Laparoscopic diverticulectomy versus non-operative treatment for uncomplicated right colonic diverticulitis

Is there consensus on diagnostics and treatment in colonic diverticulitis? Results of international survey

BACKGROUND

Clinical guidelines (CGs) developed by expert communities benefit both the patient and the clinician. Meanwhile a considerable proportion of specialists are not familiar with or follow them in their daily practice. Colonic diverticulitis (CD) is the third most common cause of hospitalization among patients with gastrointestinal diseases and common indication for colon resection. Actual tactics for diagnosis and treatment of CD, as well as data on what influences its choice and how the decisions made agree with the existing CGs can be identified by anonymous surveys.

METHODS

An anonymous internet survey of surgeons and coloproctologists was conducted. Groups of questions included demographics of the respondents; self-esteem score; sources of guidance in decision-making; classification systems for CD; preferable diagnostic tests; management of CD; indications for elective surgery; and outcomes of surgical treatment and others (n = 17). The study was conducted in accordance with the CHERRIES criteria. The required minimum sample size was calculated as 377 participants.

RESULTS

The study involved 401 respondents from 9 countries: 76.1% were general surgeons and 14.5% were colorectal surgeons. Excellent or good knowledge of the problem was claimed by 82.8% of the colorectal vs 66.2% of the general surgeons (p = 0.013). In decision-making respondents were largely guided by their professional experience, methods adopted in their clinic and domestic CGs. General Surgeons more often chose tactics inconsistent with CGs than coloproctologists. The largest differences between subgroups were noted for awareness of the reversal of Hartmann's procedure, most common postoperative complications and indications for elective surgery.

CONCLUSION

Adherence to the existing CGs was poor, which entails significant variation in the approaches practiced by the respondents from different cohorts. There is no consensus on the aspects that are not yet covered in the CGs. Further research is needed to elucidate these gaps and update the guidelines accordingly.

Right-sided diverticulitis in a Western population

BACKGROUND

While left-sided colonic diverticular disease is common in Western Caucasian populations, right-sided colonic disease (RCD) is rare. The present study aimed to determine the rate of RCD and to identify the symptoms, clinical features, treatment, and outcomes in a single medical center in Israel.

METHODS

Data for this descriptive retrospective analysis were collected from the electronic medical records of all patients diagnosed with colonic diverticulitis from January 2014 to June 2019.

RESULTS

During the study period, 1000 patients with diverticulitis were admitted to our institution, of which 99 had RCD (10%). Mean age was 50.2 years. The main presenting symptom was acute onset of right-sided abdominal pain. The diagnosis was made almost exclusively by computed tomography scan and the cecum was the most frequent site. The clinical course was benign, without major complications for most patients (90.1%). Nine patients presented with abscess (n = 1), covered perforation (n = 7), or partial obstruction (n = 1). All patients were treated with intravenous antibiotics with a median length of hospital stay of 3 days and a median 9 days of antibiotic treatment. Only 1 patient underwent diagnostic laparoscopy due to suspected intestinal perforation. Three patients experienced disease recurrence after a median follow-up of 48 months. Upon recovery, half of the patients underwent colonoscopy; no further pathology was found in any.

CONCLUSION

Unlike sigmoid colon diverticulitis, the incidence of RCD in Western populations is low. The clinical course is benign, with conservative treatment without the need for surgery. The complication and recurrence rates are low.

Management and long-term outcomes of acute right colonic diverticulitis and risk factors of recurrence

Background

Acute right-sided colonic diverticulitis (RCD) is a common disease in Asian populations for which the optimal treatment remains controversial. The aim of this study was to investigate management and evaluate long-term outcomes of treatment in patients with acute RCD.

Methods

We retrospectively collected and analyzed clinical data for patients with acute RCD admitted to the Tongren Hospital, Shanghai Jiao Tong University School of Medicine from December 2015 to December 2020. The patients were divided into two groups, according to primary treatment strategy, which was either conservative treatment or surgical treatment.

Results

A total of 162 consecutive patients with acute RCD were enrolled in the study. There was no significant difference in age, sex, history of abdominal surgery, medical co-morbidities, fever, previous history of RCD, treatment success rate and incidence of complications between the conservative and surgery groups. However, the recurrence rate in conservative groups was significantly higher than in surgery groups (16.53% vs 2.44%, P = 0.020). And more frequent bowel movements and previous history of RCD increased the risk of recurrence of acute RCD. Moreover, there was no significant difference in either treatment success rate or the overall recurrence rate between the patients with uncomplicated diverticulitis and patients with complicated diverticulitis.

Conclusions

Surgical treatment is also safe and effective for acute RCD. Surgical treatment should mainly be considered for patients with acute RCD with recurrence risk factors (more frequent bowel movements and previous history of RCD) or with complicated acute RCD.

Right sided diverticulitis in western countries: A review

BACKGROUND

Although the treatment guidelines for left sided diverticulitis are clear, the management of right colonic diverticulitis is not well established. This disease can no longer be ignored due to significant spread throughout Asia.

AIM

To analyse epidemiology, diagnosis and treatment of right-sided diverticulitis in western countries.

METHODS

MEDLINE and PubMed searches were performed using the key words “right-sided diverticulitis’’, ‘‘right colon diverticulitis’’, ‘‘caecal diverticulitis’’, ‘‘ascending colon diverticulitis’’ and ‘‘caecum diverticula’’ in order to find relevant articles published until 2021.

RESULTS

A total of 18 studies with 422 patients were found. Correct diagnosis was made only in 32.2%, mostly intraoperatively or via CT scan. The main reason for misdiagnosis was a suspected acute appendicitis (56.8%). The treatment was a non-operative management (NOM) in 184 patients (43.6%) and surgical in 238 patients (56.4%), seven of which after NOM failure. Recurrence rate was low (5.45%), similar to eastern studies and inferior to left -sided diverticulitis. Recurrent patients were successfully conservatively retreated in most cases.

CONCLUSION

The management of right- sided diverticulitis is not well clarified in the western world and no selective guidelines have been considered even if principles are similar to those with left- sided diverticulitis. Wrong diagnosis is one of the most important problems and CT scan seems to be the best imaging modality. NOM offers a safe and effective treatment; surgery should be considered only in cases of complicated diverticulitis or if malignancy cannot be excluded. Further studies are needed to clarify the correct treatment.

Essential updates 2018/2019: Colorectal (benign): Recent updates (2018-2019) in the surgical treatment of benign colorectal diseases

This review outlines current topics on the surgical treatment of benign colorectal diseases, with a focus on inflammatory bowel disease (IBD) and diverticulitis. Treatment options for IBD and diverticulitis have evolved in the last few years as a result of medical advances in technology and new clinical trials. Therefore, treatment options and strategies need to be updated to provide optimal care for patients. The purpose of this review is to elucidate recent global trends and update the surgical treatment strategy for IBD and diverticulitis based on literature published in the past 2 years. Prevalence of IBD, including ulcerative colitis and Crohn's disease, has increased over the last few decades. During this period, many new medical therapies were introduced for the treatment of IBD, including biological therapy, immunomodulators, and leukocyte apheresis therapy. As a result, new surgical strategies for IBD are required. In order to improve surgical outcomes in IBD patients, the influence of preoperative treatment on postoperative complications needs to be considered. The incidence of diverticulitis is also increasing with lifestyle changes and increasing numbers of older people. For diverticulitis with perforation and generalized peritonitis, surgery is the gold standard. Elective surgery after conservative treatment of diverticulitis is also an option because of high recurrence rates. With an increase in diverticulitis, systematic strategies are essential for an appropriate approach to diverticulitis, taking into account various factors, including the patient's background.