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JVS-887; No. of Pages 9 ARTICLE IN PRESS

Journal of Visceral Surgery (2018) xxx, xxx—xxx

Available online at

ScienceDirect
www.sciencedirect.com

ORIGINAL ARTICLE

Long-term outcome and management of

right colonic diverticulitis in western
countries: Multicentric Retrospective Study
L. Courtot a, V. Bridoux b, Z. Lakkis c, G. Piessen d,
G. Manceau e, A. Mulliri f,g, G. Meurette h, A. Bouayed i,
A. Vénara j, B. Blanc k, N. Tabchouri a, E. Salamé a,
M. Ouaïssi a,∗

a
Department of Digestive, Oncological, Endocrine, and Hepatic Surgery, and Hepatic
Transplantation, Trousseau Hospital, 37000 Tours, France
b
Department of Digestive Surgery, Rouen University Hospital, 76000 Rouen, France
c
Department of Digestive Surgery, Besançon University Hospital, 25000 Besançon, France
d
Department of digestive and oncological surgery, University Hospital Claude Huriez-Regional
University Hospital Center, place de Verdun, 59037, Lille cedex, France
e
Department of Digestive and Hepato-Pancreato-Biliary Surgery, Medecine Sorbonne
University, Pitié-Salpêtrière University Hospital, Paris VI University Institute of Cancerology,
Assistance publique—Hôpitaux de Paris, 75651 Paris, France
f
Department of digestive surgery, university hospital of Caen, avenue de la Côte-de-Nacre,
14033 Caen cedex, France
g
UNICAEN, Inserm UMR1086, centre François-Baclesse, Normandie université, CHU de Caen,
3, avenue du Général-Harris, 14045 Caen cedex, France
h
Colorectal Unit, Institut des Maladies de l’Appareil Digestif, University Hospital of Nantes,
44000 Nantes, France
i
Department of Digestive surgery, Salon Hospital, 13340 Salon-de-Provence, France
j
Department of Digestive Surgery, Angers University Hospital, 49000 Angers, France
k
Department of Digestive surgery, Dax hospital, 40100 Dax, France

KEYWORDS Summary
Uncomplicated right Aim of the study: Right colonic Diverticulitis (RD) is rare in Europe; few studies have focused
diverticulitis; on it and its management is not standardised. The aim of this study was to analyse the clinical
Complicated right presentation (complicated, uncomplicated), acute phase management and long-term outcome
diverticulitis; of RD in western countries.
Conservative Patients and methods: From 2003 to 2017, 93 consecutive patients who presented with RD were
treatment; retrospectively included at 11 French Hospital Centres.

Abbreviations: RD, Right Diverticulitis; LD, Left Diverticulitis; CRD, Complicated Right Diverticulitis; URD, Uncomplicated Right Divertic-
ulitis; CT, Computed Tomography; BMI, Body Mass Index; ASA, American Society of Anesthesiologists; NSAID, Non-Steroidal Anti-Inflammatory
Drug; CRP, C-Reactive Protein.
∗ Corresponding author.

E-mail address: [email protected] (M. Ouaïssi).

https://doi.org/10.1016/j.jviscsurg.2019.01.005
1878-7886/© 2019 Published by Elsevier Masson SAS.

Please cite this article in press as: Courtot L, et al. Long-term outcome and management of right
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Results The study population consisted of two groups: Uncomplicated Right Diverticulitis
Surgery; (URD) group (63.5%, (n = 59)) and Complicated Right Diverticulitis (CRD) group (36.5%, [n = 34]).
Recurrence 84.7% (n = 50/59) of URD were treated conservatively. 41.2% (n = 14/34) of patients with CRD
had emergency surgery (mostly laparotomy) for Hinchey III peritonitis, clinical intolerance or
hemodynamic instability. Altogether 5.2% (n = 2/34) patients with CRD had surgery after a cool-
ing off period (initially abscess). The overall rate of severe postoperative complications was
low (8%). Recurrence rate was low and comparable in both groups: 6.8% (n = 4/59) for URD and
8.8% (n = 3/34) for CRD, all recurrences occurred in the same locations with an uncomplicated
form, 42.9% (n = 3/7) of them had elective laparoscopic surgery and the rest were conservatively
treated. Median follow up was 33.2 months.
Conclusion: Conservative treatment can be proposed safely and efficiently for URD and for
selected patients with CRD. Surgery should be reserved for unstable patients or patients with
severe forms of complicated diverticulitis in emergency.
© 2019 Published by Elsevier Masson SAS.

Introduction Rouen, Besançon, Paris La Pitié-Salpétrière, Nantes, Angers,

Caen, federal Hospital of Dax and Salon-de-Provence). All
In western countries, diverticulitis mostly affects the left included patients underwent abdominal computed tomog-
colon and the incidence of right-sided diverticulitis is esti- raphy (CT) scan for acute abdominal pain.
mated < 4% [1—4], unlike in Asian populations, where right
diverticulitis represents 55—70% of diverticular disease [5].
In Asian countries, the natural history of uncomplicated and
RD diagnosis (complicated and uncomplicated)
complicated left diverticulitis (LD) appears to be different
RD was defined as abdominal pain due to an inflam-
than in western countries, with a rare incidence of LD and
mation of a diverticula located between the ileo-caecal
a frequently complicated presentation [6].
valve and the left transverse colon. RD was considered
Thanks to older Caucasian studies dealing with divertic-
uncomplicated when CT scan showed bowel wall thicken-
ulitis (mainly left colon), it is known that the recurrence rate
ing, sub-mucosal thickening with diffuse low enhancement,
is low and is estimated at 19% (5% after an initial uncompli-
peri-colic fat stranding, along with evidence of peri-colic
cated episode and 23% after an initial complicated episode).
phlegmon [20].
Recurrence is rarely associated with complications [7] and
Abdominopelvic CT findings were categorized by using
the risk of peritonitis even decreases with recurrences
the modified Hinchey classification, with patients classified
[7,8]. Among the recurrent forms, 18% require emergency
as having stages Ib, II, III, and IV diverticulitis, as well as fis-
surgery, 39% elective surgery and 43% have a conserva-
tula, obstruction or perforated-blocked diverticulitis being
tive treatment that is sufficient. Abscessed diverticulitis
defined as having CRD [21].
has a high recurrence rate (61%) after initial conservative
The diagnosis of diverticulitis was made based on either
treatment; it more frequently develops local complications
intraoperative findings or CT scans.
(fistula, chronic abscess, stenosis 63%) and requires emer-
Disease recurrence was diagnosed when patients pre-
gency surgery in 26% of cases [9].
sented with recurrent symptoms associated with the same
Right diverticulitis (RD) management in Asian coun-
CT scan signs listed above [20].
tries is similar to LD management in western countries
[10—14]. The Asian management usually recommended for
Uncomplicated Right Diverticulitis (URD) is conservative Clinical features
treatment in the presence of an uncomplicated and well-
documented episode, as recurrence rates are low; delayed The following patient demographic characteristics were col-
right colectomy is necessary in very rare cases [10,15—19]. lected: age, gender, Body Mass Index (BMI) score, American
Complicated Right Diverticulitis (CRD) is rare and the per- Society of Anesthesiologists (ASA) score and comorbidities
centage of right colectomies is unknown. (smoking, diabetes mellitus, elevated blood pressure, car-
To our knowledge, no western study has yet analysed the dio vascular disease, cortico-steroids, immunosuppressor,
natural history, management modalities and long-term out- Non-Steroidal Anti-Inflammatory Drug (NSAID) taking and
come of CRD and URD. The aim of this study was to analyse previous appendectomy or diverticulectomy). The following
clinical presentation (complicated, uncomplicated), mana- clinical data upon admission were also collected for each
gement in the acute phase and the long-term outcome of RD patient: body temperature above 38 ◦ C, abdominal pain over
in western countries. 7 days, white blood cell count and C-reactive protein (CRP).

Treatment characteristics
Materials and methods
Based on patient evaluation and RD severity, management
Patients consisted of conservative treatment only (antibiotics with
or without percutaneous drainage), emergent surgery and
From January 2003 to December 2017, 93 consecutive elective surgery following conservative treatment. Based on
patients who presented with RD were retrospectively each management modality, oral diet type, antibiotic dura-
included at 11 French Hospital Centres (CHU in Tours, Lille, tion, and overall in-hospital stay were collected for each

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outcome and management of right colonic diverticulitis in western countries 3

patient. Recurrent RD episodes were recorded similarly to was 24.3 kg/m2 (16—39). The male/female gender ratio was
first RD episodes. 0.63 for the whole series. Eighty seven percent (n = 81) of
patients were considered at low risk (ASA 1 and 2). There
Intraoperative course were more women in the CRD group than in the URD group
(76.5% (n = 26) vs. 55.9% (n = 33); P = 0.0729). There were
The following intraoperative variables were collected for fewer smokers in the CRD group than in the URD group, with-
all patients: time interval between RD episode and surgical out this difference being significant (14.7% [n = 5] vs. 33.9%
procedure, surgical indication (failed conservative treat- [n = 20]; P = 0.0539). Steroid and immunosuppressor, as well
ment and elective surgery, emergent surgery) procedure as NSAID consumption were higher in the CRD group than
performed (appendicectomy alone, appendicectomy and in the URD group, without this difference being significant
diverticulectomy, right colectomy with diversion or primary (5.9% (n = 2) vs. 3.4% (n = 2); P = 0.6214 and 11.8% (n = 4) vs.
anastomosis and ileocolectomy with diversion or primary 6.8% (n = 4); P = 0.4576, respectively). There was no signifi-
anastomosis), surgical approach (conversion was defined as cant association between severity of the acute diverticulitis
the completion of the right colectomy procedure through and site or number of diverticula. Body temperature ≥ 38 ◦ C,
either an enlarged incision or an abdominal incision mea- white blood cell count and CRP did not differ between the
suring ≥ 6 cm) and operative time. two groups. According to the Hinchey classification, 70.6%
(n = 24) of patients presented with Hinchey I diverticulitis,
Postoperative outcomes 17.6% (n = 6) with Hinchey II, and 11.8% (n = 4) with Hinchey
III. No patients presented with Hinchey IV diverticulitis.
Postoperative morbidity and mortality were defined as
events occurring during hospital stay or within 30 and Treatment modality
90 postoperative days. Postoperative complications were
classified according to Dindo-Clavien, their management Fewer patients were treated conservatively in the CRD group
(medical, radiological, surgical) and their severity [22]. than in the URD group (50.0% (n = 17) vs. 84.7% (n = 50);
Postoperative complications included ileus, intra-abdominal P = 0.0114) and more patients were scheduled for emergency
abscess, wound infection and anastomotic leakage. surgery in the CRD group (41.2% [n = 14] vs. 8.5% [n = 5];
P = 0.0114) (Table 2 and Fig. 1). Nevertheless, the number
Postoperative follow up of patients who underwent elective surgery after initial con-
servative treatment was similar between both groups (5.9%
Patients were systematically clinically examined at 4 to 6 [n = 2] vs. 6.8% [n = 4] respectively; P = 1.0000). Antibiotics
weeks after discharge from hospital. The length of hospi- and diet durations did not vary according to RD episode
talisation was measured from the time of surgery to the severity (12.0 vs. 11.6 days P = 0.3688 and 1.8 vs. 1.3 days
date of discharge from hospital. Follow-up information was P = 0.2283, respectively). Length of hospital stay was longer
obtained from medical records, direct consultation with in the CRD group (9.9 vs. 5.2 days; P = 0.0430).
patients and/or telephone interview. At the end of the
follow up, the statuse of all patients were assessed, i.e. Intraoperative course
mortality, recurrence and lost to follow-up. The endpoint of
data collection was December 2017. Patient follow up was Overall, 26.9% (n = 25) of patients underwent surgical treat-
carried out from the time of surgery to this endpoint, until ment (19 in an emergent setting and 6 in an elective
death if occurring prior to this date, or until the date of last setting) (Table 3). Median time to emergent surgery was
contact. Loss to follow-up was defined as a follow up of less 0 days. Regarding the elective setting, median time to
than 3 months, in the absence of death. Median follow up surgery was shorter in the CRD group (106 vs. 195 days
was 33 months. P = 0.5923). In the URD group, 5 patients underwent emer-
gent surgical treatment: 4 misdiagnoses and 1 failure of
Statistical Analysis conservative treatment. The diagnosis of appendicitis was
suspected in the presence of right abdominal pain, bio-
Statistical analyses were performed using IBM SPSS Statis- logical inflammatory syndrome and scan images suggestive
tics version 20 (IBM SPSS Inc., Chicago, IL, USA). Continuous of acute appendicitis. In retrospect, after surgical explo-
variables are expressed as their means ± standard devia- ration, it was contact appendicitis with caecal diverticulitis.
tions, or as their medians and ranges (min, max). Categorical In the CRD group 14 (41.2%) patients underwent emergency
variables are reported as numbers and percentages. Mean surgery: 2 misdiagnoses, 9 acute abdomens and 3 failures of
values between the two groups were compared using Stu- medical treatment. In the URD group, procedures performed
dent’s t-test or the Mann—Whitney U test, when necessary. for emergency surgery were as follows: 2 appendicectomies
Comparisons between percentages were made using the ␹2 (contact appendicitis), 1 diverticulectomy alone and 2 ileo-
test or Fisher’s exact test, as appropriate, for the qualitative colectomies with primary anastomosis. In the CRD group,
variables. Statistical significance was defined as a P-value procedures performed for emergency surgery were as fol-
of < 0.05. lows: 8 right colectomies and 4 ileocolectomies with primary
anastomosis and 2 right colectomies with primary diversion
(both were Hinchey III).
Results In the URD group, all surgeries (n = 9) were started with
laparoscopy and only one was converted (emergency surgery
Clinical and radiological features for suspected appendicular peritonitis, CRP 264 and the
procedure performed was an ileocolectomy and cholecys-
The study population thus consisted of two groups: URD tectomy). For emergency surgery in the CRD group, just one
group (63.5%, [n = 59]) and CRD group (36.5%, [n = 34]) of the 14 was full laparoscopic (right colectomy for CRD
(Table 1). Median age was 54 years (23—87) and median BMI perforated-blocked with acute abdomen).

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Table 1 Clinical and radiological features.

Variables Uncomplicated Right colonic Complicated Right All Right colonic P value
Diverticulitis (URD) colonic Diverticulitis Diverticulitis
(n = 59) (CRD) (n = 34) (n = 93)
Age
Median (range) 54 (26—87) 55 (23—85) 54 (23—87) 0.7212
Gender
Female (%) 33 (55.9%) 26 (76.5%) 59 (63.4%) 0.0729
Male (%) 26 (44.1%) 8 (23.5%) 34 (36.6%)
ASA
1 37 (62.7%) 17 (50%) 54 (58.1%) 0.4193
2 16 (27.1%) 11 (32.4%) 27 (29%)
3 6 (10.2%) 6 (17.6%) 12 (12.9%)
4 0 0 0
BMI
Median (range) 24.9 (19—39) 23.4 (16—34) 24.3 (16—39) 0.2928
Comorbidity
Smoking (%) 20 (33.9%) 5 (14.7%) 25 (26.9%) 0.0539
Cardiovascular (%) 5 (8.5%) 5 (14.7%) 10 (10.8%) 0.4887
Diabetes (%) 4 (6.8%) 5 (14.7%) 9 (9.7%) 0.2793
Arterial Hypertension 14 (23.7%) 13 (38.2%) 27 (29%) 0.1596
(%)
Steroids or 2 (3.4%) 2 (5.9%) 4 (4.3%) 0.6214
immunosuppressants (%)
NSAIDs (%) 4 (6.8%) 4 (11.8%) 8 (8.6%) 0.4576
Clinical features
Body temperature > 38◦ 23 (38.9%) 13 (38.2%) 36 (38.7%) 0.8256
(%)
Abdominal pain over 7 5 (8.4%) 5 (14.7%) 10 (10.8%) 0.4887
days (%)
Biological data
WBC count (10.3/mm3 ) 13.4 (4—27) 12.4 (3—17) 13 (3—27) 0.0731
CRP (mg/L) 114.3 (3—347) 129.8 (2—354) 119.9 (2—354) 0.8285
Pneumoperitoneum (%) 0 15 (44.1%) 15 (17%) < 0.0001
Site of diverticulitis
Right only (%) 31 (50.8%) 13 (35.2%) 44 (47.3%) 0.2017
Right and left (%) 28 (45.7%) 21 (58.8%) 49 (52.7%) 0.2027
Number of diverticula
Solitary (%) 15 (23.7%) 12 (32.3%) 27 (29.0%) 0.3487
Multiple (%) 44 (71.2%) 22 (58.8%) 66 (71.0%) 0.3487
Hinchey
I (%) 0 24 (70.6%) 24 (25.8%)
II (%) 0 6 (17.6%) 6 (6.5%)
III (%) 0 4 (11.8%) 4 (4.3%)
IV (%) 0 0 0
ASA: American Society of Anesthesiologists; BMI: body mass index; NSAID: non-steroidal anti-inflammatory drug; WBC: white blood cells;
CRP: C-reactive proein.

The 2 patients who underwent delayed surgery after an emergency surgery was longer in the CRD group than in the
episode of CRD were abscessed forms and had no recur- URD group (120 vs. 75 mins P = 0.1505).
rence or persistent symptoms. The 4 indications for elective
surgery in the URD group were as follows: 1 patient had 4 Postoperative features
recurrent episodes, 1 patient had 1 recurrent episode, 1 had
2 recurrent episodes with persistent symptoms and the last Mortality was zero for the whole series. According to the
had chronic symptoms. Clavien-Dindo classification, the postoperative complication
All elective procedures were right colectomies and were (stage I and II) rate in the URD group was no different after
laparoscopic. In the URD group, operative time was shorter emergency surgery than after elective surgery (60% [n = 3/5]
for emergency surgery than for elective surgery (median vs. 50% [n = 2/4]; P = 0.5238 respectively). The postopera-
times 75 vs. 190 minutes P = 0.7078). Operative time for tive complication (stage I and II) rate following emergency

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outcome and management of right colonic diverticulitis in western countries 5

Table 2 Type of treatment and recurrence characteristics.

Non Complicated Complicated Right All Right Colonic P value
Right Colonic Colonic Diverticulitis Diverticulitis
Diverticulitis (n = 59) (n = 34) (n = 93)
Type of treatment
Conservative treatment 50 (84.7%) 17 (50.0%) 67 (72.0%) 0.0114
only (%)
Emergency surgery (%) 5 (8.5%) 14 (41.2%) 19 (20.4%)
Elective surgery (%) 4 (6.8%) 2 (5.9%) 6 (6.5%) 1.0000
Radiological drainage (%) 0 1 (2.9%) 1 (1.1%) 1.0000
Antibiotics duration, days 11.6 (0—21) 12 (0—42) 12 (0—42) 0.2283
(range)
Median diet duration, days 1.3 (0—7) 1.8 (0—5) 1 (0—7) 0.2858
(range)
Median length of stay, days 5.2 (1—19) 9.9 (2—34) 5 (1—34) 0.0430
(range)
Colonoscopy (%) 26 (44.1%) 12 (35.3%) 38 (40.9%) 0.1233
Recurrence characteristics
Number of recurrences (%) 4 (6.8%) 3 (8.8%) 7 (7.5%) 0.7035
Median time to recurrence, 27.9 (5.1—70.6) 13.3 (1.4—30.6) 20,6 (1.4—70.6) 0.4832
months (range)
Same localisation of 4/4 (100%) 3/3 (100%) 7/7 (100%) 1.0000
recurrence (%)
Uncomplicated 4/4 (100%) 3/3 (100%) 7/7 (100%) 1.0000
presentation (%)
Treatment of the recurrence
Conservative treatment 1/4 (25%) 3/3 (100%) 5/7 (71,4%) 0.4286
only (%)
Emergency surgery (%) 0 0 0 1.0000
Elective surgery (%) 3/4 (75%) 0 2/7 (28.6%) 0.4286
Radiological drainage (%) 0 0 0 1.0000
Number of Recurences ≥ 2 2 (3.4%) 0 2 (2.1%) 0.5311
Follow up (months) 35.9 (0—127) 27 (1—121) 33.2 (0—127) 0.6241

surgery was higher in the CRD group than in the URD group at the same location and there were all uncomplicated.
(71.4% n = 10/14 vs. 60% n = 3/5 P = 1.000). For the entire Time to recurrence was shorter after CRD than after URD
series, the rate of serious postoperative complication (grade (median 8 vs. 7.8 months P = 0.4476). All recurrences of CRD
III and IV) was low, 8% n = 2/25. (n = 3/7) were treated conservatively with medical treat-
Of the 5 patients with an URD undergoing emergency ment only, whereas 50% (n = 2/4) of URD recurrences had
surgery, 3 had a postoperative complication: 1 postoperative elective surgery.
ileus and 2 wound abscess. Among the 4 patients operated
after a cooling off period following an episode of URD, 3
had a postoperative complication: 1 postoperative ileus, 1 a
Discussion
grade II complication related to a perianastomotic obstruc-
tion and 1 grade III with haemoperitoneum requiring surgical This study has reported the first European series to include
reintervention. large numbers of patients focusing on right colonic diver-
Among the 14 patients in the CRD group who under- ticulitis. Ninety-three patients were reviewed, and their
went emergency surgery, we identified 11 postoperative clinical presentation, management and recurrence were
complications: 6 grade I complications (including 3 postop- analysed. The rate of complicated episode occurrence was
erative ileus and 3 wound abscess), 4 grade II complications 36.6% (n = 34/93). Eighty four percent (n = 50/59) of patients
(including 1 acute pancreatitis, 1 acute respiratory distress with unncomplicated forms were treated conservatively
syndrome and 2 central line infections) and 1 grade IV whereas 6.8% (n = 4/59) of them had elective surgery. In con-
complication (acute renal failure with dialysis required). Of trast concerning patients who presented with complicated
the 2 patients with CRD who had elective surgery, 1 had a diverticulitis, emergency surgery was realized in 41.2%
wound abscess and the other had a medically treated anas- (n = 14/34) whereas 5.9% (n = 2/34) of them had elective
tomotic fistula. surgery. Recurrence rate was low and comparable in both
groups (6.8% and 8.8%, respectively) and all recurrences
Recurrence characteristics and treatment occurred at the same locations and in an uncomplicated
form. The rate of severe postoperative complications was
Median follow up was 33.2 months for the whole series low (8%).
(Table 2). Recurrence rate was 7.5% for the whole series, This western study sought to analyse the natural history
8.8% (n = 3/34) in the CRD group vs. 6.8% (n = 4/59) in the of RD with a large number of patients admitted into spe-
URD group (P = 0.7035). All recurrences (n = 7/7) occurred cialised colorectal centres considering the incidence of this

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Figure 1. Flowchart, natural history.

pathology in Caucasian patients. In the Asian population, RD Among URD cases, 91.5% (n = 54/59) were medically
has a reported incidence of up to 55% compared to 12.1% and treated in the acute phase. Only 6.8% (n = 4) of them
32.6% for left and bilateral diverticulitis, respectively [23]. recurred, all in uncomplicated form. Regarding CRD, 55%
Because Few European studies have analysed RCD, it was (n = 19/34) were treated conservatively in the acute phase
legitimate to question the natural history of this pathology in and only 8.8% (n = 3/34) recurred in an uncomplicated form
the Caucasian population, especially since the management and had subsequent conservative treatment. A conserva-
of right diverticulitis is not standardised in our countries. tive strategy seems reasonable and safe for URD and in
Failing a consensus on management, each centre could have some selected patients with CRD (Hinchey Ib, II, perforated-
different practices with a possible centre effect. Also, the blocked). This is consistent with previous studies that have
decision to perform emergency or elective surgery, and the highlighted the value of initial conservative treatment for
exact type of proposed surgery were all dependent on the these patients [5,12,15,24]. Park HC even offered oral
primary surgeon. antibiotic therapy without associated diet (compared to Iv
In terms of anthropometric results, our study found a antibiotic therapy and diet) for URD (based on the fact that
median age of 54 years with a male sex ratio of 0.57; recurrence rate was comparable) [12].
these results differ from the reported Asian series, where A total of 8.5% (n = 5/59) of patients underwent emer-
patients were mainly male (58.1%) and younger (43.4 ± 13.7 gent surgical management for URD, of which 4 had suspected
years) [5,6,20]. This is in accordance with reported studies appendicitis and one had a failed medical treatment.
that stated that there is an ethnic and genetic compo- Several Asian studies have reported similar results, with
nent, explaining the higher prevalence of RCD in the Asian patients undergoing surgery for suspected appendicitis. This
population, which may therefore explain the differences in was explained by the absence of systematic initial CT scan
population characteristics that have been found [16]. Most and the fact that appendicitis is the most frequent clini-
patients did not present with many comorbidities (79% of cal diagnosis for right iliac fossa pain associated with mild
patients were classified ASA I or II), which is in accordance inflammatory syndrome [23,25]. In our study, all patients
with recently reported series [6]. Surprisingly, no association had initial CT scans, but the diagnosis of appendicitis was
was found between the use of immunosuppressive drugs or suspected when confronted with an inflammatory aspect of
NSAIDs and the occurrence of CRD. the appendix. Among these 4 patients with suspected appen-
On CT examination, diverticula was generally not very dicitis, only 2 had an appendicectomy (which was considered
numerous but not unique, while Park described small num- ‘‘appendicitis of contiguity’’). The value of appendicectomy
bers of diverticula in most cases and even frequently in these situations is debatable [26,27].
isolated [12]. Concerning the emergency surgical management of CRD,
A total of 36.6% (n = 34) of patients had complicated surgery was indicated in case of Hinchey peritonitis greater
diverticulitis, which seems greater than in the pre-existing than III, poor clinical tolerance, haemodynamic instability
literature where the rate varied between 3.3 and 9.5% or failure of primary medical treatment. In 2001, Chiu had
[18,24]. already proposed emergency colectomy for grade III and

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Table 3 Operative features.

Non Complicated Right P value Complicated Right P value All Right Colonic P value
Colonic Diverticulitis Colonic Diverticulitis Diverticulitis
(n = 9) (n = 16) (n = 25)
Emergency surgery Elective surgery Emergency surgery Elective surgery
(n = 5) (n = 4) (n = 14) (n = 2)
Time to surgery, days 0 (0—2) 195 (90—300) 0 (0—23) 106 (105—107) 0 (0—300)
(range)
Indication surgery
Suspected 4/5 (80%) 0 2/14 (14.3%) 0 6 (24%)
appendicitis (%)
Acute abdomen (%) 0 0 9/14 (64.3%) 0 9 (36%)

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Failure of 1/5 (20%) 0 3/14 (21.4%) 0 4 (16%)
conservative
treatment (%)
Elective surgery (%) 0 4/4 (100%) 0 2/2 (100%) 6 (24%)
Procedure performed
Appendicectomy 2/5 (40%) 0 0 0 2 (8%)
alone (%)
Appendicectomy and 0 0 0 0 0
diverticulectomy (%)
Diverticulectomy 1/5 (20%) 0 0 0 1(4%)
alone (%)
Right colectomy 0 4/4 (100%) 8/14 (57.1%) 2/2 (100%) 14 (56%)
primary
anastomosis(%)
Right colectomy with 0 0 2/14 (14.3%) 0 2 (8%)
diversion (%)
Ileocolectomy 2/5 (40%) 0 4/14 (28.6%) 0 6 (24%)
primary anastomosis
(%)
Ileocolectomy 0 0 0 0 0
diversion (%)
Type of surgery
Open surgery (%) 0 0 9/14 (64.3%) 0 9 (36%)
Laparoscopic surgery 4/5 (80%) 4/4 (100%) 1/14 (7.1%) 2/2 (100%) 11(44%)
(%)
Conversion (%) 1/5 (20%) 0 4/14 (28.6%) 0 5 (20%)
Operative time, min, 75 (60—160) 190 (170—210) 120 (50—315) 137.5 (125—150) 123 (50—315)
(range)

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8 L. Courtot et al.

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Please cite this article in press as: Courtot L, et al. Long-term outcome and management of right
colonic diverticulitis in western countries: Multicentric Retrospective Study. Journal of Visceral Surgery (2018),
https://doi.org/10.1016/j.jviscsurg.2019.01.005
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outcome and management of right colonic diverticulitis in western countries 9

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Please cite this article in press as: Courtot L, et al. Long-term outcome and management of right
colonic diverticulitis in western countries: Multicentric Retrospective Study. Journal of Visceral Surgery (2018),
https://doi.org/10.1016/j.jviscsurg.2019.01.005