis

are

preferred

when

operating

in

an

inflamed

milieu

Preventive

Surgery

The

question

of

when

to

recommend

elective

preventive

surgery

for

patients

with

diverticulitis

remains

very

controversial

Current

American

Society

of

Colon

and

Rectal

Surgeons

-LRB-

ASCRS

-RRB-

guidelines

suggest

preemptive

surgery

for

any

patient

who

has

had

two

attacks

of

acute

diverticulitis

with

the

intention

of

preventing

another

attack

that

could

present

with

perforation

and

would

necessitate

a

stoma

This

recommendation

for

surgery

after

the

second

episode

of

diverticulitis

is

based

on

the

data

published

in

by

showing

that

the

mortality

rate

for

each

subsequent

attack

of

diverticulitis

increases

from

during

the

first

admission

to

during

each

subsequent

admission

Parks

is

also

widely

quoted

for

stating

that

each

subsequent

episode

of

diverticulitis

is

less

likely

to

respond

to

medical

therapy

with

a

response

after

the

first

episode

vs

response

after

the

third

episode

However

there

are

little

data

to

support

this

concept

of

poor

response

to

medical

treatment

in

subsequent

attacks

of

diverticulitis

Furthermore

the

advent

of

CT

scanning

and

better

antibiotics

has

improved

nonoperative

management

of

these

patients

In

a

modern

series

of

patients

with

diverticular

disease

only

of

patients

required

emergency

operations

during

a

follow

up

of

years

Another

study

of

patients

showed

that

recurrence

was

not

associated

with

an

increased

rate

of

either

complications

or

less

successful

medical

management

Looking

at

the

issue

from

another

angle

Somasekar

et

al.

reviewed

patients

admitted

with

complicated

diverticulitis

Almost

all

of

them

-LRB-

-RRB-

required

emergency

surgery

Interestingly

only

of

these

patients

were

previously

diagnosed

with

diverticular

disease

and

only

three

patients

had

been

admitted

in

the

past

with

a

prior

episode

of

acute

diverticulitis

In

other

words

only

of

patients

in

this

group

would

have

benefited

from

an

elective

resection

Complications

would

still

have

occurred

in

of

patients

in

whom

these

attacks

happened

de

novo

Thus

it

appears

that

elective

resection

might

have

little

impact

on

the

incidence

of

patients

requiring

emergency

procedures

because

most

of

these

occur

with

the

first

attack

of

diverticulitis

Subsequent

attacks

of

diverticulitis

in

the

same

patient

seem

to

be

akin

to

their

previous

ones

suggesting

that

specific

patients

are

predisposed

to

a

set

pattern

of

diverticulitis

and

once

settled

into

this

pattern

they

stay

within

it

The

threat

of

the

colostomy

bag

to

a

patient

who

has

been

successfully

managed

medically

during

two

previous

attacks

may

be

unwarranted

and

misleading

In

addition

it

is

important

to

recognize

that

elective

surgery

for

diverticulitis

is

not

without

complications

Bookey

et

al.

demonstrated

that

elective

diverticular

disease

resection

is

associated

with

higher

rates

of

morbidity

and

mortality

than

elective

colorectal

carcinoma

resection

with

the

mortality

rate

increasing

from

to

with

advancing

age

Furthermore

colectomy

is

not

a

guaranteed

cure

for

diverticulitis

with

recurrence

rates

varying

from

to

These

rates

have

improved

however

with

the

recognition

that

the

chances

of

recurrence

are

fourfold

higher

if

a

colosigmoid

anastomosis

is

performed

emphasizing

the

importance

of

resecting

the

entire

sigmoid

colon

in

an

operation

for

diverticulitis

With

these

conflicting

data

in

mind

we

maintain

that

the

patients

with

uncomplicated

diverticulitis

can

be

managed

nonoperatively

regardless

of

the

number

of

recurrent

episodes

Patients

who

develop

complications

such

as

fistulas

obstruction

or

nonresolving

smoldering

disease

are

best

managed

with

surgical

resection

Elective

surgery

may

also

be

offered

to

patients

who

have

had

two

or

more

episodes

of

severe

diverticulitis

as

determined

by

their

clinical

presentation

and

CT

grade

In

addition

elective

surgery

may

be

justified

in

patients

with

limited

access

to

medical

care

or

in

those

who

are

concerned

about

the

negative

impact

of

repeated

illnesses

with

regard

to

work

productivity

and/or

psychosocial

issues

In

elective

or

semielective

circumstances

both

open

and

laparoscopic

sigmoid

resection

with

a

primary

anastomosis

have

been

considered

as

acceptable

methods

of

treatment

Laparoscopy

has

been

shown

to

be

associated

with

an

approximate

rate

of

conversion

to

open

surgery

Interestingly

no

direct

relationship

has

been

found

between

the

number

of

attacks

of

diverticulitis

or

the

timing

after

an

acute

attack

with

regard

to

complications

or

conversion

rates

with

laparoscopic

colectomy

Diverticulitis

in

Young

Men

Many

authors

believe

that

diverticulitis

is

a

more

virulent

disease

in

younger

patients

As

such

it

has

been

argued

that

all

patients

younger

than

should

undergo

elective

colon

resection

after

an

initial

attack

of

diverticulitis

This

argument

arose

from

studies

in

the

pre-CT

era

which

were

replete

with

data

indicating

a

high

risk

of

surgical

intervention

in

young

patients

eventually

diagnosed

with

diverticulitis

Subsequent

authors

have

argued

that

these

earlier

studies

were

flawed

because

of

a

significant

rate

of

unnecessary

laparotomies

in

the

younger

patients

because

of

erroneous

preoperative

diagnoses

of

appendicitis

Vignati

et

al.

were

among

the

first

to

challenge

the

concept

that

diverticulitis

in

the

young

is

a

more

virulent

disease

These

authors

surveyed

patients

under

the

age

of

that

where

treated

with

intravenous

antibiotics

and

bowel

rest

and

found

that

at

a

to

follow-up

of

these

patients

required

colostomies

One

third

of

them

did

undergo

surgery

but

most

of

these

procedures

where

either

elective

or

if

urgent

still

conducive

to

a

successful

primary

anastomosis

Guzzo

et

al.

performed

a

retrospective

review

of

patients

with

diverticulitis

treated

at

their

institution

from

and

found

that

of

the

patients

under

age

improved

with

antibiotics

and

did

not

require

surgery

during

their

first

attack

These

rates

did

not

differ

from

the

rates

of

surgery

in

the

elderly

patients

Of

the

patients

treated

nonoperatively

only

four

patients

had

a

recurrence

requiring

surgery

at

a

later

time

and

only

one

needed

a

colostomy

Thirty-eight

additional

patients

underwent

preemptive

elective

surgery

based

upon

their

surgeon

's

recommendation

One

hundred

fifty-five

patients

of

the

entire

group

did

not

require

surgery

at

all

A

prospective

study

from

Switzerland

followed

patients

who

had

their

first

attack

of

diverticulitis

and

found

that

recurrence

rates

in

the

younger

patients

were

similar

to

those

seen

in

the

older

patients

once

stratified

by

their

CT

severity

Based

upon

these

studies

we

believe

that

young

patients

should

generally

be

treated

using

the

same

criteria

as

older

patients

and

that

the

there

is

no

justification

for

the

routine

recommendation

for

surgery

after

a

single

attack

of

diverticulitis

in

young

patients

Elective

preemptive

surgery

should

be

reserved

for

those

who

had

at

least

two

episodes

of

severe

diverticulitis

and

this

decision

should

be

supported

by

CT

scan

documentation

of

prior

complicated

disease

Fistulas

As

we

succeed

with

the

nonoperative

treatment

of

acute

diverticulitis

the

incidence

of

fistulas

appears

to

be

increasing

reported

to

occur

in

approximately

of

patients

Colovesical

fistulas

account

for

two

thirds

of

the

cases

followed

by

colovaginal

colocutaneous

and

enterocolic

cases

These

patients

can

present

a

significant

challenge

to

the

surgeon

Some

fistulas

will

close

spontaneously

as

the

inflammatory

process

resolves

Therefore

a

selective

approach

should

be

used

in

which

operation

is

offered

to

those

patients

with

persistent

symptoms

after

months

after

an

acute

attack

The

most

commonly

reported

symptoms

in

this

group

of

patients

include

abdominal

pain

-LRB-

-RRB-

pneumaturia

-LRB-

-RRB-

cystitis

-LRB-

-RRB-

fecaluria

-LRB-

-RRB-

diarrhea

-LRB-

-RRB-

and

hematuria

-LRB-

-RRB-

In

the

operating

room

the

surgeon

should

expect

a

significant

desmoplastic

reaction

and

a

contained

abscess

cavity

in

the

area

of

fistulization

It

may

be

prudent

to

place

ureteral

stents

before

the

procedure

although

most

fistulas

to

the

bladder

will

be

at

the

dome

and

away

from

the

trigone

region

allowing

relatively

safe

access

for

identification

dissection

and

closure

Most

of

these

cases

should

be

amenable

to

resection

with

primary

anastomosis

avoiding

the

need

for

a

temporary

stoma

In

expert

hands

a

colectomy

can

be

accomplished

by

either

an

open

or

laparoscopic

approach

Some

authors

suggest

that

these

procedures

are

best

performed

by

surgeons

whose

main

interest

focuses

on

colon

and

rectal

surgery

A

study

from

McGill

University

comparing

outcomes

of

surgery

for

diverticulitis-induced

fistulas

found

that

colorectal

surgeons

performed

less

diverting

Hartmann

's

and

colostomies

-LRB-

vs

-RRB-

and

had

a

lower

rate

of

complications

including

wound

infections

and

anastomotic

leaks

It

is

not

clear

however

whether

the

data

from

this

small

study

of

patients

are

applicable

to

all

surgeons

in

all

centers

Diverticulitis

in

the

Immunocompromised

Patient

Diverticulitis

in

immunocompromised

patients

can

be

virulent

because

there

is

an

increased

likelihood

of

free

perforation

and

fecal

peritonitis

In

addition

the

clinical

presentation

of

these

patients

often

underestimates

the

severity

of

their

disease

Marked

differences

have

also

been

noted

in

the

response

of

these

patients

to

medical

treatment

In

the

nonimmunocompromised

group

one

should

expect

that

of

patients

will

respond

to

antibiotics

In

contrast

a

very

large

percentage

of

immunocompromised

patients

will

fail

standard

nonoperative

treatment

As

such

most

of

these

patients

require

urgent

surgical

intervention

and

this

is

associated

with

a

significantly

higher

mortality

rate

vs

in

noncompromised

patients

Given

these

data

most

authors

and

the

ASCRS

recommend

elective

sigmoid

resection

after

the

first

episode

of

diverticulitis

in

immunocompromised

patients

Conclusion

The

management

of

patients

with

sigmoid

diverticulitis

is

still

evolving

We

should

continue

to

constantly

reassess

the

surgical

dogma

regarding

the

appropriate

treatment

of

this

common

disease

entity

Clearly

a

randomized

controlled

study

comparing

the

Hartmann

's

procedure

to

primary

anastomosis

in

the

setting

of

perforated

diverticulitis

would

be

worthwhile

It

is

becoming

increasingly

clear

that

mandatory

operations

may

not

be

warranted

in

young

patients

or

those

with

two

episodes

of

diverticulitis

As

in

other

areas

of

clinical

surgery

we

must

tailor

our

treatment

to

the

specific

situation

for

each

individual

patient

O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

sigmoid diverticulitis
surgical management
diagnosis
elective surgery