Michael R. Mill, MD

• Professor of Surgery
• Chief, Division of Cardiothoracic Surgery
• Director, Heart-Lung Transplant Program
• Director, UNC Comprehensive Transplant Center
• Program Director, Cardiothoracic Surgery Residency Program
• University of North Carolina School of Medicine
• Chapel Hill, North Carolina

It has been shown that the presence of active perianal disease when vedoluzimab is initiated is a predictor of decreased response to the medication and lower chances for clinical remission acne in pregnancy purchase benzac 20gr amex. Most common procedure used is the endorectal advancement flap with healing rates ranging between 55% and 72% retinol 05 acne benzac 20 gr discount. Other techniques for long strictures include the isoperistaltic acne topical medications generic benzac 20 gr on line, side-to-side strictureplasty acne neck order genuine benzac online. Several studies have demonstrated that strictureplasty is as safe and effective as resection acne before period generic benzac 20 gr free shipping. Meta-analysis of 3529 small bowel strictureplasties in more than 1000 patients demonstrated a 13% morbidity acne medicine trusted 20 gr benzac. There are cases where both techniques may be incorporated into the same operation. Recurrence of the disease after surgery is influenced by several factors, some modifiable. In contrast, cigarette smoking, surgical technique (need for negative gross surgical margin), the presence of significant postoperative complications, and the initiation of appropriate medical treatment are modifiable parameters. The principle of all strictureplasty techniques involves incising the stricture and reapproximating surrounding bowel to preserve intestinal length while enlarging luminal diameter. Infliximab was not superior to placebo in preventing clinical recurrence up to 76 weeks after resection. Currently, postoperative risk stratification for early recurrence based on known risk factors is the safest guide to determine postoperative "preventive" treatment. For a small portion of lower risk of recurrence patients, who place a higher value on avoiding the small risks of adverse events from pharmacologic prophylaxis and a lower value on the potential risk of early disease recurrence, selecting endoscopy-guided pharmacologic treatment is reasonable. Inflammatory bowel disease in a Swedish twin cohort: a long-term follow-up of concordance and clinical characteristics. Epidemiology of inflammatory bowel disease in a German twin cohort: results of a nationwide study. Association analyses identify 38 susceptibility loci for inflammatory bowel disease and highlight shared genetic risk across populations. Monogenic diseases associated with intestinal inflammation: implications for the understanding of inflammatory bowel disease. Risk of inflammatory bowel disease in first- and second-generation immigrants in Sweden: a nationwide follow-up study. Inflammatory bowel disease in immigrants to Canada and their children: a populationbased cohort study. Incidence and prevalence rates of inflammatory bowel diseases, in midwestern of Sao Paulo State, Brazil. Increasing incidence of paediatric inflammatory bowel disease in Ontario, Canada: evidence from health administrative data. Medical therapy is evolving based on increasing discovery of new mechanism based therapies. Epidemiology of pediatric inflammatory bowel disease: a systematic review of international trends. Increasing incidence of paediatric inflammatory bowel disease in northern Stockholm County, 2002-2007. Dietary intake and risk of developing inflammatory bowel disease: a systematic review of the literature. Linoleic acid, a dietary n-6 polyunsaturated fatty acid, and the aetiology of ulcerative colitis: a nested case-control study within a European prospective cohort study. Incidence, prevalence, and time trends of pediatric inflammatory bowel disease in Northern California, 1996 to 2006. Bacterial sensor Nod2 prevents inflammation of the small intestine by restricting the expansion of the commensal Bacteroides vulgatus. Genome-wide association study identifies new susceptibility loci for Crohn disease and implicates autophagy in disease pathogenesis. A key role for autophagy and the autophagy gene Atg16l1 in mouse and human intestinal Paneth cells. Reduction in diversity of the colonic mucosa associated bacterial microflora in patients with active inflammatory bowel disease. Molecular-phylogenetic characterization of microbial community imbalances in human inflammatory bowel diseases. The microbiome in inflammatory bowel disease: current status and the future ahead. Impact of diet in shaping gut microbiota revealed by a comparative study in children from Europe and rural Africa. A vegan or vegetarian diet substantially alters the human colonic faecal microbiota. Smoking cessation induces profound changes in the composition of the intestinal microbiota in humans. Impact of gastroenterologist care on health outcomes of hospitalised ulcerative colitis patients. Quality indicators for inflammatory bowel disease: development of process and outcome measures. Defining quality indicators for best-practice management of inflammatory bowel disease in Canada. Variation in treatment of patients with inflammatory bowel diseases at major referral centers in the United States. Improved outcomes in a quality improvement collaborative for pediatric inflammatory bowel disease. Patient trust-in-physician and race are predictors of adherence to medical management in inflammatory bowel disease. Northwest Gastrointestinal Research Group: Guided self-management and patient-directed follow-up of ulcerative colitis: a randomised trial. Delphi consensus statement: quality indicators for inflammatory bowel disease comprehensive care units. Optimising the inflammatory bowel disease unit to improve quality of care: expert recommendations. Impact of depressive mood on relapse in patients with inflammatory bowel disease: a prospective 18-month follow-up study. A one year prospective, longitudinal comparison of nurse-led versus conventional follow-up. Clinical features and outcome of patients with inflammatory bowel disease who use narcotics: a case-control study. Commensal Bacteroides species induce colitis in host-genotype-specific fashion in a mouse model of inflammatory bowel disease. A dietary fiber-deprived gut microbiota degrades the colonic mucus barrier and enhances pathogen susceptibility. Long-term prognosis for patients with ulcerative proctosigmoiditis (ulcerative colitis confirmed to the rectum and sigmoid colon). Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Application of computational methods in genetic study of inflammatory bowel disease. Assessment of gaps in care and the development of a care pathway for anemia in patients with inflammatory bowel diseases. A survey of current practice of venous thromboembolism prophylaxis in hospitalized inflammatory bowel disease patients in the United States. Testing for Clostridium difficile in patients newly diagnosed with inflammatory bowel disease in a community setting. Racial and geographic variations in colectomy rates among hospitalized ulcerative colitis patients. Impact of hospital volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis. Narcotic use for inflammatory bowel disease and risk factors during hospitalization. The prevalence and predictors of opioid use in inflammatory bowel disease: a population-based analysis. Pediatric inflammatory bowel disease and imaging-related radiation: are we increasing the likelihood of malignancy Meta-analysis: diagnostic medical radiation exposure in inflammatory bowel disease. Practice Parameters Committee of the American College of Gastroenterology: Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee. Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus. Third European evidence-based consensus on diagnosis and management of ulcerative colitis. A review of activity indices and efficacy end points for clinical trials of medical therapy in adults with ulcerative colitis. Is endoscopy necessary for the measurement of disease activity in ulcerative colitis Can endoscopy be avoided in the assessment of ulcerative colitis in clinical trials Use of the noninvasive components of the Mayo score to assess clinical response in ulcerative colitis. An optimized patientreported ulcerative colitis disease activity measure derived from the Mayo score and the simple clinical colitis activity index. Mucosal healing in inflammatory bowel disease: results from a Norwegian population-based cohort. Mucosal healing predicts late outcomes after the first course of corticosteroids for newly diagnosed ulcerative colitis. Early mucosal healing with infliximab is associated with improved long-term clinical outcomes in ulcerative colitis. Mucosal healing is associated with improved long-term outcomes of patients with ulcerative colitis: a systematic review and meta-analysis. Intestinal antiinflammatory effect of 5-aminosalicylic acid is dependent on peroxisome proliferator-activated receptor-gamma. Clinical evidence supporting the radical scavenger mechanism of 5-aminosalicylic acid. Efficacy of 5-aminosalicylates in ulcerative colitis: systematic review and meta-analysis. A meta-analysis and overview of the literature on treatment options for left-sided ulcerative colitis and ulcerative proctitis. A double-blind comparison of oral versus rectal mesalamine versus combination therapy in the treatment of distal ulcerative colitis. Combined oral and enema treatment with Pentasa (mesalazine) is superior to oral therapy alone in patients with extensive mild/moderate active ulcerative colitis: a randomised, double blind, placebo controlled study. Combined therapy with 5-aminosalicylic acid tablets and enemas for maintaining remission in ulcerative colitis: a randomized double-blind study. Response to corticosteroids in severe ulcerative colitis: a systematic review of the literature and a meta-regression. Predictive factors of outcome of intensive intravenous treatment for attacks of ulcerative colitis. Continuous infusion versus bolus administration of steroids in severe attacks of ulcerative colitis: a randomized, double-blind trial. Treatment of hospitalized adult patients with severe ulcerative colitis: Toronto consensus statements. Increased risk for non-melanoma skin cancer in patients with inflammatory bowel disease. Therapeutic drug monitoring of tumor necrosis factor antagonists in inflammatory bowel disease. Adalimumab induces and maintains clinical remission in patients with moderate-to-severe ulcerative colitis. Adalimumab for induction of clinical remission in moderately to severely active ulcerative colitis: results of a randomised controlled trial. Subcutaneous golimumab maintains clinical response in patients with moderate-to-severe ulcerative colitis. Subcutaneous golimumab induces clinical response and remission in patients with moderateto-severe ulcerative colitis. Comparison of infliximab and adalimumab in biologic-naive patients with ulcerative colitis: a nationwide Danish cohort study. Comparative effectiveness and safety of infliximab and adalimumab in patients with ulcerative colitis. Comparison of real-world outcomes of adalimumab and infliximab for patients with ulcerative colitis in the United States. Effects of combination therapy with immunomodulators on trough levels and antibodies against tumor necrosis factor antagonists in patients with inflammatory bowel disease: a meta-analysis. Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study. Clinical trial: colectomy after rescue therapy in ulcerative colitis-3-year follow-up of the Swedish-Danish controlled infliximab study. Infliximab for acute, not steroid-refractory ulcerative colitis: a randomized pilot study. Oral corticosteroids and the risk of serious infections in patients with elderly-onset inflammatory bowel diseases.

Diseases

• Mesomelic dysplasia Thai type
• Miller Dieker syndrome
• Spinal cord injury
• Gamma aminobutyric acid transaminase deficiency
• Hepatic ductular hypoplasia
• Schindler disease
• Argentine hemorrhagic fever
• Ophthalmo acromelic syndrome
• Amnesia, transient global
• Cytomegalovirus

Synovial tendon sheaths Are synovial fluid-filled tubular sacs around muscle tendons that facilitate movement by reducing friction acne cream discount benzac express. Fascia Is a fibrous sheet that envelops the body under the skin and invests the muscles and may limit the spread of pus and extravasated fluids such as urine and blood skin care diet buy benzac online now. Superficial fascia Is a loose connective tissue between the dermis and the deep (investing) fascia and has a fatty superficial layer (fat acne 2017 order benzac amex, cutaneous vessels acne x factor cheap benzac 20gr visa, nerves acne under eyes discount benzac online american express, lymphatics skin care advice buy cheap benzac line, and glands) and a membranous deep layer. The skin is connected to the underlying bones or deep fascia by a layer of loose areolar connective tissue. This layer, usually referred to as superficial fascia, is of variable thickness and fat content. These include both skeletal muscles (platysma, palmaris brevis) and smooth muscles (subareolar muscle of the nipple, dartos, corrugator cutis ani). The superficial fascia is most distinct on the lower abdominal wall where it differentiates into two layers. Strong connective tissue bands traverse the superficial fascia binding the skin to the underlying aponeurosis of the scalp, palm and sole. Deep Fascia Is a sheet of fibrous tissue that invests the muscles and helps support them by serving as an elastic sheath or stocking. Provides origins or insertions for muscles, forms fibrous sheaths or retinacula for tendons, and forms potential pathways the limbs and body wall are wrapped in deep fascia. In the iliotibial tract of the fascia lata, for example, it is very well developed, while over the rectus sheath and external for infection or extravasation of fluids. Where deep fascia passes directly over bone it is always anchored firmly to the periosteum and the underlying bone is described as being subcutaneous. In the neck, as well as the investing layer of deep fascia, there are other deeper fascial layers enclosing neurovascular structures, glands and muscles. Intermuscular septa are laminae of deep fascia which extend between muscle groups. Transverse thickenings of deep fascia over tendons, attached at their margins to bones, form retinaculae at the wrists and ankles and fibrous sheaths on the fingers and toes. Retinacula at the joints 14 In the vicinity of the joints, the tendons of the muscles of the leg are bound down by localized, band-shaped thickenings of the deep fascia termed retinacula, which collectively serve to prevent bowstringing of the underlying tendons during muscle contraction. General Anatomy Portal Venous Circulation Portal circulation is a capillary network that lies between two veins. Blood supplying the organ thus passes through two sets In hepatic portal system blood supplying the abdominal organs passes through two sets of capillaries before it returns to A portal circulation also connects the median eminence and infundibulum of the hypothalamus with the adenohypophysis. Shunt vessels basically bypass the capillary circulation and connect small arteries to the small veins in case of resting organ. When the organ is active these shunts are closed and the blood circulates through the capillaries. According to the local demands, the shunt vessels may open/close and can deliver the blood directly to the venules or let it flow normally through the capillaries. Shunt vessels are important for temperature regulation as evidenced in cold environment. To conserve central (core) temperature the shunt vessels open up in the peripheries (hand, feet etc. Hence, we feel our finger tips getting cold very quickly as relative to the central body. Lymphatic System Lymphatic system is a collection of vessels that function to drain extracellular fluid from tissues of the body and return it to the venous system. The lymphatic system consists of lymphatic organs, a conducting network of lymphatic vessels, and the circulating lymph. Primary or central lymphoid organs generate lymphocytes from immature progenitor (stem) cells. The thymus and the bone marrow constitute the primary lymphoid organs involved in the production and early clonal selection of lymphocyte tissues. Bone marrow is responsible for both the creation of T cells and the production and maturation of B cells. From the bone marrow, B lymphocytes immediately join the circulatory system and travel to secondary lymphoid organs in search of pathogens. T lymphocytes on the other hand, travel from the bone marrow to the thymus, where they develop further. The other 95% of T cells begin a process of apoptosis, a form of programmed cell death. Secondary or peripheral lymphoid organs, which include lymph nodes and the spleen, maintain mature naive lymphocytes and initiate an adaptive immune response. The peripheral lymphoid organs are the sites of lymphocyte activation by antigens. Mature lymphocytes recirculate between the blood and the peripheral lymphoid organs until they encounter their specific antigen. Secondary lymphoid tissue provides the environment for the foreign or altered native molecules (antigens) to interact with the lymphocytes. In the gastrointestinal wall the vermiform appendix has mucosa resembling that of the colon, but here it is heavily infiltrated with lymphocytes. Right upper quadrant of the body drains the lymphatics into the right lymphatic duct and rest of the body drains into thoracic duct. The confluence of lymph trunks receives lymph from fourma in lymphatic trunks: the right and left lumbar lymph trunks and the right and left intestinal lymph trunks. In a small percentage of population this abdominal confluence of lymph trunks is represented as a dilated sac called the cisterna chyli. Thoracic Duct begins in the abdomen at T-12 vertebral level as the continuation of cisterna chyli. It is usually beaded because of its numerous valves and often forms double or triple ducts. It drains the body below diaphragm (lower limbs, pelvis, abdomen) and left half of the body above diaphragm (thorax, Thoracic duct passes through the aortic hiatus in the diaphragm and ascends through the posterior mediastinum between At T-5 vertebral level it deviates to left side of midline and keep ascending up to pass the thoracic inlet. It arches laterally over the apex of the left pleura and between the left carotid sheath in front and the vertebral artery behind, runs behind the left internal jugular vein, and eventually empties into the left venous angle - junction of the left internal jugular and subclavian veins (Beginning right brachiocephalic vein). Tributaries of thoracic duct: Bilateral (right and left) descending thoracic lymph trunks, which convey lymph from the lower intercostal spaces (6 to 11). Left upper intercostal lymph trunks, which convey lymph from the left upper intercostal spaces (1 to 5). It begins as a convergence of the right sided lymphatic vessels (subclavian lymph trunk, jugular lymph trunk, and It drains into the right venous angle - junction of the right internal jugular and subclavian veins (Beginning of left Right lymphatic duct drains right side of the head and neck, upper limb, thorax (including breast and lung) and superficial Schematic diagram for lymphatic drainage of the body is given in: thoracoabdominal wall (above umbilicus). Ends into junction between left subclavian and internal jugular vein 18 General Anatomy 3. In its place methanol is used, which is cheaper and more toxic to bacteria than ethanol. It alters enzymes and lysins of the body and arrest decomposition - fixing the specimen in such a way that it retains its original structure with minimal alteration. Pre-embryonic period extends from fertilization to the end of second week of intrauterine life. Embryonic period extends from beginning of the third week to the end of eighth week of intrauterine life. Note: Some authors consider the embryonic period from fertilization to the end of eight week. Flowchart 1: Subdivision of prenatal period and events occurring in these periods. Cell Division the cell cycle is an ordered sequence of events, culminating in cell growth and division to produce two daughter cells. In contrast, the duration of G1 shows considerable variation, sometimes ranging from less than 2 hours in rapidly dividing cells to more than 100 hours, within the same tissue. In the ovaries, primary oocytes become diplotene by the fifth month in utero and each remains at this stage until the period before ovulation (up to 50 years). Therefore, within teratomas are present derivatives of all three germ layers and may include skin, bone, teeth, gut tissue. Spermatogenesis Spermatogenesis is the process in which spermatozoa are produced from spermatogonial stem cells by way of mitosis and meiosis the primordial germ cells form spermatogonia, which yield primary spermatocytes by mitosis. Thus, the primary spermatocyte gives rise to two cells, the secondary spermatocytes, and the two secondary spermatocytes by their subdivision produce four spermatids. Only one pair of homologous chromosomes has been shown (red, maternal origin; blue, paternal origin). As a result of meiosis, each spermatid contains only half of the genetic material present in the original primary spermatocyte. Early round spermatids undergo further maturational event (spermiogenesis) to develop into spermatozoa. Initial stages of spermatogenesis takes place within the testes (seminiferous tubules) and progress to the epididymis where the developing gametes mature, gain progressive motility and are stored until ejaculation. Type A (pale) cells, which are the spermatogonial stem cells that undergo active mitosis to produce Type B cells. Oogenesis Primordial germ cells (46, 2N) derived from the epiblast cells, reach the endodermal wall of the yolk sac and differentiate into oogonia (46, 2N), which populate the ovary through mitotic division. After puberty, 5 to 15 primary oocytes begin maturation with each ovarian cycle, but only 1 reaches full maturity to undergo ovulation. Secondary oocyte is degenerated after 24 hours of ovulation, hence fertilization must take place within a few hours, and no more than a day after ovulation. Approximate number of primary oocytes at 5th month of intrauterine life is 7 million, most of them get degenerated by birth and the count comes down to 600,000 to 2 million. The degeneration continues and at puberty, only 40,000 are present, out of which 400-500 undergo ovulation in the female reproductive life. Only one pair of homologous chromosomes is shown (red, maternal origin; blue, paternal origin). Meiosis I is a reduction division and reduces the chromosome number to half in gamete. Primary oocyte completes meiosis I to form a secondary oocyte (23,2N) and a first polar body (which later degenerates). Abnormal persistence of which of the following cells from primitive streak result in sacrococcygeal teratoma After ovulation has occurred, the oocyte (ovum) remains fertilizable for 48 hours, although the chance is mostly lost by 18-24 hours.

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Depending on the clinical presentation acne keloidalis cure purchase benzac 20 gr mastercard, some patients who are stable and not septic may be treated with intravenous antibiotics skin care japanese product benzac 20 gr with amex. While a laparoscopic approach is also feasible acne out active discount 20gr benzac otc, it is more commonly done by an open approach in the emergency setting acne removal buy benzac 20gr with mastercard. Primary sigmoid resection with fecal diversion: In selected urgent or emergent cases acne 6 dpo benzac 20 gr online, a sigmoid resection and primary anastomosis may be performed with a diverting loop ileostomy acne prone skin cheap benzac 20gr with amex. This procedure obviates the need for a potentially difficult Hartmann takedown in the future while mitigating the potential consequences of an anastomotic leak. If such a procedure is performed in a patient who has not had a bowel preparation, on-table lavage and cleansing of the colon should be considered. Comparative data are lacking to guide surgical decision making in patients with free perforation of diverticulitis. The authors found that the probability of morbidity and mortality was lowest for Hartmann procedure and highest for primary anastomosis without diversion. However, stomas remained permanent in 27% of patients with end colostomy but in only 8% of patients with anastomosis and fecal diversion. A decision model revealed that the optimal strategy was primary anastomosis with proximal fecal diversion because of the high complication rate without diversion. However, Hartmann procedure became the optimal strategy in very high-risk patients with substantial morbidity and mortality. The initial series in 1996 included eight patients with perforated diverticulitis and purulent peritonitis who underwent laparoscopic lavage as the sole treatment with no interval resection. The technique received little attention until the publication of a prospective multiinstitutional trial in 2008 of 100 patients with perforated diverticulitis who underwent laparoscopic lavage. From this total, eight patients were found to have feculent peritonitis, converted to an open Hartmann resection. Ninety-two patients were managed with laparoscopic lavage, and no patient required subsequent resection for diverticulitis. Two patients developed a pelvic abscess in the postoperative period and required drainage, and two patients presented with a subsequent attack of diverticulitis. The morbidity was 4%, and the mortality was 3%, much lower than what has historically been reported for the Hartmann procedure. Three randomized trials have recently examined the role of laparoscopic lavage in the treatment of patients with perforated diverticulitis. The primary outcome was severe postoperative complications within 90 days, which occurred in 30. The authors concluded that lavage did not reduce severe postoperative complications and led to worse outcomes. Lavage resulted in no difference in mortality and morbidity, but was associated with shorter operating time and shorter hospital stay. There may be a group of patients who may best be served with lavage and do not want a stoma but need surgery to control sepsis. For example, which patients should be selected for lavage, should patients have subsequent resection after lavage, and what are the long-term results In addition, many series include patients initially thought to have perforated diverticulitis but ultimately noted to have perforated colon cancer, which highlights the importance of colonoscopic evaluation at some point in the postoperative period for patients in whom subsequent resection is not recommended. A number of clinical practice guidelines have been refined to include a statement on the role of lavage. The Association of Coloproctology of Great Britain and Ireland states that "laparoscopic lavage may play a role in some patients with acute diverticulitis. Whilst this is an alternative to resection in the acute setting for some patients, it is not certain whether it is an acute alternative to delayed resection. Hartmann takedown is associated with considerable morbidity and mortality, and up to a third of patients, for a variety of reasons, never undergo stoma reversal. Hartmann takedown (reversal): After Hartmann resection for perforated diverticulitis, most patients are eager to proceed as soon as possible with stoma reversal. These patients have often presented with free perforation as the initial manifestation of diverticulitis and never anticipated requiring a stoma for treatment. Reversal surgery may be undertaken early (<3 months from the initial surgery) or later (>3 months from the initial procedure). There are advocates of each approach and no randomized trials to guide recommendations. Proceeding with a Hartmann takedown close to the time of initial surgery has several disadvantages, predominantly due to adhesions and the acute inflammatory response after initial surgery, which may lead to a difficult dissection, potential enterotomies, and difficulty with identification of the Hartmann stump. While waiting for at least 3 months will presumably allow the patient sufficient time to heal and facilitate identification of the Hartmann stump, waiting longer may make identification of the stump more difficult secondary to fibrosis. Prior to reversal, a Gastrografin enema through the rectum is helpful to provide an assessment of the length and configuration of the rectal segment, in addition to assessing residual sigmoid colon and/or diverticula. This protocol may be especially helpful if the surgeon reversing the Hartmann is not the same surgeon who performed the initial resection. Another advantage to this imaging study is that fecal residue may be evacuated, which ultimately helps with passing the circular stapler and the sizer. Colonoscopy or barium enema is performed through the stoma, and a mechanical bowel preparation is administered prior to surgery. The patient is placed in low lithotomy position or (preferably) on the split-leg table with the legs abducted. Initial dissection is focused on lysing adhesions of the small bowel to identify the Hartmann pouch; in the majority of cases this involves lysing the majority of the adhesions from the ligament of Treitz to the ileocecal valve. With few exceptions, there are generally small bowel adhesions or omental adhesions to the top of the Hartmann pouch. While some have advocated tacking the top of the Hartmann with a long suture, we have not found this helpful and find passing a scope or sizer per rectum more useful in identifying the Hartmann. Mobilization of the Hartmann pouch is carried out as needed to be able to pass the sizer. It is best to begin the rectal mobilization at the mid rectum, as the top of the Hartmann tends to be most scarred. The stoma is taken down and resected and a purse-string suture placed, and the anvil of the circular stapler is secured. A circular end-to-end stapler is most commonly used, although a handsewn anastomosis may also be performed. In cases where it is difficult to pass the stapler, we prefer to staple the side of the colon to the top of the rectum. In a study of 183 patients who had surgery for diverticulitis, 22% reported ongoing diffuse abdominal pain after resection, and 5% to 10% of patients reported no long-term relief of symptoms postoperatively. Two studies have specifically addressed the risk of recurrent diverticulitis following sigmoid resection and have reported similar results. Benn and colleagues reviewed 501 patients who underwent sigmoid resection for diverticular disease at the Mayo Clinic. The authors concluded that the distal resection margin should be the proximal rectum (as evidenced by the area where the taenia fan out) to decrease the risk of recurrent diverticulitis. A subsequent study at the Cleveland Clinic of 236 patients who underwent sigmoid resection for diverticular disease had similar conclusions, and the risk of recurrent diverticulitis was four times higher in patients who had a colosigmoid versus a colorectal anastomosis. As the bowel tends to be somewhat foreshortened in diverticular disease, mobilization of the splenic flexure is often necessary to perform a tension-free anastomosis. The traditional understanding of diverticulitis as an episodic condition is now changing, and a growing body of data is noting some chronicity to the condition. In addition, information for patients regarding the role of diet, family history, and treatment need to be evidence based. With the growing focus on patient-centered outcomes, the value of colectomy in patients with diverticulitis needs to be better developed. Laparoscopic lavage versus primary resection for acute perforated diverticulitis: review and meta-analysis. Is the decline in the surgical treatment for diverticulitis associated with an increase in complicated diverticulitis Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Changing views on diverticular disease: impact of aging, obesity, diet, and microbiota. A prospective study of alcohol, smoking, caffeine and the risk of symptomatic diverticular disease in men. Pathogenesis of multiple diverticula of the sigmoid colon in diverticular disease. The aetiology of diverticulosis of the colon with special reference to the action of certain drugs on the behaviour of the colon. Interstitial cells of Cajal, enteric nerves, and glial cells in colonic diverticular disease. Alterations in colonic motility and relationship to pain in colonic diverticulosis. The anatomy, pathology, and some clinical features of diverticulitis of the colon. Diverticular disease of the colon: new perspectives in symptom development and treatment. Assessment of small intestinal bacterial overgrowth in uncomplicated acute diverticulitis of the colon. Diverticulitis in the young is not more aggressive than in the elderly, but it tends to recur more often: systematic review and meta-analysis. Prevention of complications and symptomatic recurrences in diverticular disease with mesalazine: a 12-month follow-up. A randomized clinical trial of observational versus antibiotic treatment for a first episode of uncomplicated acute diverticulitis. Temporal trends in the incidence and natural history of diverticulitis: a population based study. American Gastroenterological Association Institute guideline on management of acute diverticulitis. Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the Sigma Trial. Hand-assisted laparoscopic vs open colectomy: an assessment from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted cohort. Systematic review of evidence and consensus on diverticulitis; an analysis of national and international guidelines. Risk of emergency colectomy and colostomy on patients with diverticulitis disease. Diverticular disease as a chronic illness: evolving epidemiological and clinical insights. Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory Concurrent drug use and the risk of perforated colonic diverticular diseases: a population-based case-control study. Higher serum levels of vitamin D are associated with a reduced risk of diverticulitis. Deverticulitis in transplant patients and patients on chronic corticosteroid therapy: a systematic review. Obesity, physical inactivity, and colonic diverticular disease requiring hospitalisation in women: a prospective cohort study. Diverticular disease and the risk of colon cancer-a population-based case-control study. Is laparoscopic surgery the best treatment in fistulas complicating diverticular disease of the sigmoid colon The management of acute complicated diverticulitis and the role of computed tomography. Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery. Diverticular disease associated with inflammatory bowel disease-like colitis: a systematic review. Long term outcome of mesocolic and pelvic diverticular abscesses of the left colon-a prospective study of 73 cases. Percutaneous drainage of colonic diverticular abscess; is colon resection necessary Medically treated diverticular abscess associated with high risk of recurrence and disease complications. Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis. Treatment of patients with acute colonic diverticulitis complicated by abscess formation: a systematic review. Operative strategies for diverticular peritonitis: a decision analysis between primary 105. Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Incidence and risk factors of recurrence after surgery for pathology proven diverticular disease. Determinants of recurrence after sigmoid resection for uncomplicated diverticulitis. Symptomatic internal hemorrhoids typically cause rectal bleeding, while external hemorrhoids typically cause thrombosisandpain. In addition, a thrombosed hemorrhoid is extremely tender to palpation, and a thrombus may be palpablewithinthehemorrhoid.

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