Does localization change management in complicated right and left-sided diverticulitis?

Abstract

BACKGROUND

Distribution of the colonic diverticula differs in different populations, and right-sided colon diverticulitis (RCD) and left-sided colon diverticulitis (LCD) manifest distinct clinical features. Complicated diverticulitis (CD) mostly requires hospitalization and can be treated within a spectrum from observation to surgery. Treatment choice is formed depending on the patient’s general condition, the presence of diffuse peritonitis, the localization of diverticulitis, Hinchey stage, and responsiveness to the prior treatment. Clinical disparities regarding right and LCD also led to the differences in the incidences of both emergency surgery and future elective surgery.

AIM

To evaluate the clinical features of CD, display the differences according to colonic localizations, and present treatment approaches.

METHODS

This was a retrospective study from a single centre analysing data from a prospective database. The 253 patients with history of hospitalization for CD were included and divided into two groups: RCD and LCD. To compare the differences between the two groups, the Student’s t-test was used when the parametric test prerequisites were fulfilled, and the Mann-Whitney U test was used when such requirements were not fulfilled.

RESULTS

The 208 (82.2%) patients were found to have LCD, and 45 (17.8%) had RCD. The majority of the patients had Hinchey 1A diverticulitis (49.8%). Male gender was significantly more common in patients who underwent surgery for LCD. While persistent abdominal pain was the main prior finding in the conservative treatment of both localizations, surgery was most performed due to abscess in RCD and perforation in LCD. The presence of an accompanying malignancy during colonoscopy was significantly more common in LCD cases who underwent surgery. Hartmann’s procedure was the most performed technique in emergency settings (56.3%), while laparoscopic colectomy with anastomosis was in elective settings (53.9%). In addition, surgery was found to prolong the mean length of hospital stay in LCD patients.

CONCLUSION

Although diverticulitis is a benign condition, the need for an individualized and evidence-based approach makes management challenging. Localization of the disease has an important role in determining the appropriate treatment.

Key Words: Colonoscopy; Complicated diverticulitis; Left-sided; Right-sided; Surgery

Core Tip: Diverticular disease has a globally increasing incidence. Most of the current studies on diverticulitis refer to left colonic diverticulitis. However, right-sided colon diverticulitis (RCD) and left-sided colon diverticulitis (LCD) manifest distinct features. This retrospective study consisted of 253 patients with complicated diverticulitis and compared the characteristics and treatment approaches of RCD and LCD. Age, Charlson comorbidity index, prior complication, Hinchey stage, number of episodes, and the mean length of hospital stay were significantly different between RCD and LCD. The presence of an accompanying lesion during elective colonoscopy was statistically significant among LCD. Although conservative treatment was adequate in most RCD, there is still no standard treatment management in LCD, since the course of the disease differs among individuals.

INTRODUCTION

Diverticular disease, which used to be attributed as a disease of Western populations, has an increasing incidence all around the world because of globalization and industrialization. Distribution of the colonic diverticula differs according to the population. Asian populations have a predominance for developing right colon diverticula with the rate of 70%-85%, while Western populations have for left colon diverticula with the rate of 80%-90%[1-3].

Although it usually remains asymptomatic, 15%-20% of the patients with diverticular disease develop complications and become symptomatic[4]. These complications (abscess, fistula, free perforation, stricture, and bleeding) may threaten life, unless they are timely and properly intervened. Complicated diverticulitis (CD) mostly requires hospitalization and can be treated within a spectrum from observation to surgery. Treatment choice differs depending on the patient’s general condition, the presence of diffuse peritonitis, the localization of diverticulitis, Hinchey stage and responsiveness to the prior treatment.

Treatment of CD has been altered in recent years, favouring less aggressive approaches and minimally invasive interventions[5]. Although management of the cases requiring emergency surgery is quite clear, indications for elective surgery in patients who recovered from an episode of CD are still vague.

This study mainly aimed to evaluate the clinical features of CD from a single-centre, display the differences according to colonic localizations, and present the treatment approaches. In addition, secondary endpoints were determined as demographic and clinical features affecting the surgical decision making.

MATERIALS AND METHODS

The retrospective study protocol was approved by the institutional Ethics Committee (No. 619). A written informed consent was obtained from each patient. The study was conducted in accordance with the principles of the Declaration of Helsinki, revised in 2013.

Patients

Patients with history of hospitalization for diverticulitis between January 2015 and December 2019 in our department of general surgery were evaluated. The median duration of follow-up for all participants was 23.2 months.

The inclusion criteria were: (1) To be diagnosed with CD (Hinchey stage 1A, 1B, 2, 3, 4); (2) To be treated by hospitalization; and (3) To undergo colonoscopy (preoperative, intraoperative or during the follow-up).

Exclusion criteria were: (1) To be diagnosed with uncomplicated diverticulitis (Hinchey stage 0); (2) To receive outpatient treatment; (3) To have rectum diverticulitis; (4) The absence of a current colonoscopy; and (5) Lacking follow-up data.

Medical records of 328 patients with CD were retrospectively examined. Among these 328 patients, 253 with available long-term follow-up data were included in the study. Follow-up data were collected from the electronic follow-up platform of our hospital.

The following parameters were analyzed for all patients: Age, gender, Charlson comorbidity index (CCI)[6], modified Hinchey classification stage[7], the presence of immunosuppression [type 1 diabetes and autoimmune diseases (systemic lupus erythematosus, autoimmune hepatitis or rheumatoid arthritis)], number of previous episodes, treatment choice (conservative/surgical), operative condition (emergency/elective), type of the surgical procedure, presence of additional lesions in colonoscopy, length of hospital stay, and early and late-term outcomes (morbidity/mortality).

The diagnosis and staging of CD were performed by clinical, imaging (ultrasonography and/or computed tomography), and endoscopic findings. The CD was divided into two groups according to its localization in the colon; right-sided colon diverticulitis (RCD) and left-sided colon diverticulitis (LCD). RCD included diverticulitis in the caecum, ascending colon, hepatic flexure, and transverse colon. LCD included diverticulitis in the splenic flexure, descending colon, and sigmoid colon.

Patients who were observed conservatively underwent colonoscopy 6-10 weeks after discharge, and those who had surgery underwent colonoscopy either intraoperatively or 6-12 months after the operation. Objectives of the colonoscopy were to confirm the diagnosis, to detect additional pathologies, to determine the resection margin, and/or to check the anastomosis line.

Management and surgical procedures

Patients with stable vital signs and without any signs of peritonitis were treated conservatively. Conservative management of CD included bowel rest and antibiotics. The patients received intravenous amoxicillin-clavulanic acid or a combination of fluoroquinolone and metronidazole, which was later switched to oral form at least after two days of parenteral administration. Abscesses, which were larger than 4 cm or symptomatic despite the medical treatment, were assessed for percutaneous drainage (PD).

Patients, who developed complications that could not be treated conservatively or with minimally invasive interventions, did not have any improvement during the hospital stay and/or had diffuse peritonitis, underwent emergency surgery. Elective surgery was performed in patients with colonic mass (suspicious or malignant) detected during colonoscopy, benign stricture, ongoing abdominal complaints (> 3 months) and frequently recurring diverticulitis (> 2 episodes within 1 year).

Antibiotic prophylaxis (2 g of cefazolin) was administered to all patients scheduled for surgery and bowel preparation was given for elective cases. Surgical procedures included three techniques: (1) Diversion with a proximal colostomy and drainage of the perforated area without resection (DD); (2) Colectomy with end colostomy (Hartmann’s procedure); and (3) Colectomy with anastomosis (with or without diverting ileostomy). Colectomy was fulfilled with open or laparoscopic approach, and only the inflammatory and hypertrophic segment causing CD was resected[8,9]. The term “colectomy” comprised ileocecal resection, right hemicolectomy, sigmoidectomy and anterior resection. End-to-side anastomosis was performed in patients undergoing ileocecal resection and right hemicolectomy, while end-to-end anastomosis was preferred after all other resections. Our study is an observational and cross-sectional study.

Statistical analysis

For discrete and continuous variables, descriptive statistics (mean, SD, median, minimum value, maximum value, and percentile) were given. In addition, the homogeneity of the variances, which is one of the prerequisites of parametric tests, was checked through Levene’s test. The assumption of normality was tested via the Shapiro-Wilk test. To compare the differences between the two groups, the Student’s t-test was used when the parametric test prerequisites were fulfilled, and the Mann-Whitney U test was used when such prerequisites were not fulfilled. χ² test was used for determining the relationships between two discrete variables. When the expected sources were less than 20%, values were determined through the Monte Carlo Simulation Method to include such sources in analysis[10].

An equivalence test of means using two one-sided tests on data from a parallel-group design with sample sizes of 43 in the RCD group and 196 in the LCD group achieves 80.078% power at a 5% significance level when the true difference between the means is 0.00, the standard deviation is 8.70, and the equivalence limits are -4.50 and 4.50.

The data were evaluated via SPPS 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). P < 0.05 was taken as significance levels.

RESULTS

Demographic and clinical characteristics of all patients

Demographic and clinical characteristics of all patients (Table 1). Among the 253 patients included in the study, 127 (50.2%) were male, and the mean age was 59.59 ± 14.97 years (21-90 years). When the patients were divided into three subgroups by age, most patients were between the sixth and seventh decades of life (44.2%). Mean CCI score was 2.28 ± 1.99. Majority of the patients were found to have LCD (82.2%). Persistent abdominal pain (54.2%) without any major complication was the most common prior finding, and followed by perforation (23.3%), abscess (13.8%), obstruction (3.2%), bleeding (2.4%), peritonitis (2%) and fistula (1.2%), respectively. In terms of modified Hinchey classification, most patients had Hinchey 1A diverticulitis (49.8%). Hinchey 1B, 2, 3 and 4 were diagnosed in 19.8%, 17.4%, 11.5% and 1.6% of the patients, respectively (Figure 1). In addition, 216 patients (85.4%) had their first episode of diverticulitis, while eight (3.2%) had at least three episodes.

Figure 1 Images from emergency surgeries performed due to diverticulitis. A: Laparoscopic view of Hinchey stage 2 left-sided diverticulitis; B: Pelvic abscess.

Table 1 Demographic and clinical features of patients (n = 253).

Item	Value
Gender, n (%)
Female	126 (49.8)
Male	127 (50.2)
Age (year; mean)	59.59 ± 14.97 (21-90)
Age group (year), n (%)
≤ 50	70 (27.7)
50-70	112 (44.2)
≥ 70	71 (28.1)
CCI (mean)	2.28 ± 1.99
Immunosuppression, n (%)	17 (6.7)
Localization, n (%)
Right colon	45 (17.8)
Left colon	208 (82.2)
Prior finding, n (%)
Abscess	35 (13.8)
Bleeding	6 (2.4)
Fistula	3 (1.2)
Obstruction	8 (3.2)
Perforation	59 (23.3)
Peritonitis	5 (2)
Sole persistent abdominal pain	137 (54.2)
Hinchey, n (%)
1A	126 (49.8)
1B	50 (19.8)
2	44 (17.4)
3	29 (11.5)
4	4 (1.6)
Number of episodes, n (%)
1	216 (85.4)
2	29 (11.5)
≥ 3	8 (3.2)

CCI: Charlson comorbidity index.

Conservative treatment was adequate in majority of the patients (77.1%). PD was performed in 39 patients (15.4%). Three (7.7%) of them failed and eventually required emergency surgery. Readmission rate within six weeks after discharge among the patients who received conservative treatment was 28.7% (n = 56). Conservative treatment failed in 17 of them, and these patients underwent surgery.

A total of 32 patients (12.6%) had to undergo emergency surgery, while 26 (10.3%) underwent elective surgery. Developing a complication (mostly abscess and free perforation) and/or presence of a concomitant malignancy were the most common indications for surgery (87.9%). The most preferred surgical procedure was colectomy (with stoma or anastomosis) (94.8%), and three patients underwent DD. Postoperative complications were encountered in 23 (39.7%) patients. Surgical site infection (30.7%) and incisional hernia (21.7%) were the most common early and late complications, respectively. Management and fate of the patients are summarized in Table 2.

Table 2 Management of patients (n = 253).

Item	Value
Percutaneous drainage, n (%)	39 (15.4)
Type of treatment, n (%)
Conservative	195 (77.1)
Surgical	58 (22.9)
Emergency	32 (12.6)
Elective	26 (10.3)
Surgical indication, n (%)
Complication or concomitant malignancy1	51 (87.9)
Recurrent episodes	7 (12.1)
Surgery type, n (%)
DD	3 (5.2)
Hartmann’s procedure	19 (32.8)
Colectomy with anastomosis	36 (62)
Open	20 (34.4)
Laparoscopic	16 (27.6)
Postoperative complication, n (%)	23 (39.7)
Early period	14 (60.9)
SSI	7 (30.7)
Anastomosis leak	3 (13)
Intraabdominal abscess	2 (8.7)
Evisceration	1 (4.3)
Brid ileus	1 (4.3)
Late period	9 (39.1)
Incisional hernia	5 (21.7)
Parastomal hernia	3 (13)
Anastomosis stenosis	1 (4.3)
Colonoscopic finding, n (%)
Sole diverticul/diverticulitis	219 (86.6)
Polyp(s)	23 (9.1)
Malignancy or suspected malignancy	10 (4)
Ulcerative colitis	1 (0.4)
The mean length of hospital stays (day; range)	5.15 ± 2.82 (2-23)
Mortality, n (%)	3 (1.2)

¹Abscess, bleeding, fistula, obstruction, perforation, peritonitis.

DD: Diversion with a proximal colostomy and drainage of the perforated area without resection; SSI: Surgical site infection.

All patients underwent an early or late colonoscopies after the hospitalization. No additional findings were detected except diverticula in majority of the patients (86.6%). Polyp (9.1%), malignancy (4%) and ulcerative colitis (0.4%) were detected in the rest of the patients. The mean length of hospital stay was 5.15 ± 2.82 days. Mortality occurred in three patients who had high CCI score and had undergone emergency surgery due to LCD.

When the clinical features of RCD and LCD were compared, age (mean and distribution), CCI, prior finding, Hinchey stage, number of the episodes and the mean length of hospital stay were found to be statistically significant (P < 0.01; Table 3). Patients with RCD were significantly younger with the mean age of 49.27 ± 15.54 years, and these patients’ mean CCI score were lower than LCD’s. Regarding prior complication, sole persistent pain was significantly more common in RCD (71.1%), while bleeding or fistula did not occur in any of the cases with RCD. On the other hand, perforation, the second most common complication in the series, had significantly higher incidence among LCD (27.9%). Hinchey 1A disease was more common among RCD (66.7%), while more advanced Hinchey stages were encountered more frequently in LCD. All patients with RCD had only one episode of diverticulitis. The mean length of hospital stay was significantly shorter in RCD (3.69 ± 1.16 days). No significant difference was found between the groups in terms of gender, status of immunosuppression, PD, type of the treatment, and performed surgical procedure.

Table 3 Comparison of right colon and left colon diverticula.

	Right colon (n = 45)	Left colon (n = 208)	P value
Gender, n (%)
Female	21 (46.7)	105 (50.5)	0.643
Male	24 (53.3)	103 (49.5)
Age (year; mean)	49.27 ± 15.54	61.83 ± 13.91	0.001
Age group (year), n (%)
≤ 50	23 (51.1)	47 (22.6)	0.001
50-70	17 (37.8)	95 (45.7)
≥ 70	5 (11.1)	66 (31.7)
CCI (mean)	1.02 ± 1.42	2.57 ± 2	0.001
Immunosuppression, n (%)	3 (6.7)	14 (6.7)	0.988
Prior finding, n (%)
Abscess	10 (22.2)	25 (12)	0.006
Bleeding	-	6 (2.9)
Fistula	-	3 (1.4)
Obstruction	1 (2.2)	7 (3.4)
Perforation	1 (2.2)	58 (27.9)
Peritonitis	1 (2.2)	4 (1.9)
Sole persistent abdominal pain	32 (71.1)	105 (50.5)
Hinchey, n (%)
1A	30 (66.7)	96 (46.2)	0.016
1B	11 (24.4)	39 (18.8)
2	2 (4.4)	42 (20.2)
3	2 (4.4)	27 (13)
4	-	4 (1.9)
Number of episodes, n (%)
1	45 (100)	171 (82.2)	0.009
2	-	29 (13.9)
≥ 3	-	8 (3.8)
Percutaneous drainage, n (%)	2 (4.4)	37 (17.8)	0.025
Type of treatment, n (%)
Medical	41 (91.1)	154 (74)	0.041
Surgical	4 (8.9)	54 (26)
Emergency	3 (6.7)	29 (13.9)
Elective	1 (2.2)	25 (12.1)
Performed surgery, n (%)
DD	-	3 (5.6)	0.08
Hartmann’s procedure	-	19 (35.1)
Colectomy with anastomosis
Open	3 (75)	17 (31.5)
Laparoscopic	1 (25)	15 (27.8)
Postoperative complication, n (%)	-	23 (26.1)	0.697
The mean length of hospital stays (day)	3.69 ± 1.16	5.48 ± 2.98	0.001
Mortality, n (%)	-	3 (1.4)	-

CCI: Charlson comorbidity index; DD: Diversion with a proximal colostomy and drainage of the perforated area without resection.

Treatment approaches according to localization

General management of patients is shown in Figure 2, and Table 4 compares conservative treatment and surgery in RCD and LCD. Gender, status of immunosuppression, presence of an accompanying lesion during colonoscopy and the mean length of hospital stay were found to be statistically significant between observation and surgery groups in LCD (P < 0.01). Additionally, at prior complication and Hinchey stage, there were significant differences between observation and surgery groups in both RCD and LCD (P < 0.01). Male gender was significantly more common in patients who underwent surgery for LCD, while female gender was more frequent in LCD patients who underwent conservative treatment. The incidence of immunosuppression, which was 9.3% in LCD patients who underwent surgery, was also significantly higher than LCD patients who underwent observation. However, the status of immunosuppression did not have any statistical significance in RCD, since all three (7.3%) immunosuppressive patients were managed with conservative treatment. Among the RCD patients, the most common prior complication was persistent abdominal pain (78%) in conservative treatment group, and abscess (75%) in surgery group. Persistent abdominal pain (63.6%) was also the most common prior complication in conservative treatment group of LCD, however perforation (48.1%) was the most common in surgery group.

Figure 2 General management of patients.

Table 4 Comparison of patients undergoing observation and surgery.

	Right colon (n = 45)			Left colon (n = 208)
	Observation (n = 41)	Surgery (n = 4)	P value	Observation (n = 154)	Surgery (n = 54)	P value
Gender, n (%)
Female	20 (48.8)	1 (25)	0.363	88 (57.1)	17 (31.5)	0.001
Male	21 (51.2)	3 (75)		66 (42.9)	37 (68.5)
Age (year; mean)	49.32 ± 15.65	48.75 ± 16.58	0.95	61.47 ± 14.09	62.87 ± 13.43	0.52
Age group, n (%)						0.957
≤ 50	21 (51.2)	2 (50)	0.621	35 (22.7)	12 (22.2)
50-70	16 (39)	1 (25)		71 (46.1)	24 (44.4)
≥ 70	4 (9.8)	1 (25)		48 (31.2)	18 (33.4)
CCI (mean)	1.02 ± 1.44	1 ± 1.41	0.97	2.5 ± 1.93	2.75 ± 2.18	0.42
Immunosuppression, n (%)	3 (7.3)	-	0.575	9 (5.8)	5 (9.3)	0.001
Prior finding, n (%)
Abscess	7 (17.1)	3 (75)	0.001	16 (10.4)	9 (16.7)	0.001
Bleeding	-	-		5 (3.2)	1 (1.9)
Fistula	-	-		-	3 (5.6)
Obstruction	1 (2.4)	-		3 (1.9)	4 (7.4)
Perforation	1 (2.4)	-		32 (20.8)	26 (48.1)
Peritonitis	-	1 (25)		-	4 (7.4)
Sole persistent abdominal pain	32 (78)	-		98 (63.6)	7 (13)
Hinchey, n (%)
1A	30 (73.2)	-	0.001	92 (59.7)	4 (7.4)	0.001
1B	10 (24.4)	1 (25)		34 (22.1)	5 (9.3)
2	1 (2.4)	1 (25)		24 (15.6)	18 (33.3)
3	-	2 (50)		4 (2.6)	23 (42.6)
4	-	-		-	4 (7.4)
Number of episodes, n (%)			-
1	41 (100)	4 (100)		141 (91.6)	30 (55.6)	0.389
2	-	-		13 (8.4)	16 (29.6)
≥ 3	-	-		-	8 (14.8)
Percutaneous drainage, n (%)	1 (2.4)	1 (25)	0.037	23 (14.9)	14 (25.9)	0.069
Accompanying lesion on colonoscopy, n (%)	1 (2.4)	1 (25)		21 (13.5)	11 (19.4)
Polyp	1 (2.4)	-	0.005	19 (12.3)	3 (5.6)	0.001
Malignancy	-	1 (25)		1 (0.6)	8 (14.8)
Ulcerative colitis	-	-		1 (0.6)	-
The mean length of hospital stays (day), (range)	3.49 ± 0.84	5.75 ± 2.06	0.11	4.68 ± 1.5	7.74 ± 4.6	0.001
Mortality, n (%)	-	-	-	-	3 (5.6)	-

CCI: Charlson comorbidity index.

DISCUSSION

This study displayed several differences in clinical features between RCD and LCD, and in their managements. Younger age, lower Hinchey stages and significantly higher incidences of conservative treatment in RCD, and higher incidence of surgery in male and immunosuppressive LCD patients were the main endpoints.

Right and left colon diverticula have distinct backgrounds and pathophysiology which also affect their clinical manifestation. Right-sided diverticula are usually congenital, and for this reason, becomes symptomatic in younger ages. On the other hand, left-sided diverticula are acquired, and their prevalence increases by the advancing age. In their studies comparing the clinical features of the patients with right and left-sided diverticulitis, Lee et al[11] and Soh et al[12] reported the mean ages of RCD patients as 41.4 and 45.7, respectively, which were significantly younger than LCD patients. In addition, in the meta-analysis by Hajibandeh et al[13], it was determined that RCD affected younger patients. Left colon diverticulitis has more tendency to perforation than RCD since LCD mainly develops from pseudo-diverticula lacking muscularis propria and serosal layers. This also results in more advanced Hinchey stages in LCD than RCD[11]. All these well-known demographic and clinical data were compatible with our results.

In addition to the previous studies, our study also demonstrated that patients with RCD had lower CCI score, a smaller number of episodes and shorter mean length of hospital stay[11,12].

Management of CD differs according to Hinchey stage (severity of the disease), type of the complications, and underlying comorbid conditions. Conservative treatment with/without PD will be more beneficial in RCD, since they have lower Hinchey stages[13,14]. Zuckerman et al[15] published that 76.6% of RCD patients benefited from conservative treatment. This situation is a little more complicated in LCD. Generally, antibiotics with/without PD are usually adequate in Hinchey 1 and 2 cases, while Hinchey 3 and 4 require surgery[13,16]. PD is an intermediate treatment modality between medical treatment and surgery. This modality provides the opportunity for performing an elective single-stage operation in the conditions which usually require a stoma and further multiple surgical interventions[17]. Current guidelines have recommended PD for the abscesses larger than 3 cm, those that do not display regression with antibiotics, and/or in the presence of patient deterioration[18,19]. In their study of 447 patients with diverticular abscess, Lambrichts et al[20] reported that abscesses larger than 3 cm were more likely to experience treatment failure (26.8%), and abscesses 5 cm or larger were associated with the need for surgery (8.9%). In the retrospective study of Elagili et al[21], selected patients treated with initial antibiotics alone vs PD were compared, and medical treatment and PD were found to fail in 25% and 18% of the patients, respectively.

In our study, the percentage of the patients who were treated conservatively was 91.1% and 74% in RCD and LCD, respectively. This difference was due to Hinchey 1 disease was significantly more common among RCD. Conservative treatment was successful in all RCD patients, while it failed in 13 patients (8.3%) with LCD. PD was performed in two patients (4.4%) with RCD and 37 patients (17.8%) with LCD. Three (7.7%) of them failed and eventually required emergency surgery.

Indications for emergency surgery have been quite clear since early 1900s. Patients with diffuse peritonitis (Hinchey 3 and 4 disease) or those who do not show any improvement under the conservative treatment are the main candidates for emergency surgery[19]. Resection with anastomosis is almost a standard surgical technique in RCD. However, which surgical technique to choose can be confusing in some conditions, since there is not a gold standard treatment for LCD. Many studies in the literature have demonstrated both the advantages and the disadvantages of peritoneal lavage, Hartmann’s procedure, resection with anastomosis and anastomosis with a diverting stoma[16]. Hartmann’s procedure is a traditional and most performed technique in the emergency settings. It is considered as a fast and leery approach especially in patients with comorbidities and poor general condition. Main handicap concerning Hartmann’s procedure is that the stoma reversal cannot be achieved in 30%-40% of the patients[22,23]. Oberkofler et al[24], favoured primary anastomosis with diverting ileostomy over Hartmann’s procedure in patients with perforated diverticulitis based on the facts that stoma reversal rate was higher in ileostomy group and there was no difference in complication and mortality rates. DIVERTI trial in 2017 reported similar outcomes showing that Hartmann’s procedure and primary anastomosis with a diverting stoma had similar morbidity and mortality[25]. In addition, 2019 LADIES trial showed that primary anastomosis for Hinchey 3 and 4 diseases is a safe approach in hemodynamically stable, immunocompetent patients younger than 85 years[20]. Primary anastomosis in Hinchey 3 and 4 diseases has been moderately-strongly recommended in recent ASCRS guidelines (2020), once it was weakly recommended in 2014[19]. The preference of diverting ileostomy, on the other hand, has been left to the surgeon. After all, Hartmann’s procedure is still indispensable especially in high-risk patients[26].

In our series, among the 32 patients undergoing emergency surgery, the rates of Hartmann’s procedure, primary anastomosis and DD were 56.2%, 34.4%, and 9.4%, respectively. It was not possible to compare RCD and LCD in terms of surgical techniques, since only three patients underwent emergency surgery in RCD group. Nevertheless, it was obtained that all patients from RCD group underwent resection and primary anastomosis. More frequent application of Hartmann’s procedure can be explained with relatively high mean CCI score of 2.88 and the fact that they were mostly performed in the past years. Hartmann colostomy reversal could not be achieved in four patients (21.1%) due to the patient preference and high-risk comorbidities.

Readmission rate after conservatively treated CD has been reported between 9.6%-61%[27,28]. El-Sayed et al[29] published that 11.2% of the non-operatively treated diverticulitis patients developed recurrence, and that 55.5% of them did not require further surgical intervention. Same study showed that complicated cases without PD had the highest risk for the readmission. In our study, readmission rate was 28.7% among 195 patients who underwent conservative treatment, and 69.6% of them responded conservative treatment once more.

Patients with CD carry a risk for malignancy[30]. Sharma et al[31] showed that the risk of malignancy was 11% in patients with CD and 0.7% in patients with uncomplicated diverticulitis. Therefore, after the recovery of acute CD episode, routine endoscopic evaluation should be performed to confirm the diagnosis and evaluate additional pathologies if patient has not undergone a recent colonoscopy[19]. In our series, polyp and malignancy/suspected malignancy was detected in 23 (9.1%) and 10 (4%) patients, respectively.

Its retrospective design and the fact that reflecting the outcomes of a single-centre were the main limitations of this study. Data regarding the smoking and/or alcohol consumption is not available. In addition, due to the small sample size of the RCD patients undergoing surgery, an adequate statistical comparison could not be obtained. However, this is the first study from Europe comparing the right and left-sided CD and the second largest (the number of patients) in English-language literature. Additionally, comprising patients from Türkiye who can be genetically defined as Eurasian and from a centre which has patients from both rural and urban areas makes this study unique.

CONCLUSION

In conclusion, although conservative treatment is adequate in most RCD, there is still no standard treatment management in LCD, since the severity and course of the disease differs among individuals. This situation also affects the need for elective surgery. While elective surgery is required less often in RCD due to lower rates of recurrence, complications and accompanying malignancy; LCD is more prone to elective surgery due to severe clinical symptoms, and high rates of recurrence and readmission. Thus, stoma requirement is also reduced, and better postoperative results are obtained with less invasive methods (laparoscopic or robotic).

ACKNOWLEDGEMENTS

Izmir Katip Celebi University Faculty of Medicine, Izmir Ataturk Training and Research Hospital, kindly supported this work.