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Inicio Cirugía Española Enfermedad diverticular: revisión histórica y estado actual
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Vol. 70. Núm. 5.
Páginas 253-260 (noviembre 2001)
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Vol. 70. Núm. 5.
Páginas 253-260 (noviembre 2001)
Acceso a texto completo
Enfermedad diverticular: revisión histórica y estado actual
Diverticular disease: Historical review and current situation
Visitas
20217
M. Rodríguez
,1
Autor para correspondencia
marobla@terra.es

Correspondencia: Dr. M. Rodríguez. Servicio de Cirugía General y Digestiva. Hospital de la Santa Creu i Sant Pau. Sant Antoni Maria Claret, 167. 08025 Barcelona.
, V. Artigas*, M. Trías*, J.V. Roig**, R. Belda***
* Servicios de Cirugía General y Digestiva. Hospital de la Santa Creu i Sant Pau. Barcelona
** Hospital de Sagunto
*** Hospital de Torrecárdenas
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Resumen
Bibliografía
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Resumen
Introducción

La enfermedad diverticular del colon presenta una incidencia elevada en los países occidentales. El presente trabajo se propone llevar a cabo tanto una revisión histórica como del estado actual de las actuaciones diagnósticas y del tratamiento en sus diferentes estadios.

Material y métodos

Para la revisión bibliográfica se ha recurrido a la búsqueda a través de Medline de las publicaciones previas.

Resultados y conclusión

La enfermedad diverticular presenta una clara relación con la dieta pobre en fibra. En el diagnóstico de diverticulitis aguda no deben emplearse métodos invasivos (enema opaco, fibrocolonoscopia) por el riesgo de complicaciones que conllevan, siendo preferible los métodos de imagen (tomografía axial computarizada; ecografía abdominal). El enema opaco y la fibrocolonoscopia son útiles en el estudio de la enfermedad en fase no aguda y para el diagnóstico diferencial. El tratamiento de la diverticulitis aguda no complicada es médico en los primeros episodios y quirúrgico en los casos recidivantes, siendo preferible la cirugía programada en un solo tiempo. Los abscesos abdominales pueden tratarse mediante punción guiada por ecografía o TAC, permitiendo así realizar la cirugía en un segundo tiempo, cuando ha remitido la fase aguda. La cirugía laparoscópica puede suponer una vía de abordaje en el tratamiento de la diverticulitis aguda no complicada.

Palabras clave:
Diverticulitis
Colon
Enfermedad diverticular
Palabras clave:
Diverticulitis
Colon
Diverticular disease
Introduction

Diverticular disease of the colon is very frequent in the occidental countries. In this paper we review the diagnosis and treatment in different stages of the disease.

Material and methods

We performed a sistematic review of the Medline data base.

Results and conclusions

Diverticular disease is related to poor fibre diet. Aggressive methods of diagnosis should not be used in the management due to the increased risk of complications. CT and ultrasonography should be prefered. However, colonoscopy and barium enema is the best diagnostic method in not acute cases. The treatment of diverticular disease should be preferably medical. But surgery may be necessary in acute relapsing cases. Abdominal absess should be treated by percutaneous drainage, and elective surgery performed in a elective phase. The laparoscopic approach in non complicated case is promising.

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Bibliografía
[1.]
A. Littre.
1700. Citado por Finney JM. Diverticulitis and its surgical treatment. Proc Interstate Post-grad.
Med Ass Nort Am, 55 (1928), pp. 57-65
[2.]
J. Cruveilhier.
Bailliere, (1849),
[3.]
E. Graser.
Das falsche Darmdivertikel.
Arch Klin Chir, 59 (1899), pp. 638-647
[4.]
E. Beer.
Some pathological and clinical aspects of adquired diverticula of the intestine.
Am J Med Sci, 128 (1904), pp. 135-145
[5.]
W.H. Telling.
Acquired diverticula of the sigmoid flexure, considered especially in relation to secundary pathological processes and their clinical symptoms.
Lancet, 1 (1908), pp. 843-850
[6.]
W.H. Telling, O.C. Gruner.
Adquired diverticula, diverticulitis, and peridiverticulitis of the large intestine.
Br J Surg, 4 (1917), pp. 468-530
[7.]
F.W. Rankin, P.W. Brown.
Diverticulitis of the colon.
Surg Gynecol Obstet, 50 (1930), pp. 836-847
[8.]
T.G. Parks.
Natural history of diverticular disease of the colon.
Clin Gastroenterol, 4 (1975), pp. 53-69
[9.]
D.A. Thompson, H.R. Bailey.
Management of acute diverticulitis with abscess.
Semin Colon Rectal Surg, 1 (1990), pp. 74-80
[10.]
J.S.S. Gear, A. Ware, P. Fursdon, J.I. Mann, D.J. Nolan, A.J.M. Brodribb, et al.
Simptomless diverticular disease and intake of dietary fiber.
Lancet, 1 (1979), pp. 511-514
[11.]
N.S. Painter, D.P. Burkitt.
Diverticular disease of the colon, a 20th century problem.
Clin Gastroenterol, 4 (1975), pp. 3-21
[12.]
N.S. Painter, S.C. Truelove, G.M. Ardran.
Segmentation and localization of intraluminal pressures in the human colon, with especial reference to the pathogenesis of colonic diverticula.
Gastroenterology, 49 (1965), pp. 169-177
[13.]
I.F. Trotman, J.J. Misiewicz.
Sigmoid motility in diverticular disease and the irritable bowel syndrome.
Gut, 29 (1988), pp. 218-222
[14.]
L. Wess, M.A. Eastwood, C.A. Edwards, A. Busuttil, A. Miller.
Colagen alteration in an animal model of colonic diverticulosis.
Gut, 38 (1996), pp. 701-706
[15.]
L. Wess, M.A. Eastwood, T.J. Wess, A. Busuttil, A. Miller.
Cross linking of collagen is increased in colonic diverticulosis.
Gut, 37 (1995), pp. 91-94
[16.]
W.H. Aldoori, E.L. Giovannucci, E.B. Rimm, A. Ascherio, M.J. Stampfer, G.A. Colditz, et al.
Prospective study of physical activity and the risk of symptomatic diverticular disease in men.
Gut, (1995), pp. 276-282
[17.]
P.R. Schauer, R. Ramos, A.A. Ghiatas, K.R. Sirinek.
Virulent diverticular disease in young obese men.
Am J Surg, 164 (1992), pp. 446-448
[18.]
C.E. Welch.
Controversial problems association with diverticulitis.
Proc R Soc Med, 63 (1970), pp. 57-61
[19.]
T.G. Parks.
Natural history of diverticular disease of the colon.
Clin Gastroenterol, 4 (1975), pp. 53-69
[20.]
T.G. Parks.
Natural history of diverticular disease of the colon. A review of 251 cases.
BMJ, 4 (1969), pp. 639-645
[21.]
R.S. Boles, S.M. Jordan.
The clinical significance of diverticulosis.
Gastroenterology, 35 (1958), pp. 579-582
[22.]
E.F. Hinchey, P.G. Schaal, G.K. Richards.
Treatment of perforated diverticular disease of the colon.
Adv Surg, 12 (1978), pp. 85-109
[23.]
Z.H. Krukowski, N.A. Matheson.
Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis; a review.
Br J Surg, 71 (1984), pp. 921-927
[24.]
The Standars Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis- supporting documentation.
Dis Colon Rectum, 38 (1995), pp. 126-132
[25.]
D.A. Thompson, H.R. Bailey.
Manegament of acute diverticulitis with abscess.
Semin Colon Rectal Surg, 1 (1990), pp. 74-80
[26.]
A.L. Imbembo.
Diverticular disease of the colon.
pp. 13461-13589
[27.]
D.H. Hulnik, A.J. Megibow, E.J. Balthazar, D.P. Naidich, M.A. Bosniak.
Computed tomography in the evaluation of diverticulitis.
Radiology, 152 (1984), pp. 491-495
[28.]
S. Saini, P.R. Mueller, J. Wittenberg, R.J. Butch, G.V. Rodkey, C.E. Welch.
Percutaneous drainage of diverticular abscess. An adjunct to surgical therapy.
Arch Surg, 121 (1986), pp. 475-478
[29.]
N.S. Goldstein, E. Ahmad.
Histology of the mucosa in sigmoid colon specimens with diverticular disease: observations for the interpretation of sigmoid colonoscopic biopsy specimens.
Am J Clin Pathol, 107 (1997), pp. 438-444
[30.]
D.K. Rex, D. Mark, B. Clarke, J.C. Lappas, G.A. Lehman.
Flexible sigmoidoscopy plus air-contrast barium enema versus colonoscopy for evaluation of symptomatic patients without evidence of bleeding.
Gastrintest Endosc, 42 (1995), pp. 132-138
[31.]
P. Ambrosetti, J. Robert, J.A. Witzing, D. Mirescu, R. de Gautard, F. Borts.
Prognostic factors from computed tomography in acute left colonic diverticulitis.
Br J Surg, 79 (1992), pp. 117-119
[32.]
E. Doringer, et al.
Computerized tomography of colonic diverticulitis.
Crit Rev Diagn Imaging, 33 (1992), pp. 421-435
[33.]
K.C. Cho, H.T. Morehouse, D.D. Alterman, B.A. Thornhill.
Sigmoid diverticulitis: diagnostic role of CT. Comparison with barium enema studies.
Radiology, 176 (1990), pp. 111-115
[34.]
Ambrosetti P, Grossholz M, Becker C, Terrier F, Morel P. Computed tomography in acute left colonic diverticulitis
[35.]
J.E. Jacobs, B.A. Birnbaum.
CT of inflamatory disease of the colon. Seminars in Ultrasound.
CT ans MRI, 16 (1995), pp. 91-101
[36.]
R.V. Rege, D.L. Nahrwold.
Diverticular disease.
Curr Probl Surg, 26 (1998), pp. 133-189
[37.]
A. Zielke, C. Hasse, C. Nies.
Prospective evaluation of ultrasonography in acute colonic diverticulitis.
Br J Surg, 84 (1997), pp. 385-388
[38.]
W.B. Schwerk, S. Schwarz, M. Rothmund.
Sonography in acute colonic diverticulitis. A prospective study.
Dis Colon Rectum, 35 (1992), pp. 1077-1084
[39.]
J. Verbank, S. Lambrecht, L. Rutgeerts, G. Ghillebert, T. Buyse, M. Naesnes, et al.
Can sonography diagnose acute colonic diverticulitis in patients with acute intestinal inflamation? A prospective study.
J Clin Ultrasound, 17 (1989), pp. 661-666
[40.]
H.B. Eggesbo, T. Jacobsen, F. Kolmannskog.
Diagnosis of acute leftsided colonic diverticulitis by three radiological modalities.
Acta Radiol, 39 (1998), pp. 315-321
[41.]
V.L. Schiller, L. Schereiber, C. Seaton, D.A. Sarti.
Transvaginal sonographic diagnosis of sigmoid diverticulitis.
Abdom Imaging, 20 (1995), pp. 253-255
[42.]
S.R. Wilson, A. Toi.
The value of sonography in the diagnosis of acute diverticulitis of the colon.
Am J Roentgenol, 154 (1990), pp. 1199-1202
[43.]
N. Farmakis, R.G. Tudor, M.R. Keighley.
The 5-year natural history of complicated diverticular disease.
Br J Surg, 81 (1994), pp. 733-735
[44.]
D.J. Schoetz.
Diverticular disease of the colon. A century-old problem.
Dis Colon Rectum, 42 (1999), pp. 703-709
[45.]
A.J.M. Brodribb, D.M. Humphereys.
Diverticular disease: three studies.
Br Med J, 1 (1976), pp. 424-430
[46.]
P. Ambrosetti, J.H. Robert, J.A. Witzig, D. Mirescu, P. Mathey, F. Borts, et al.
Acute left colonic diverticulitis in young patients.
J Am Coll Surg, 179 (1994), pp. 156-160
[47.]
C.E. Hannan, J.J. Knightly, R.J. Coffey.
Diverticular disease of the colon in the younger age group.
Dis Colon Rectum, 4 (1961), pp. 419-423
[48.]
J. Mäkelä, S. Vuolio, H. Kiviniemi, S. Laitinen.
Natural history of diverticular disease: when to operate?.
Dis Colon Rectum, 41 (1998), pp. 1523-1528
[49.]
P.V. Vignati, J.P. Welch, J.L. Cohen.
Long-term management of diverticulitis in young patients.
Dis Colon Rectum, 38 (1995), pp. 627-629
[50.]
W.J. Mayo, L.B. Wilson, H.Z. Giffin.
Acquired diverticulitis of the large intestine.
Surg Gynecol Obstet, 5 (1907), pp. 8-15
[51.]
R.H. Smithwick.
Experiences with the surgical management of diverticulitis of the sigmoid.
Ann Surg, 115 (1942), pp. 969-985
[52.]
J.J. Byrne, E.I. Garick.
Surgical treatment of diverticulitis.
Am J Surg, 121 (1971), pp. 379-384
[53.]
C.E. Welch, A.W. Allen, G.A. Donaldson.
An appraisal of resection of the colon for diverticulitis of the sigmoid.
Ann Surg, 138 (1953), pp. 332-343
[54.]
B.P. Colcock.
Surgical treatment of diverticulitis. Twenty years’ experience.
Am J Surg, 115 (1968), pp. 264-270
[55.]
G.V. Rodkey, C.E. Welch.
Changing patterns in the surgical treatment of diverticular disease.
Ann Surg, 200 (1984), pp. 466-478
[56.]
J.L. Madden, P.Y. Tan.
Primary resection and anastomosis in the treatment of perforated lesions of the colon with abscess or diffusing peritonitis.
Surg Gynecol Obstet, 113 (1961), pp. 646-650
[57.]
A.W. Hackford, D.J. Schoetz, J.A. Coller, M.C. Veidenheimer.
Surgical management of complicated diverticulitis. The Lahey Clinic experience, 1967 to 1982.
Dis Colon Rectum, 28 (1985), pp. 317-321
[58.]
E.J. Hinchey, P.G.H. Schaal, G.K. Richards, et al.
Treatment of perforated diverticular disease of the colon.
pp. 88-89
[59.]
J. Díaz Oller, A. Arcos Navarro, J.D. Tutosaus Gómez, A. Nevado Infante, M. Numancia Andreu, et al.
Enfoque actual del diagnóstico y tratamiento de la diverticulitis colónica aguda.
Rev And Pat Digest, 21 (1998), pp. 163-172
[60.]
M.P. Hachigian, S. Honickman, T.E. Eisenstat, R.J. Rubin, E.P. Salvati.
Computed tomography in the initial management of acute left-sided diverticulitis.
Dis Colon Rectum, 35 (1992), pp. 1123-1129
[61.]
J.M. Sackier.
Colonic surgery for acute conditions: perforated diverticular disease.
pp. 387-396
[62.]
B.E. Stabile, E. Puccio, E. vanSonnenberg.
Preoperative percutaneous drainage of diverticular abscesses.
Am J Surg, 159 (1990), pp. 99-105
[63.]
P.R. Mueller, S. Saini, J. Wittenburg.
Sigmoid diverticular abscess: percutaneous drainage as an adjunt to surgical resection in 24 cases.
Radiology, 164 (1987), pp. 321-325
[64.]
M.B. Sanford, J.A. Ryan.
The proper surgical treatment of perforated sigmoid diverticulitis with generalized peritonitis.
pp. 223-241
[65.]
S.E. Ross, R.A. Cobean, D.B. Hoyt.
Blunt colonic injury- a multicenter review.
J Trauma, 33 (1992), pp. 379-384
[66.]
T.B. Elliot, S. Yego, T.T. Irvin.
Five-year audit of the acute complications of diverticular disease.
Br J Surg, 84 (1997), pp. 535-539
[67.]
U. Haglund, R. Hellberg, C. Johsén, L. Hulten.
Complicated diverticular disease of the sigmoid colon. An analysis of short and long term outcome in 392 patiens.
Ann Chir Gynaecol, 68 (1979), pp. 41-46
[68.]
O. Kronborg.
Treatment of perforated sigmoid diverticulitis: a prospective randomized trial.
Br J Surg, 80 (1993), pp. 505-507
[69.]
Z.H. Krukowsky, N.A. Matheson.
Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review.
Br J Surg, 71 (1984), pp. 921-927
[70.]
L. Köhler, S. Saulerland, Neugebauer, et al.
Diagnosis and treatment of diverticular disease.
Surg Endosc, 13 (1999), pp. 430-436
[71.]
G. Navarra, S. Occhionorelli, D. Marcello, V. Bresadola, M. Santini, M. Rubbini.
Gasless video-asisted reversal of Hartmann’s procedure.
Surg Endosc, 9 (1995), pp. 687-689
[72.]
L. Morgestern.
Malignant diverticulitis.
Diverticular disease. Management of the difficult surgical case, pp. 181-193
[73.]
P. Roberts, M. Abel, L. Rosen, W. Cirocco, J. Fleshman, et al.
Practice parameters for sigmoid diverticulitis-supporting documentation.
Dis Colon Rectum, 38 (1995), pp. 125-132
[74.]
T.C. Counihan, S.L. Schmitt, P.F. Caushaj.
Hepatic abscess complicating diverticulitis.
Diverticular disease. Management of the difficult surgical case, pp. 442-452
[75.]
E.D. Srivastava, J.F. Mayberry.
Pyogenic liver abscess: a review of etiology, diagnosis and intervention.
Dig Dis, 8 (1990), pp. 287-293
[76.]
M. Bokhari, A.M. Vernava, T. Ure, W.E. Longo.
Diverticular hemorrhage in the elderly-is it well tolerated?.
Dis colon Rectum, 39 (1996), pp. 191-195
[77.]
P.G. Foutch.
Diverticular bleeding: are nonsteroidal antiinflamatory drugs risk factors for hemorrhage and can colonoscopy predict outcomo for patients?.
Am J Gastroenterol, 90 (1995), pp. 1779-1784
[78.]
H.H. McGuire.
Bleeding colonic diverticula. A reappraisal of natural history and management.
Ann Surg, 220 (1994), pp. 653-656
[79.]
B.M. Parkes, F.N. Obeid, V.J. Sorensen, H.M. Horst, J.J. Fath.
The management of massive lower gastrointestinal bleeding.
Am Surg, 59 (1993), pp. 676-678
[80.]
T.G. Allen Mersh.
Should Primary anastomosis and on-table colonic lavage be standard treatament for left colon emergencies?.
Ann R Coll Surg Engl, 75 (1993), pp. 195-198
[81.]
K.A. Forde.
Colonscopy in acute rectal bleeding.
Gastrointest Endosc, 27 (1981), pp. 219-220
[82.]
Y.I. Kim, E.N. Marcon.
Inyection therapy for colonic diverticular bleeding. A case study.
J Clin Gastroenterol, 17 (1993), pp. 46-48
[83.]
F.C. Ramírez, D.A. Johson, St. Zierer, G.J. Walker, R.A. Sanowki.
Successful endoscopic hemostasis of bleeding colonic diverticula with epinephine inyection.
Gastrointest Endosc, 43 (1996), pp. 167-170
[84.]
W. Browwder, E.J. Cerise, M.S. Litwin.
Impact of emergency angiography in masive lower gastrointestinal bleeding.
Ann Surg, 204 (1986), pp. 530-536
[85.]
B.G. Wolff, F.A. Frizelle.
Recurrent diverticulitis following resection.
Diverticular disease. Management of the difficult surgical case, pp. 343-351
[86.]
P.L. Benn, B.G. Wolff, D.M. Ilstrup.
Level of anastomosis and recurrent colonic diverticulitis.
Am J Surg, 151 (1986), pp. 269-271
[87.]
F.A. Frizelle, J.M. Domínguez, G.A. Santoro.
Management of postoperative recurrent diverticulitis: a review of the literature.
J R Coll Surg Edinburg, 42 (1997), pp. 186-188
[88.]
B.G. Wolff, R.L. Ready, R.L. MacCarty.
Influence of sigmoid resection on progression of diverticular disease of the colon.
Dis Colon Rectum, 27 (1984), pp. 645-647
[89.]
C.J. Bruce, J.A. Coller, J.J. Murray, D.J. Schoetz, P.L. Roberts, L.C. Rusin.
Laparoscopic resection for diverticular disease.
Dis Colon Rectum, 39 (1996), pp. S1-S6
[90.]
Q.A. Eijsbouts, M.A. Cuesta, L.M. De Brauw, C. Sietses.
Elective laparoscopic- asisted sigmoid resection for diverticular disease.
Surg Endosc, 11 (1997), pp. 750-753
[91.]
D.L. Fowler, S.A. White, C.A. Anderson.
Laparoscopic colon resection: 60 cases.
Surg Laparosc Endosc, 5 (1995), pp. 468-471
[92.]
M.E. Franklin.
Laparoscopic management of colorectal disease. The United States experience.
Dig Surg, 12 (1995), pp. 284-287
[93.]
F. Köckerling, C. Schneider, M.A. Reymond, H. Scheidbach, J. Konradt, E. Bärlehner, et al.
Laparoscopic Colorectal Study Group. Early results of a prospective multicenter study on 500 consecutive cases of laparoscopic colorectal surgery.
Surg Endosc, 12 (1998), pp. 37-41
[94.]
L. Köhler, D. Rixen, H. Troidl.
Laparoscopic colorectal resection for diverticulitis.
Int J Colorect, 13 (1998), pp. 43-47
[95.]
Liberman MA, Phillips EH, Carroll BJ, Fallas M, Rosenthal R. Laparoscopic colectomy vs traditional colectomy for diverticulitis: outcome and cost. Surg Endosc 10: 15-18
[96.]
M.E. Sher, F. Agachan, M. Bortul, J.J. Nogueras, E.G. Weiss, S.D. Wesner.
Laparoscopic surgery for diverticulitis.
Surg Endosc, 11 (1997), pp. 264-267
[97.]
P.J. Hewwett, R. Stitz.
The treatment of internal fistulae that complicate diverticular disease of the sigmoid colon by laparoscopically assisted colectomy.
Surg Endosc, 9 (1995), pp. 411-413
[98.]
E.C. Lee, J.J. Murray, J.A. Coller, P.L. Roberts, D.J. Schoetz.
Intraoperative colonic lavage in nonelective surgery for diverticular disease.
Dis Colon Rectum, 40 (1997), pp. 669-674
[99.]
M.E. Franklin, J.P. Dorman, M. Jacobs, G. Plasencia.
Is laparoscopic surgery applicable to complicated colonic diverticular disease?.
Surg Endosc, 11 (1997), pp. 1021-1025
[100.]
A.L. Khan, A.K. Ah See, T.J. Crofts, S.D. Heys, O. Eremin.
Surgical management of the septic complications of diverticular disease.
Ann R Coll Surg Engl, 77 (1995), pp. 16-20
[101.]
D.G. Morton, M.R. Keighley.
Prospective nationale Studie zur Komplizierten Diverticulitis in Grossbritannien.
Chirug, 66 (1995), pp. 1173-1176
[102.]
G.C. O’Sullivan, D. Murphy, M.G. O’Brien, A. Ireland.
Laparoscopic management of generalized peritonitis due to perforated colonic diverticula.
Am J Surg, 171 (1996), pp. 432-434
[103.]
C. Schulz, H.P. Lemmens, H. Weideman, E. Rivas, P. Neuhaus.
Die Resektion mit primärer Anastomose bei der komplizierten Diverticulitis. EINE risikoanalyse.
Chirug, 65 (1994), pp. 50-53
[104.]
G. Tucci, A. Torquati, M. Gande, I. Stroppa, M. Sianesi, A.M. Farinon.
Major acute inflammatory complications of diverticular disease of the colon: planing of surgical management.
Hepatogastroenterology, 43 (1996), pp. 839-845
[105.]
F. Köckerling, C. Schneider, M.A. Reymond, H. Scheidebach, H. Scheuerlein, et al.
Laparoscopic resection for sigmoid diverticulitis. Results of a multicenter study. Laparoscopic Colorectal Surgery Study Group.
Surg Endosc, 13 (1999), pp. 567-571
[106.]
E.C. Lee, J.J. Murray, J.A. Coller, P.L. Roberts, D.J. Schoetz.
Intraoperative colonic lavage in nonelective surgery for diverticular disease.
Dis Colon Rectum, 40 (1997), pp. 669-674
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