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

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.

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

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 studics.Brit,Med.」 .1(1976)4424.BurHtt,D,P.,Walker,A.R.and 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.

Colccck,B.P,and S協 血 ann,F.D.: Fismal complicating diverdcular dsease or the singoid colon.Ann.Surg.

175 (1972) 838.

Curvellicr,J.: Trおに d Anatomie dcscriptive.Paris m組.1(1849)593.

Deucher, F.: Rundtischgcsprach: c。 londivcrtik■ditis. Langenbccks Arch. Chir. 342(1976)453.

Dcuchcr, F., Blessing, H.and Fartab W[.: Dic chiIコ ピgぃche Behadnlung dcr Kolondvcrtikulitis.Bericht tbcr

152 Falle. in: Kolondivertikulitis: [ヽ. ReifFerscheid Thiemc―Sttttgart 1974.

Fichcr,A.巾V.: む bcr dic R6ntgenuntersuchung dcs DicLdames mit HilFc ciner Kombination von LuFtcinblasung

und Kontrastcinla胡 ヽLangenbecLs Arch.Chir, 134(1925)209.

Craser,E.: Entzindliche Ste■osen des Dickdarmcs bdingt durch Perroration multゃlcr falSChcr Divertikcl Zbl.

Chir。 25(1898)140. ・

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 i v e r d k e l i n d e r n e x u r a s i t t o i d c a . M d n c h . m c d . W s c h c r . 4 6 ( 1 8 9 9 b )

741.

Goulard,A.」r,and Hampton,A.O.t Corrdation of the clinical pathological attd rOentgcnological indings in

divcrticulitis.Am.J.Roentgenol.72(1954)213.

Habcrshon, S.O.: Obscrvations on the 夕limentary canal. London 1857.

Hcberer,G.,Brehm,H.Y and ttrshfeld,J.: Dic Diverdkdcrkrallkungen des DicLdamcs.Chirurg 41(1970)

252.

Hebcrer,C。 ,HofFmaIIn,K.Bary,S.V.and Naran。 ,H.: zur oPcrativen TheraPie dcr Dickdamdivertikulids.

1ヽ工nch.medo Wschr. 116(1974)1075.

Heuck,F.: Die Divertikulids in R6ntgcnbttd,Langenbecks Arch.Cri 342(1976)4j21.

Hodgson,」 .: An interim report in prOducdon oF colon divertictda in the rabbit.GUT 13(1972)802.

Hodgson,」 キ Transverse taeniomyotomy for diverdcdar diseasc.Dお .Col.&Rect.16(1973)233.

Ho■ ender,L.F。 ,Meyer,C.B,F.and Marrie,A.: Plあ doyer Fdrてhe Ftthresektion dcr S耗 軍nc‐Diverticulitis. in:

KolcI週 ivertikulitis.Hrsgo M. ReiIFcrscheid Thieme,Smttgart(1974).

Hughcs,L.E.: Pcst HIortcm survey oF divcrticular disettc of thc colon Part.I,Divcrdculosお and dverdculitお .

CUT 10(1969a)336.

H u g h c s , L . E . : P o s t‐m o r t c m s u r v e y o F d i v c r d c u l a r d i s e a s e o f t h c c o l o n P a r t H . T h e m u s c u l c r a b n o r a m l i t y i n t h c か

sigmoid colon.GUT 10(1969b)344.

Krart‐Kinz,」 ・and Prcxl,A.J.: Dieと ompliziertc Divertikulitis und ihre Bchandlung.Langcnbecks Arch.Chir.

3442(1976)431. ャ

Kiimmerle,F.and Pross,E.: Ein― oder mchrzeitigcs Vorgehcn bci dcr komplizicrten Divertikulitお 。in: Kolondi‐

vcrtikulitis.Hrsg.M.ReifFescheid Tl■ icmc‐Sttttgart(1974).

Kyrlc9 P.: Die Myotomie als Bchandlung dcr Divα tikulitis.Langenbecks Arch.Ch士 。342(1976)44j5.

Madden,J.L.: Primary rescction and anastomosis in the treatnent or perFOrated lesions oF thc colo■ .Amer.Surg.

31 (1965) 731.

Miller,DoW.」r・and wichern,W.A.Jr.: PerfOrated sigmoid diverticulitis.Appraisal oF primary versus dclaycd

rcscction.Amcr.」 ・Surg.121(1971)536.

Morson,B.C.: Thc mttdc abnOrmalitt in divcrdcular disease of the sk邦■Oid C。lon.Brit.」・Radiol,36(1963)

385.

Morson,C.B,and Dawson,I.ヽ 1.P.: Castrointestinal Patho10gγ.Muscular disorders.Chapter 35.Blackwcll Scicn‐

Ot品摺十a挽

麒 礼置fttt鮒漁瑞盤,総i.碓i tthL H6ぃZ→Ю位Ottettann,R.: Divcrdkulosc und Divcrtikulitis aus intemer Sicht.in: Kolondivertikulitお.Hrsg. 1ヽ.ReifFercsheid,

Thieme‐Stuttgart(1974b)。

Paintcr,N.S.and Truclove,S.C,: Intralulllnal pressure pattern in dverdculosis oF thc colo■.GUT 5(1964) `

201.

Parks,A.G.: Diverdkuliは ,PathoPhysiologic und chimrglschc ln月:とう由m.In: Kolondverdkulitお : Hrsg.

ReifFersd■eitt SmttgarぃThieme 1974.

Parks,A.G.: Ati。 10gic und Pathogenese der Divcrtikdose.Schweiz.med.Wschr.105(1975)825.

こ巡 、T.G.: Natural history oF diverticular disease oF the colo■.A rtttew of 521 cases.Bit.med.J.4(1969)

639.

Parks,T.G.: Divcrticular discase cF the colo■.Chapter 84.Part II.Surgery of diverticular dsease oF the colon.

in: Gas廿oenterology. A.L. BOCKUS, Saundtt C., Plliladelphia‐London‐Toronto(1976).

1977年 9月117(575)

Parks,T.G.and Connel,A.ヽ 1.: Motility studics in diverticular disease of thc colont Part I.Basal activity and

response to food assessed by opened tube and miniattc ba■ oon tcchniques,CUT 10(1969a)534.

Par臨 ,T.C.and Connd,A.M.: Modlity sttdies in dverticular disease.Part II.EIFcct oFcolonic and rectal ttto■‐

siOn. GUT 10(1969b)538.

Prasad)J.K.and Daniel,O.: Recurrence of high intracolic Pressure Following si抑 oid myotomy.Brit.」.Surg.

58 (1971) 304.

RdfFerscheid,Wi.: Pathogcnese der Sttmadivcrtikulitis und dic lndikation zur Resektionsbehandlung.Lange‐

nbecks Arch. Kttne Ch士 . 318(1967)13生

ReifFelsheid, 1ヽ.: Die Friihrcsektion der DN苺 宜kulitお.Langcllbecks Arch.C監 .342(1976)439.

Reill乃 Tヽ.: Sig■ oid myotomy for acute divcrtiαditis.Dis.Colon&Rect.8(1965)42.

Reilly,Wi.: Si口 帆oid myotomy.Brit,J.Surg・ 53(1966)359.

Retlly, 江ヽ.: Sittnoid myotomy For dverticular disease oF the colo■.In: Irvine,W.T.(ed): ｀Iodem Trends

in Surgery.ED.3.London Buttettcrth&CO.Ltd。 (1971).

Rdily,M.: Sigmoid myotomy.Olin.Castroent.4(1975)1.

Schdlercr,W.: Nachuntesuchungsergebmsse konservadv bchandelter Diverti■ ulitis‐Padentcn. Langenbecる

Arch.Chir.342(1976)4449.

Schreiber,H.W.: Neuc Cesichtspunktt zur Divcrtikulitis dcs Dickdamest Dtsch.med,Wschr.90(1965)1998.

Schreiber,H.W.,Koch,W.and Oestern,H.F.: む ber dとn Krankheitswert der inkompletten Dickdamdiverti■eI.

Zble Chir. 91,(1966)1740.

Sch― pelick,V.and Koch,C.: Dic Bedcumg des inkomPletten Dickdamdiverばkels fむ 前e Divtttikuli体.

Langenbecks Arch. Chir.336(1974)1.

Siacと,W.W.: The anatomy,Pathology and somc dinical feamres oF diverticulosis of the colon.BHt,J・Surg.50

(1962) 185.Smiley,D.F.: Perforated sigmcid diverticulitis,宙 th spreading peritonitis.Am.J.Surg.111(1966)431,Smith,

A . N , a n d R u c H e y , C . V . : D & a s e o f t h e c o l o n . S c o t t . M e d . J . 1 6 ( 1 9 7 1 ) 1 3 0 .

Stelzner,F.: S伍コ止turverandcmngen der Colo■ wand als UIsache der Diverdほldosc und D市ertikuli体.Langen‐

becL Arch.Chir.342(1976)411.

Stelzner,F.and Lierse,W.: むber de Enttvicttung der Divertttdose und Divertikulitお.Langenbcc臨Arch.

chir.341(1976)271.

S t r o h m e y e r , G . : I n t e r n i s h s c h e A s p e k t e d e r D i v c r t i k d o s e u n d D i v e r t i k d i t i s . L a n g e n b e c k s A r c h . C h i r . 3 4 2 ( 1 9 7 6 )

412.

Taylor,F.W.and EPstein,L.I.: Treament OF massive diverdcular hemorhagc.Arche Sarg.98(1969)505.

Thiede,A.,Brider,H,Sc and Hantschmann,N.: Divmosc,Divertikulitお und Pttisittdditis.Zbl.Chir.

100(1975)1082.

Thiede,A.,Schewelises,S.and Poser,H.: Cezieltere DickdarmdiagnOstik durch Lombinicrte coloskcPisch radi。‐

logischc Dickdamsettentdarste■ ung.in Vorbereitung 1977.

Vega dc la,J,M・: Diverdcular dおeasc oF tllc coloュ.Chapter 34.Part I Medical aspects.in: CastrOentettlogy

II.H.L.Bocku.Sanunders C.,Phユ adelphia‐LondoneToronto(1976).

Welin,S.and Welin C.: The double contrast examlaation ofthe colon and exPerlences ofthe Welin‐ 1■odiflcatioB.

Thieme‐Smttagrt(1976).

Williams,J・: Mass movements(mass peristalsis)and diVerticular disease cr the colon.Brit.J.Radiol.40(1967)

2.

WOli B.S.,Khユ nani,M.and Marshak,R.H.: Diverdculosis and d市 erdculits.Rogentgen andingS and their

interprctation.Am.J.Roentgenol.77(1957)726.