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All right. Got it right. Good morning, good afternoon and good evening. Wherever you are. Nice to meet you again. Um We are going to talk about a very common problem in uh in United Kingdom. Uh At least 10 to 15% of the population suffers from diverticular disease. And uh and it's a acute abdomen uh situation as well with diverticulitis, perforation, etcetera. Uh So it is important to uh discuss this because in the plant exam also, I think I'm sure you'll be asked about this and maybe showing some X rays. And I have, I haven't got many X rays today, but when I do the intestinal obstruction, I'll be showing you and how to read an extra etcetera, right? So, there are a few words, I'm sure, you know, congenital, acquired and the pulse and diverticulum, traction, diverticulum, uh and miss centric border and timmy centric border and all that. You will have to know those words in order to describe these things. Okay. So, uh so the congenital ones, uh we will discuss that separately and acquired ones are the ones we are mostly interested in, especially especially colonic diverticular. Uh they are really publish in particular because of the increase intraluminally pressure. And also most of the acquired ones are also false diverticular because it's not the whole wall. Uh but the mucosa is pulsed out through the muscular wall. So that's, that's so you should be able to describe these things as well. So, diverticulum is a sack like protrusion uh and it could be entire bowel wall or as we just said, uh false pseudo diverticulum involves only that protrusion of the mucosa. So mucosil blow out through the muscular is propria and uh of the bowel wall. So especially when we talked about colonic diverticular, uh it is the the most weakest point which has come out between the teeny and the uh and also the clustering of the circular muscles in between those especially the weakest point will be where there was our recti recti goes through the bowel bowl. So it is obviously anti my centric border as well. Uh It can also occur from esophagus to rectosigmoid. A junction rectum will be spared and uh stomach hardly any diverticular seen because of office uh office, uh nature of the structure, the muscular wall and also the ability to have do relax, uh and adapt. So, adaptive relaxation and uh receptive relaxation, rectum also has a huge capacity into the ski, a rectal Phosa it blow out. Uh uh And, and therefore, that's why we, we said yes, the day before yesterday, that's why the Secure Ector lapses is such a big one makes the patient ill. So uh so very rarely you get that particular in them that they do, they do come but very occasional, right? So uh the first one actually not belong to the gut, the pharyngeal pouch, you all heard about this thing. It is again, it's chronic intraluminally pressure. We call it Zenker's diverticulum. You, you know, the sinkers triangle or the Killian, did he Asians? You have already heard these things and the perennial power protrudes through because of the poor coordination between the inferior constrictor and the cricopharyngeal is the progress you mucosal out pouching. And uh main thing that any doctor must know that when you do endoscopy, not to perforate this because very difficult to uh because a lot of us, we put the endoscope without actually looking, looking through, try and get it into the esophagus. So you have to be very careful if the patient is complaining of upper upper, it's a radial this failure. So um we are not doing barium meal and follow through these days or even double contrast barrier minimus barium studies. Uh some of the countries do that, but therefore, that's why you need to be absolutely careful when you put. Uh and it's very distressing for the patient. Uh the when you, especially when you're trying to eat, it's called the wrong way. They cough and get into distress and they get uh just infections often and all that. And you have no choice that need to be operated on. So you need to remove that and uh we're not going to talk about any surgery at the moment. So there are, it's a failure diverticular in the lower part of it, lower to lower one third. And they are known as Epic Phrenic diverticular just about the uh diaphragm. That's why it's called Epic phrenic. There. They are not that important uh may be due to uh due to Gored that they get because of reflux and the pressure developing there, but they hardly cause any, any, any any major problems. Uh The other one is the traction, diverticular. So traction is the when there is some inflammation or even new plastic uh new plastic disease that uh there is a failure wall get involved and it pulled out and it becomes like conical that the diseases they mentioned is uh not all of us had seen type tuberculosis, various granular granular martyrs disease, histoplasmosis. And of course, neoplastic disease, it is a kind of a conical loud pouching, not a globular one like a pulse diverticular. So uh fibrotic healing and the eggs attraction to the esophageal wall. And occasionally, especially if with this neoplastic, you may get a road, digest your fistulas and obviously jest infections and there are very difficult to operate on this. Uh There are various tense available but it's it's it's not very successful and it's distressing for the patient. So the the the or Denham. We said that the stomach you hardly ever get uh the Ordina the second part of the or Denham, the pancreatic see border, you get sometimes multiple diverticular in the MS enteric border. And the main, main thing again for the endoscopy is when you're going to do your CP, you cannot find the ampullae. So you can't cannulate the am pillar of water. So that is the main difficulty. Otherwise, again, very reality cause obstruction or infection or various uh nutritious prob nutritional problems may cause obstruction. Very rarely. And the uh small bubble, only 1% of the population get a small bowel. Again, they are more, more, more, more pliable and more distensible. Uh And if you get in the proximal D june, um again, on the MS centric side at the point of entry of the blood vessels, they are multiple. Therefore, they are causing the change of bacterial flora, bacterial stasis and overgrowth and malabsorption. And you get what we call blind loop type syndrome, weight loss, fever, joint pain, skin rash and tendonitis and muscular pain. That's uh that's, that's again, a malabsorption problem. Mikhail's diverticulum is very important for you, especially when you're going to do an appendicectomy. If the appendix is normal, you have to go and look for it. So 2% of the population, the surgeons like to uh go through this jargon with you and two inches tall, two ft proximal to the I see. Well, and this may get obstructed, inflamed, same way as appendix, uh the wide mouth soft and if there is no bleeding, just we just leave it but narrow pouch, uh narrow mouth, then of course, uh and if there is any ectopic mucosa, which ulcerates and bleeds and inflame's. So the ectopic mucosa, you may get gastric pancreatic and colonic mucosa. So you have got all the problems of the peptic uh peptic mucosa are causing. So it can perforate ulcerates and it can be the leading head of an inter susceptible, susceptible. Um So, and it may obstruct and uh it may obstruct and also uh you will be asked why, how do, how do you get a megastar particular um is a remnant of with white lo intestinal duct. So you can have uh either a band or assist uh or even a sinus at the umbilicus or even a fistula connecting it to the small bowel two ft from the ileocecal. Well, and another thing you must know is that this is the first narrowest point of the small bowel. Now, if you have a Goldstone ideas, we'll be talking about that when we talked about intestinal obstruction if you have and Goldstone ideas, this is the first place you get your Goldstone get lodged. Uh And if that MRS, obviously, it will be the second one is the only one Ileocecal valve. So I think a lot of people think it is idea ossicle. Well, but the first ob obstruction comes at two ft from the ileocecal valve. So, and that's why you get your shadow or the stone, uh, the regular strad shadow, the stone that you get it around the, uh, around the sacroiliac joint. So look on either side again, we'll be seeing express when we talked about Goldstone Alias. It's an important. So, uh, all these needs to be treated if there's a band. Obviously, you have uh you, you have uh you have to uh you may have all the small bowel get entangled and you may have intestinal obstruction. Again, we'll come back to that when we do intestinal obstruction, right? Good. Uh So uh main concern to us uh these days is uh the other zaria is the colonic diverticular a sacked like protrusion of the mucosa. I said mucosal blow out through the colonic wall. Muscular is mucosa, uh sorry, muscular is propria and through the muscular layer due to intraluminally pressure. So, protrusion occurs in the week area. As we said, that is the area between the teeny and because of this pressure, even the circular muscle get clustered in uh along the along the bowel. So, uh so, so it is anti me centric border and where the was a rector joints, okay. Uh function of the colon. I think, you know that I'm not going to go to that affect 50% of people over the over 60. Uh I initially said it incorrectly uh it is actually more than 50%. Uh but there could be just diverticula osis. Uh Only 20% of that diverticulosis, which is no inflammation or anything, no complications. Only 20% developed symptomatic disease. So, it's prevalent among the males. Uh and very rare in the developing nations we call, we think that it is due to a high fiber diet that they take. So, uh so it's a, is a muscle blowout, mucosil blow out through the muscle wall. And this is a histological structure. You can see the diverticulum here and there is no muscular later here and that is your muscle. So it has come through the muscles and usually it comes uh there will be a versa uh recti coming through that and it is so thin and the vasa recta get flattened out and also uh the hard feces getting there and cause erosion into the, into the blood vessels and cause severe bleeding. So, uh what happens? Um the uh you get edema fibrosis and thickening and then obviously, stenosis, the the the main problem in this uh thing is that the mucosa looks normal. You may see when you do it, endoscopy little pouch pouch inside it. But sometimes you wonder now when we do uh colorectal incision, excisions, resections, we normally can tattoo the colon from inside doing a colonoscopy in order because you can, you have to do laparoscopically. You can't feel uh we are the pathological area is. So, so therefore you need to tattoo that and you can't do that with the uh diverticular disease because uh you just have to look and see what in the segment. How thick is it? Uh you cannot tattoo that because the because it's normal. So maybe you can select the areas where there are modern, particular, more little sex in that area. So uh uh the uh why do you get more in the sigmoid colon? Sigmoid is the most irritable, irritable, the narrow of a segment, it is almost act like a social sphincter. My boss, his name is in the very and Lowney less painter in in Royal Free and Manaus Hospital in London. He, he's the one who did a lot of work with Gallagher uh is a famous chapter again for diverticular disease, high fiber diet. They are the those two people are the ones who introduced that. Remember, transit time, it's very important word for you all to answer in the exam. So it's a, it's a physical principle of pressure relationship, highest intraluminally pressure per unit. Uh mascular herbal tension. Uh The Laplace is low is applied that you studied for the A levels. It's a pressure tension radius. And if the radius is low, uh the, the pressure pressure at the tension on the world increases very much we with their thing equation. So uh the, the pressure increases up to 90 degrees millimeters of mercury. I'm sure you know about the peristaltic uh the for the absorption you have the segmentation. Uh and that is the sigma is the most uh lower radius. So that's why the tension is high. And also it's act like a social sphincter after the, after the rectal normal Fink test. Because if you're in a party or something, something like that, you're trying to restrain yourself not to go to the toilet. And then of course, that is also another cause for that particular formation, right? So that place is low. I'm not going to go through that. Just you, you can just say it's uh it's a tension, uh ball, ball tension, intraluminal pressure and radius relationship. Uh And that's all you need to know. Now again, like surgeons like us, we love to ask this question, what is sayings tried. So, same strategy is the association of hiatus hernia, gallbladder disease and diverticula losis. And actually, if you do some survey, you ask the patient, they have a high to sena and they have already had a laparoscopic cholecystectomy and they come with left tire course of pain. So remember that the PSA Saints tried is uh is not that important to you, but the examiners like to ask those questions. What did you, have you ever heard of Saint Stride? And especially it's a British South African general surgeon Charles Frederick Morris ST. So Saints tried. So, uh they may ask you about uh peristalsis, the segmentation contraction forming circulation. That's the time where the pressure increases within the intraluminal pressure increases and antiperistalsis there is kind of a breaks and breaks for absorption, we call it and also mass movements. And then of course, it again applied the pressure on the wall with giant migrating contraction that you cannot stop. Uh So uh remember about, about the peristaltic views. Okay. So, diverticula osis, they are a symptomatic, mostly they have diverticular. You may see it incidentally, uh the little circulation's and diverticular disease when they become symptomatic diverticulitis. Obviously, uh there is infection, uh inflammation associated with diverticular and remember bleeding, we have the habit of giving antibiotics when the patient come with diverticular bleeding. But bleeding is really not always due to infection. So, if there's no temperature, if there is uh if there is uh no other problems like CRP is going up, yes, are going up. I try not to give any antibiotics unnecessarily. Uh So uh uh low fiber diet. Uh they're talking about to increase the uh the pressure within the bowel uh physical in activity. Now, they talked about obesity and the main thing is that remember the conditions I talked to you about uh constipation, hemorroids, diverticular disease and colorectal cancer. So, don't miss the colorectal cancer. So that is the first thing again, even if you're sure that there is diverticular. This is Meet me coexist because of the four conditions syndrome. I'm very particular about asking this uh to exclude serious illness. So, uh was directory. That is where the weakest point is. Uh and that is where it kind of protrudes through patho physiology. So we said just now with Sigma involvement, it's about 95% of cases and the involvement of the entire colon. It's possible it's only about 7%. Uh okay. Diverticular, often symptomless individual, diverticular may become inflamed probably because of obstruction of the narrow opening, results of the diverticular abscess and inflammation and fistula formation. So mild cases, they may have low abdominal pain, distention, flatulence, heaviness in the low abdomen. Uh they may have almost like cancer. They may have alternating in constipation uh and, and uh and diarrhea as well. Uh Surgery is mainly for complications because, you know, a colorectal surgery is a serious condition. So, uh so low abdominal pain, they come with crams, distention in the in the chronic situation lose too uh diarrhea. They may have constipation, they may have fatigue if this chronic infection going on general weakness. So, uh 5 to 15% may bleed because of the reason we just mentioned uh diverticulitis 15 to 25%. Uh right. So, abdominal pain fever, leukocytosis is CRP is up. I think uh the recurrent nature of the problem. That's why we eventually uh come for resection, but we try not to do it unless there is a perforation, peritonitis or constipation or serious constipation. And we uh we talked about the clinical scenario, the patient may come with left direct for some tenderness and pain. Uh You may even feel a mass in the left iliac fossa because of the inflammation, because of the flagman, the congo merit. Uh So, uh hemorrhage, we said that not all get hemorrhage, okay. So they may have abscess obstruction, stricture perforation leading to peritonitis. And uh right, uh pneumoperitoneum is possible in about 10 to 12%. Um and we'll talk about how to look at the X rays when we do the uh intestinal obstruction. Now, if you have a patient uh on your ward and just come into the world, how are you going to deal with with this problem? That's the scenario you may be asked. So uh uh see you that I can, right? So history is important. They may have a previous episode uh and make sure you put the patient in bed. So and then ask them whether they are comfortable, give them a pillow if you want because the, you don't have to have a pillow, less patient because it is very difficult for even a normal person to lie without the pillow. So ask them the comfort and ask them whether they are. It's an acute situation. I'm talking severe left. I like for some pain, patient, convict temperature, uh tachycardia, etcetera. So uh get them uh and ask them whether they have got any pain. So you're not going to examine this patient without making them comfortable. So that's important and you are not making uh cover the signs and symptoms because you have given some pethidine for the patient because it is very, very uh in human not to give something before you start poking your hair, hands onto the painful abdomen. So it is important to give them some painkillers, especially we prefer pethidine than morphine. Uh that is recommended by the World Gastro Android, the organization as well. And also uh you, you, you make a diagnosis, do a pr examination, not in the exam because we won't allow you to do the pr invest you test in the. So you take blood as soon as you say you take blood, don't say I'm going to resuscitate this patient with IV fluids. You take blood for investigations, you put a cannula, take blood. Always that order you put a cannula, take blood for investigation. And if you think the situation is serious, may even uh cross match blood for the patient if you think there is patient likely to go to theater. So uh okay. And of course that uh you, you have to give antibiotics if you think that is sepsis, ongoing sepsis. Usually we give a third generation careful of scoring. And the and of course, Metronidz. So one of the questions we normally asked, why do you give you metroNIDAZOLE? So it's Anna Robes but mainly mainly for uh the the colonic bacteria. Uh bacteroides. So bacteroides is, is the one that we are in the wings of this colon and they may have come out antispasmodics. We don't recommend it to be given although it is written in many books, the not in the acute situation. Um NSAID S risk perforation. So I will stop and if the patient is on nsaids, I will stop that because they may get stress ulcers as well. So, uh so you stop that medication. Uh So patient with mild symptoms can be treated, but I wouldn't really say that in the exam in the community that will be up to the GP. But when the patient comes to the hospital, you treat the way that we just described. Uh So uh no about uh antibiotics IV dose and the oral dose as well. Uh We see whether we can see any. So uh in a chronic situation, uh you have to do a pr examination obviously. And also you can do a rigid sigma to Skopje in the clinics. We still have it. Uh but it has disappeared from the Asian subcontinent. But in UK, we still have the plastic disposable uh sigmoidoscope which we can see up to the rectosigmoid junction and, and you always have to do that pr examination for cross copy. Uh I think it's better to say that because you, you don't send the patient to even colonoscopy or even uh flexible sigmoidoscope B or bari a minimum because you may uh the, you must do the pr examination as we said if you don't put your finger, you may put your foot in it. Remember the Balian love special jargon and uh the uh flexible sigma ticks will be fine. But if the patient is bleeding, you end up always having eventually a full colonoscopy. Because even if you see a tumor somewhere in the left side of the colon with flexible, you need to know about the whole of the colon ba before you operate on anything because uh you may get the, remember the word synchronous tumor and metre Cronus tumor's again. When we do colorectal tumor's, we'll talk about that, but it never forget that because that's another question will be asked, what are synchronous tumor's what our meta Chronis tumor's right. Uh Anything else? Okay. So, uh CT scan in the acute situation is, is important. Uh Let's see whether you can get a CT scan. So that's a CT scan report. Obviously, you have to roll it to find out exactly where it is. This is you cannot just see 11 section, one slice uh to make a diagnosis here. Obviously, you can see uh here here, you can see air in the urinary bladder. So may have a fistula here uh call uh cycle fistula causing infection. And also you have uh you have a segment of uh diverticular, this is the segment in gold segment, all these areas and also the streaking of uh MS century. Uh And I don't think anybody's going to ask you all that so rigid stigmatise copy you can do still uh if you don't have easy access for the flexible sigma to scopic. Uh I personally like our junior doing a gentle stretches sigma this copy because if you are not in the acute situation. So uh so you have to wait until six weeks. So acute situation, you treat the way that we just describe. Okay. So these are the uh in the barium study. These are the diverticular multiple is a disease segment here which obviously needed removal. So, double contrast barium minimum, right? We did discuss that. So, so call of a cycle fish too lied. Haven't got separate slides for that. Uh The symptoms are the signs of infection and also pneumaturia and the patient will tell you like bubbling through the your itra. Uh some people call it, which is really not true. Whistling your itra. That doesn't never happen really. But uh chronic infection comes in and pneumaturia is a well known uh symptom. Um and they may have hemorrhage and then they get very severe hemorrhage. And uh if somebody having we, we talked about uh hematochezia serious hemorrhage from the low abdominus, always more commonly due to diverticular disease, not due to tumor's or anything. Uh serious bleeding from the upper gi tea. And we, as we said, day before yesterday is due to uh is due to uh bleeding during and also a we malformation and no um uh abscesses could be pere colic or, or left iliac fossa uh that can be treated with nil oral uh nd aspiration and the uh IV fluids, uh IV antibiotics. Uh So, uh occasionally you may be able to uh radiological guidance, aspirated these abscesses and do a proper operation uh electively. Uh So, uh all right. So I don't think we need to go through that. This is an important slide uh because this is how we, how we now in the modern day treat the acute situation. So, Hian Chase staging is important to us as surgeons uh is based on the pre op finding of uh query inflammation, abscess formation and perforation. So, Henchy stage one is perry, param is a colic abscess. So, not much inflammation going on. Uh It hasn't really spread and the retroperitoneal or pelvic abscesses again, it hasn't come on to the peritoneum to cause uh peritonitis. So these two can be treated conservatively. So what is conservatively? That means that you can aspirated this radiologically under ultrasound of city guidance and the retro pertinent and pelvic capsules can be treated. So, again, nil oral IV antibiotics until it's all settled down. Wait for, wait for if you can wait because these one to may, may, may go into 34. you, you, you can treat the one to conservatively. That's why you need to know hinges staging. Just look it up in one of the books and it's it's gone into all the books now. So the three and four, obviously, you will be possibly going into surgery either laparoscopically, you wash it out and put drains and come out. I think one of the surgeons from Ireland has started doing that. I can't remember his name. So purulent peritonitis, that means pass in the peritoneal cavity and that need to be washed out and, and operated and we'll talk about the operation that we normally do. Uh And they may have fecal peritonitis. Obviously, you have no choice but to wash, wash and washed. And we, we, we jokingly say that dilution is the resolution. So, uh I again, the surgeons love to say things like that. And uh so we, we just go through on passing it on to the junior doctors as well. So, uh the pool and personalities you you have to operate. Uh and the, as I said that some people do laproscopic LaBarge and Matthew drains. But the problem here is that the feces continue to leak. If there's a fickle fickle personalities, even an abscess, you'd that make 3 may convert into four eventually. And the uh so Henchy staging is important and the uh and this is the inches staging described in this. So, abscess formation, pericholecystic or retroperitoneal uh abdomen may even be soft, but the patient is ill with high white cell count, uh temperature, tachycardia, etcetera and CRP will be going up daily because it's almost abscess formation, you know, abscess antibiotics does not reach abscess cavities because of the pyogenic membrane. That will be asked from new Y abscess, why antibiotics not reach the abscess cavities? And obviously, these two can be aspirated. And the obviously, once you're fickle peritonitis is uh and, and, and uh purulent peritonitis which is passed, you have to do something like Hartman's operation. Hartman's operation. You have to know that because you must have seen it already in your hospital. So that is your Hartman's operation here. Uh Sometimes you can almost confused with the examiner by saying Hartman's is resection without an anastomosis and any of the junior doctors now registrars I'm talking about can do that because doing an anastomosis is wrong in a septic situation. When there is spirit nineties poor blood supply, you should never do an anastomosis. But Hartman's operation is the one that you can do. So uh you close director stump. So that what is Hartman's operation? Resection of the disease segment? Left iliac fossa, end colostomy, we need these words accurately from you. So left Iraq Phosa end the colostomy. I hope, I hope, you know uh the various types of colostomy in the loop colostomies uh and end colostomies. So left dialect was the end colostomy and closure of the rectal stump. Then maybe after six weeks later, you come back and do and uh restorator you operation, if these words are very nice. So uh so that's what you do So, and another two words I want to give you is is is resuscitation of the patient. So the examiner will ask you, how do you resuscitate? Of course, hydrate the patient, you antibiotics and keep the blood pressure's normal and uh and the keep needed by mouth, etcetera and optimize the patient, you know. So uh sometimes you may have to take the patient to ICU. So remember Hartman's operation and if you remember that is enough for me. Uh So, resection of the disease segment, even for cancer, you can do that if they come as an emergency, uh establishment of the end colostomy in the left dialect, fossa and closure of the rectal stump, then you come back and do a restorative operation using the gun, staple gun and taking down the colostomy and then anastomosis. So, remember that clearly because uh we here, we don't get the juniors to get the consent because they don't know much about it. But most right through the world, especially in the Indian sub continued, the house officer or the foundation doctor will have to get the consent here. We, we try not to do that. So uh so uh but you have to know what it is because you may be asked, what have you done? You know. So, so you have already resected it, okay. The uh and the uh should be able to uh we will talk about various colostomies uh When we do the colorectal, I think we've got two sessions for colorectal surgery. So, um so you do a restorative operation like that. So, if it is a lower rectal uh resection, low anterior resection, so that's what they call it. If it is a low anterior resection, uh you do uh you have to do because it doesn't matter what genius does the operation it leaks. So that's why we are going to because the blood supply is precarious because sometimes you get it with the middle rectal and you, you divide the lateral ligament. You, you don't have to know that, but uh it is precarious anastomosis. And therefore, uh therefore, you have to do uh right. I'll yak forsa uh loop alias to me. These words must come out very clearly. Uh So that again, you have to explain to the patient that this will be closed another six weeks later. So, so that is for low interior resection. Uh I think there is high interior resection, low and d realistic shin. I will explain to you when we do the, when we do the colorectal cancer. So uh so that is the operation done for Hentges state three and four. And uh the other various fistulas, it could be call oh folic fistula, call over cycle fistula. We just described Coehlo vaginal colorectal fistula, call a vaginal and colorectal fistulas. I think the books say that is the worst thing that can happen to a woman. And uh it is terrible, terrible, very difficult to sort that out without doing uh d functioning colostomy. So now these words are coming defunction ing Colostomy that you get the fecal stream away from it. Uh And of course, the uh fickle stream complete. Usually we get them, get it away when we do a Hartman's operation completely away but loop colostomy only half of it, some of it may leak out. Now, we used to do a three stage operation. I don't know whether you are still doing that in various African countries, but which is, which should not be done. That means you do a colostomy. Loop transfers colostomy and then come back later, six weeks later and then resect it and then come back another six weeks later and get rid of the uh colostomy. That's a three stage procedure. We don't recommend it. We don't do it anymore because if you do a colostomy, what happens up to the perforator point, uh the fecal matter start leaking out. So we don't want that. So, uh so it is the wrong operation and even if some people used to exterior arise it, but the inflammation is still in the body, you may have exteriorized it, but the inflammation is still in the body. That segment need to be resected with the Hartmann's operation and elective surgeries is a very good thing to do uh in recurrent diverticulitis. Uh But any color colorectal surgery is difficult, but now we have started doing laparoscopic surgery as well. And the other information you have to give to the patient when you reverse it, reversal of colostomy, and the magnitude of the operation is as high as the original operation of Hartman's operation. So therefore, you have to explain that to the patient. Uh some old ladies in their eighty's 75 they will say doctor my one side is clean and I can manage it. I haven't got rheumatoid arthritis. So that is another thing that you must think about when you do a colostomy, whether the patient can actually manage it. If you've got severe disability, they are paralyzed. Uh doesn't know what's going on. They will be in a pool of feces if you do a colostomy. So you have to really think hard before you do colostomy on this patient. Those are, those are things you need to think about uh any fiber. I'm not going to talk about fiber again, but sometimes you have to recommend the high fiber diet. So, uh most of the chronic uh diverticula losis, even diverticulitis. Uh we give intermittent antibiotics, but also you give a high fiber diet. Obviously, you may have to describe what it is. High fiber diet, the various foodstuffs. I'm not going to talk about that. But uh antispas spasmodic, we used to give member marine hydochloride uh like call a fact. We call it in UK and also fiber gel. So uh those we give it in combination to increase the reduce the amount of spasm. Um uh My, my boss uh in Royal Free, he used to uh Neil is painter. Uh He's the one who propagated this irritability of the sigmoid colon. And he's the one who said that may. Beveren hydrochloride is good for this patient. So I also giving still giving call a fact uh and the, and the fiber gel. So uh in a chronic situation. So they say even giving hi fi die diet, the the recurrent nature can be reversed to a certain extent. But of course, once diverticular formed, they're going to remain for the rest of their lives. So, higher intake of that re fiber is associated, reduce risk of developing that particular disease. Again, this is my, always my take home message because we have, we have learned our lessons uh during my 31 years as a consultant, uh constipation, hemorroids, diverticular disease, colorectal cancer can come together. We lost one of our young colleagues because somebody treated hemorrhoids and uh he was happy and we were happy but he was dead within one year because of colorectal cancer. So don't get into that situation. And another one is ethical thing is a colleague. Should not treat another colleague. It has to be through normal pathways, then you won't miss anything. You do the same thing. Uh So if you get one or these uh 34 conditions, you must exclude especially the last one. Colorectal cancer. That's our take home message. And if you've got one that means colorectal cancer, look for another. So that is for our colorectal surgery thing because there could be synchronous tumor's. I think that's all I want to say. Uh So it is a simple thing, but it's a very common thing and uh hope you enjoyed that. And any questions please do ask Hench is staging. You must remember that because that we will be asking you even as house officers Hench is staving. So stage one abscess, para colic, para colic, we can call it pelvic abscess, retroperitoneal or pelvic abscess. So that is one and two stage to pull and peritonitis, obviously, antibiotics are required here and also fecal and peritonitis. So interest state three and four. So you decide on the treatment in the acute case uh using the Hench a staging. So uh any questions? Hello? Yes, professor, we can hear you're just waiting for. Does anyone have any questions for the professor? You need to know anyway, if you have a question, grace it while I'm talking. Uh so not to waste time because you've got five minutes left about this. The medical students should know uh what is the size of the rectum? We added directors ignored junction. And so we call it for to be easy for the medical student. It's 12 centimeters. So we added Director Sigma Junction because uh canal is four centimeters. It is at 16 centimeters. So what is the anterior resection? Anterior resection is the resection of, of the rectum and the part of the sigmoid colon through the anterior approach. So, uh what is a high end? Did a resection? Hi, anterior resection is the upper six centimeters of that 12 centimetre rectum. It's not absolutely accurate, but it's good enough for the medical student. So, low, anterior resection is the last six centimeters. But you know that you cannot resect the last six centimeters. You have to keep the last three centimeters because all you're receptive reflexes are there in the last three centimeters. So you can actually resect only three centimeters up to three centimeters because if you resect the last three centimeters, some people may call it to last three centimeters, then of course, you lose the uh problem with the latest uh and fecal matter leaking. So we cannot really do that if that happens. If you have to do that. Obviously, you do a abdominal perennial resection. Um Again, I, I like talking about colorectal surgery. I think I know it's not the uh thing today. I hope you enjoyed that and I hope you remember that. Uh and, and remember the dentist uh staging. Thank you. Thank you very much professor for no one has any questions for the professor. I think that's an amazing presentation and I hope you have an amazing day professor. Thank you very much. Can, can mess up your musa. Can I have everyone to please fill out the the feedback form as is crucial for us to continue and um hopefully see you guys in the next lecture will be starting in a couple minutes. Thank you very much again. Have a lovely day. Thank you. Goodbye.