Recurrence of Acute Right Colon Diverticulitis Following Nonoperative Management: A Systematic Review and Meta-analysis

Unusual Variations and Atypical Presentations of Diverticulitis

In this article, we describe four unusual variations of diverticulitis: nonsigmoid colonic diverticulitis, giant colonic diverticulum, segmental colitis associated with diverticulosis, and small bowel diverticulitis. We discuss the epidemiology, presentation, and treatment of these types and how they differ from the presentation of typical sigmoid diverticulitis. We also review unusual presentations of typical sigmoid diverticulitis, including hematogenous liver abscess, necrotizing soft-tissue infection, and genitourinary fistula. Diverticulitis is a heterogeneous disease, and understanding the range of its presentations will facilitate early diagnosis and treatment.

Current Management of Diverticulitis

Diverticulosis and diverticulitis remain common diagnoses in western countries, and the incidence continues to rise. Diverticulitis accounts for roughly one-third of admissions to acute care hospitals annually, with even more patients being treated as outpatients due to improved understanding of risk stratification and the natural history of disease progression. Thus, having a thorough understanding of the etiology of the disease in conjunction with computed tomography findings and patient presentation can help dictate the appropriate treatment.

Right-sided acute diverticulitis in a North African country: Presentation and management in one surgical center

PURPOSE

Right-sided diverticulitis is a rare entity in North Africa. Therefore, it is usually misdiagnosed, and the management of cecal diverticulitis is aggressive in most cases, whereas nowadays, most studies recommend a conservative approach with promising results. This study aims to describe the presentation, management, and outcomes of right-sided diverticulitis (RSD) and to present the experience of one surgical center in Tunisia.

METHODS

This is a retrospective study including all patients presented with RSD, in the Department of Surgery "A" of the Charles Nicolle Hospital between 2007 and 2021.

RESULTS

Forty patients were included in our study. The mean age was 42 years with a standard deviation of 14. The sex ratio was 1.1. Only 2 patients had chronic constipation. All patients presented right-sided abdominal pain, and only 3 patients had diarrhea. Twenty one patients were diagnosed during surgery. Fourteen patients were treated successfully by conservative management. An operative procedure was performed in 26 cases: 21 had a diverticulectomy (80%), two had an ileal resection (8%), and three had a right colectomy (11.5%). No postoperative events occurred with a short hospital stay (5 ± 3 days). Follow-up showed no recurrences.

CONCLUSION

Right-sided diverticulitis has a lower incidence and complication rate compared to left-sided diverticulitis. Conservative treatment has demonstrated favorable outcomes in managing RSD, although the available evidence remains limited.

Right Upper Quadrant Pain: A Rare Presentation of Diverticulitis

Acute diverticulitis is a prevalent medical condition with increasing incidence rates. While the sigmoid colon is the most commonly affected part of the large intestine, there have been occurrences of right-sided diverticulitis although uncommon. We present a case report highlighting the atypical presentation of diverticulitis in a 27-year-old female patient. The patient experienced right upper and epigastric pain and was ultimately diagnosed with right-sided diverticulitis, supported by her CT imaging findings. This uncommon presentation underscores the importance of considering diverse clinical manifestations when diagnosing and managing diverticulitis.

Laparoscopic Surgery for Acute Right-colon Diverticulitis: Video Vignette and Systematic Review With Meta-analysis of Current Evidence of Minimally Invasive Versus Conventional Surgery

BACKGROUND

Over the last decade, there has been growing diffusion of minimally invasive surgery in the setting of abdominal emergencies. However, right-colon diverticulitis is still mainly approached by conventional celiotomy.

MATERIALS AND METHODS

A video vignette is presented showing the details of an emergent laparoscopic right colectomy as performed to treat a 59-year-old woman who presented with clinical signs of peritonitis, and radiologic findings suggestive of acute right-colon diverticulitis complicated by perforation of the hepatic flexure and periduodenal abscess. We also aimed to evaluate the relative outcomes of laparoscopic versus conventional surgery by meta-analyzing the currently available comparative evidence on the argument.

RESULTS

A total of 2848 patients were included in the analysis, of which 979 patients received minimally invasive surgery and 1869 had conventional surgery. Laparoscopic surgery had a longer operating time and resulted in an abbreviated hospital stay. Overall, patients receiving laparoscopy had significantly lower morbidity than those whose surgery was undertaken by laparotomy, while there was no statistically significant difference in terms of postoperative mortality.

CONCLUSIONS

According to the existing literature, minimally invasive surgery improves the postoperative outcomes of patients receiving surgery for right-sided colonic diverticulitis.

Short-term outcomes following resection of right colon diverticulitis: a comparison of open and minimally invasive approaches using the NSQIP database

BACKGROUND

Right colon diverticulitis is a rare disease process for which there are no established treatment guidelines, and outcomes following surgical management are underreported in the literature. We sought to describe the demographics of patients undergoing ileocecectomy for right colon diverticulitis and compare short-term postoperative outcomes between open and minimally invasive approaches.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried for patients with diverticulitis of the colon who underwent ileocecectomy between 2012 and 2019. Patients with ascites, disseminated cancer, ASA class 5, and patients requiring mechanical ventilation were excluded. Preoperative, intraoperative, and 30-day postoperative outcomes were compared between the groups using both univariable chi-square or t-tests and multivariable logistical regression models.

RESULTS

484 patients met inclusion criteria, 150 (31%) of whom underwent open surgery and 334 (69%) who underwent minimally invasive surgery with an 18% conversion rate. 71% of patients were White, 11% of were Black, 7% were Hispanic, and 5% were Asian. The indication for surgery differed significantly by approach with acute diverticulitis representing 47% of indications for open cases and 25% for MIS cases (p < 0.0001). After adjusting for possible confounders, patients undergoing the open approach had a significantly higher chance of post-operative sepsis (p = 0.009) and ileus (p = 0.04) compared with MIS. Hospital length of stay was also significantly shorter after MIS compared to open (5.9 days vs. 11.5 days; p < 0.0001). Mean operative time was significantly longer in MIS than open (173 min vs. 198 min; p = 0.001).

CONCLUSION

Our analysis demonstrates that minimally invasive surgery is associated with equivalent or improved short-term morbidity and shorter hospital stay despite longer mean operative time. Interestingly, unlike other countries where the prevalence of right colon diverticulitis is higher, a minority of patients requiring operative therapy in our study of patients in the Western hemisphere were of Asian descent.

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.

Colonic diverticulitis location is a risk factor for recurrence: a multicenter, retrospective cohort study in Asian patients

Evidence regarding the recurrence of diverticulitis is limited in Asian patients. This study aims to investigate recurrence rates and identify predictive factors for the recurrence of diverticulitis following successful nonoperative treatment in Asian patients. A multicenter, retrospective cohort study was conducted between 2012 and 2018. Adult patients with computed tomography (CT)-proven colonic diverticulitis were included. The primary outcome was the recurrence of diverticulitis, which was defined as another episode of occurrence of the infection after index hospital stay. Cumulative recurrence rates were calculated using the Kaplan-Meier method. Cox regression models were employed to identify parameters that significantly and independently predicted recurrence. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. A total of 929 patients were included. Diverticulitis in the cecum/ascending occurred in 675 (72.6%) patients. The average follow-up period was 651 days. Recurrence was observed in 115 (12.4%) patients and most significantly observed in patients with sigmoid diverticulitis (HR, 2.24; 95% CIs 1.59-3.97), followed by those with descending colon diverticulitis (HR, 1.92; 95% CIs 1.17-3.25). Although most of the Asian patients had right-sided colonic diverticulitis, those with sigmoid diverticulitis had the highest risk of recurrence.

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.

Conservative treatment of uncomplicated right-sided diverticulitis: a systematic review and meta-analysis

PURPOSE

Right-sided diverticulitis has different epidemiologic features compared to left-sided diverticulitis. However, data on the appropriate treatment of right-sided diverticulitis are lacking. This systematic review aimed to examine the outcomes of conservative treatment for uncomplicated right-sided diverticulitis.

METHODS

MEDLINE, Embase, and the Cochrane Library were searched for articles published from January 1, 1990, to May 31, 2020. A total of 21 studies were included in the systematic review. We calculated proportions and 95% confidence intervals (CIs) to assess the outcomes of individual studies and pooled the results using a random effects model.

RESULTS

A total of 2811 patients (59.1% men; mean and median age, 37-54 years) with right-sided diverticulitis were included. The pooled rate of treatment failure was 2.5% (95% CI 1.2-4.3%; p <0.01; I² = 64.0%). The recurrence rate ranged from 0 to 26.9%, and the pooled recurrence rate was 10.9% (95% CI 8.1-14.1%; p <0.01; I² = 78.2%). The pooled rate of complicated diverticulitis at recurrence was 4.4% (95% CI 1.4-9.0%; p = 0.84; I² = 0%). The pooled rate of emergency surgery at recurrence was 9.0% (95% CI 4.6-14.7%; p = 0.12; I² = 30.3%).

CONCLUSIONS

Conservative treatment of uncomplicated right-sided diverticulitis results in a low rate of recurrence and complicated diverticulitis at recurrence. Based on these results, unnecessary surgery may be avoided and a new treatment paradigm for uncomplicated right-sided diverticulitis may be introduced.