The outcomes of right-sided and left-sided colonic diverticulitis following non-operative management: a systematic review and meta-analysis

Sih-Shiang Huang, Chih-Wei Sung, Hsiu-Po Wang, Wan-Ching Lien, Sih-Shiang Huang, Chih-Wei Sung, Hsiu-Po Wang, Wan-Ching Lien

Abstract

Background: There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was conducted to evaluate the recurrence/treatment failure in right-sided and left-sided CD.

Methods: A systematic review was conducted following PRISMA guidelines. MEDLINE, Embase, and Cochrane Library from inception to Dec 2021 were searched. The study characteristics, recurrence/treatment failure, and risk factors for recurrence/treatment failure were extracted. Proportional meta-analyses were performed to calculate the pooled recurrent/treatment failure rate of right-sided and left-sided CD using the random effect model. Logistic regression was applied for the factors associated with the recurrence/treatment failure.

Results: Thirty-eight studies with 10,129 patients were included, and only two studies comprised both sides of CD. None of the studies had a high risk of bias although significant heterogeneity existed. The pooled recurrence rate was 10% (95% CI 8-13%, I2 = 86%, p < 0.01) in right-sided and 20% (95% CI 16-24%, I2 = 92%, p < 0.01) in left-sided CD. For the uncomplicated CD, the pooled recurrence rate was 9% (95% CI 6-13%, I2 = 77%, p < 0.01) in right-sided and 15% (95% CI 8-27%, I2 = 97%, p < 0.01) in the left-sided. Age and gender were not associated with the recurrence of both sides. The treatment failure rate was 5% (95% CI 2-10%, I2 = 84%, p < 0.01) in right-sided and 4% (95% CI 2-7%, I2 = 80%, p < 0.01) in left-sided CD. The risk factors for recurrence and treatment failure were limited.

Conclusion: Non-operative management is effective with low rates of recurrence and treatment failure for both right-sided and left-sided CD although left-sided exhibits a higher recurrence. The recurrence rates did not differ between patients receiving antibiotics or not in uncomplicated CD. Age and sex were not associated with the recurrence although other risk factors were dispersing. Further risk factors for recurrence and treatment failure would be investigated for precise clinical decision-making and individualized strategy.

Keywords: Colonic diverticulitis; Left-sided; Non-operative management; Recurrence; Right-sided; Treatment failure.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Evidence search and selection
Fig. 2
Fig. 2
The risk of bias using the revised Cochrane tool for assessing the risk of bias in randomized trials (RoB 2 tool). A Right-sided colonic diverticulitis. B Left-sided colonic diverticulitis
Fig. 3
Fig. 3
The risk of bias using the Newcastle–Ottawa Scale (NOS) for quality assessment of nonrandomized studies. A Right-sided colonic diverticulitis. B Left-sided colonic diverticulitis
Fig. 4
Fig. 4
The forest plot of right-sided diverticulitis. A Recurrence. B Recurrence of uncomplicated diverticulitis. C Treatment failure
Fig. 5
Fig. 5
The forest plot of left-sided diverticulitis. A Recurrence. B Recurrence of uncomplicated diverticulitis. C Treatment failure

References

    1. Meltzer AC, Pines JM, Richards LM, Mullins P, Mazer-Amirshahi M. US emergency department visits for adults with abdominal and pelvic pain (2007–13): trends in demographics, resource utilization and medication usage. Am J Emerg Med. 2017;35(12):1966–1969. doi: 10.1016/j.ajem.2017.06.019.
    1. Kang JY, Hoare J, Tinto A, Subramanian S, Ellis C, Majeed A, et al. Diverticular disease of the colon–on the rise: a study of hospital admissions in England between 1989/1990 and 1999/2000. Aliment Pharmacol Ther. 2003;17(9):1189–1195. doi: 10.1046/j.1365-2036.2003.01551.x.
    1. Etzioni DA, Mack TM, Beart RW, Kaiser AM. Diverticulitis in the United States: 1998–2005: changing patterns of disease and treatment. Ann Surg. 2009;249(2):210–217. doi: 10.1097/SLA.0b013e3181952888.
    1. Theodoropoulos D. Current options for the emergency management of diverticular disease and options to reduce the need for colostomy. Clin Colon Rectal Surg. 2018;31(4):229–235. doi: 10.1055/s-0037-1607961.
    1. Hupfeld L, Burcharth J, Pommergaard H-C, Rosenberg J. Risk factors for recurrence after acute colonic diverticulitis: a systematic review. Int J Colorectal Dis. 2017;32(5):611–622. doi: 10.1007/s00384-017-2766-z.
    1. Ho VP, Nash GM, Milsom JW, Lee SW. Identification of diverticulitis patients at high risk for recurrence and poor outcomes. J Trauma Acute Care Surg. 2015;78(1):112–119. doi: 10.1097/TA.0000000000000466.
    1. Tan K-K, Wong J, Yan Z, Chong C-S, Liu JZ, Sim R. Colonic diverticulitis in young Asians: a predominantly mild and right-sided disease. ANZ J Surg. 2014;84(3):181–184. doi: 10.1111/ans.12273.
    1. Kim Y-C, Chung J-W, Baek J-H, Lee W-S, Kim D, Park Y-H, et al. Risk factors for recurrence of right colonic diverticulitis. Dig Surg. 2019;36(6):509–513. doi: 10.1159/000494297.
    1. Park H-C, Kim BS, Lee K, Kim MJ, Lee BH. Risk factors for recurrence of right colonic uncomplicated diverticulitis after first attack. Int J Colorectal Dis. 2014;29(10):1217–1222. doi: 10.1007/s00384-014-1941-8.
    1. Hajibandeh S, Hajibandeh S, Smart NJ, Maw A. Meta-analysis of the demographic and prognostic significance of right-sided versus left-sided acute diverticulitis. Colorectal Dis. 2020;22(12):1908–1923. doi: 10.1111/codi.15328.
    1. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71.
    1. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. doi: 10.1136/bmj.l4898.
    1. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–605. doi: 10.1007/s10654-010-9491-z.
    1. DerSimonian R, Kacker R. Random-effects model for meta-analysis of clinical trials: an update. Contemp Clin Trials. 2007;28(2):105–114. doi: 10.1016/j.cct.2006.04.004.
    1. Jackson D, Law M, Rücker G, Schwarzer G. The Hartung-Knapp modification for random-effects meta-analysis: a useful refinement but are there any residual concerns? Stat Med. 2017;36(25):3923–3934. doi: 10.1002/sim.7411.
    1. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–1558. doi: 10.1002/sim.1186.
    1. Mizuki A, Tatemichi M, Nakazawa A, Tsukada N, Nagata H, Kanai T. Changes in the clinical features and long-term outcomes of colonic diverticulitis in japanese patients. Intern Med. 2017;56(22):2971–2977. doi: 10.2169/internalmedicine.7710-16.
    1. Lee KY, Lee J, Park YY, Kim Y, Oh ST. Difference in clinical features between right- and left-sided acute colonic diverticulitis. Sci Rep. 2020;10(1):3754. doi: 10.1038/s41598-020-60397-5.
    1. Park YY, Nam S, Han JH, Lee J, Cheong C. Predictive factors for conservative treatment failure of right colonic diverticulitis. Ann Surg Treat Res. 2021;100(6):347–355. doi: 10.4174/astr.2021.100.6.347.
    1. Park SM, Kwon TS, Kim DJ, Lee YS, Cheung DY, Oh ST, et al. Prediction and management of recurrent right colon diverticulitis. Int J Colorectal Dis. 2014;29(11):1355–1360. doi: 10.1007/s00384-014-1938-3.
    1. Chen Z, Zhang B, Wu D, Jin Y. Characteristics of predominantly right-sided colonic diverticulitis without need for colectomy. BMC Surg. 2020;20(1):202. doi: 10.1186/s12893-020-00863-z.
    1. Moon HJ, Park JK, Lee JI, Lee JH, Shin HJ, Kim WS, et al. Conservative treatment for patients with acute right colonic diverticulitis. Am Surg. 2007;73(12):1237–1241. doi: 10.1177/000313480707301208.
    1. Issa N, Paran H, Yasin M, Neufeld D. Conservative treatment of right-sided colonic diverticulitis. Eur J Gastroenterol Hepatol. 2012;24(11):1254–1258.
    1. Ha GW, Lee MR, Kim JH. Efficacy of conservative management in patients with right colonic diverticulitis. ANZ J Surg. 2017;87(6):467–470. doi: 10.1111/ans.13028.
    1. Park SJ, Choi SI, Lee SH, Lee KY. Image-guided conservative management of right colonic diverticulitis. World J Gastroenterol. 2009;15(46):5838–5842. doi: 10.3748/wjg.15.5838.
    1. Kim TJ, Lee IK, Park JK, Lee YS, Si Y, Jung H, et al. Is conservative treatment with antibiotics the correct strategy for management of right colonic diverticulitis?: a prospective study. J Korean Soc Coloproctol. 2011;27(4):188–193. doi: 10.3393/jksc.2011.27.4.188.
    1. Park H-C, Kim BS, Lee BH. Management of right colonic uncomplicated diverticulitis: outpatient versus inpatient management. World J Surg. 2011;35(5):1118–1122. doi: 10.1007/s00268-011-1048-0.
    1. Kim JY, Park SG, Kang HJ, Lim YA, Pak KH, Yoo T, et al. Prospective randomized clinical trial of uncomplicated right-sided colonic diverticulitis: antibiotics versus no antibiotics. Int J Colorectal Dis. 2019;34(8):1413–1420. doi: 10.1007/s00384-019-03343-w.
    1. Courtot L, Bridoux V, Lakkis Z, Piessen G, Manceau G, Mulliri A, et al. Long-term outcome and management of right colonic diverticulitis in western countries: multicentric retrospective study. J Visc Surg. 2019;156(4):296–304. doi: 10.1016/j.jviscsurg.2019.01.005.
    1. Schneider LV, Millet I, Boulay-Coletta I, Taourel P, Loriau J, Zins M. Right colonic diverticulitis in caucasians: presentation and outcomes versus left-sided disease. Abdom Radiol (NY) 2017;42(3):810–817. doi: 10.1007/s00261-016-0958-6.
    1. Destek S, Gul VO. Effectiveness of conservative approach in right colon diverticulitis. Ulus Travma Acil Cerrahi Derg. 2019;25(4):396–402.
    1. Matsushima K. Management of right-sided diverticulitis: a retrospective review from a hospital in Japan. Surg Today. 2010;40(4):321–325. doi: 10.1007/s00595-008-4055-5.
    1. Park HC, Chang MY, Lee BH. Nonoperative management of right colonic diverticulitis using radiologic evaluation. Colorectal Dis. 2010;12(2):105–108. doi: 10.1111/j.1463-1318.2008.01734.x.
    1. Park JH, Park HC, Lee BH. One-day versus four-day antibiotic treatment for acute right colonic uncomplicated diverticulitis: a randomized clinical trial. Turk J Gastroenterol. 2019;30(7):605–610. doi: 10.5152/tjg.2019.17775.
    1. Yang HR, Huang HH, Wang YC, Hsieh CH, Chung PK, Jeng LB, et al. Management of right colon diverticulitis: a 10-year experience. World J Surg. 2006;30(10):1929–1934. doi: 10.1007/s00268-005-0746-x.
    1. Reisman Y, Ziv Y, Kravrovitc D, Negri M, Wolloch Y, Halevy A. Diverticulitis: the effect of age and location on the course of disease. Int J Colorectal Dis. 1999;14(4–5):250–254. doi: 10.1007/s003840050219.
    1. Daniels L, Ünlü Ç, de Korte N, van Dieren S, Stockmann HB, Vrouenraets BC, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104(1):52–61. doi: 10.1002/bjs.10309.
    1. Pisanu A, Vacca V, Reccia I, Podda M, Uccheddu A. Acute diverticulitis in the young: the same disease in a different patient. Gastroenterol Res Pract. 2013;2013:867961. doi: 10.1155/2013/867961.
    1. Santos A, Mentula P, Pinta T, Ismail S, Rautio T, Juusela R, et al. Comparing laparoscopic elective sigmoid resection with conservative treatment in improving quality of life of patients with diverticulitis: the laparoscopic elective sigmoid resection following diverticulitis (LASER) randomized clinical trial. JAMA Surg. 2021;156(2):129–136. doi: 10.1001/jamasurg.2020.5151.
    1. Holmer C, Lehmann KS, Engelmann S, Gröne J, Buhr HJ, Ritz J-P. Long-term outcome after conservative and surgical treatment of acute sigmoid diverticulitis. Langenbecks Arch Surg. 2011;396(6):825–832. doi: 10.1007/s00423-011-0815-6.
    1. Mizrahi I, Al-Kurd A, Chapchay K, Ag-Rejuan Y, Simanovsky N, Eid A, et al. Long-term outcomes of sigmoid diverticulitis: a single-center experience. J Surg Res. 2018;221:8–14. doi: 10.1016/j.jss.2017.07.028.
    1. Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K, Group AS Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99(4):532–539. doi: 10.1002/bjs.8688.
    1. Mueller MH, Glatzle J, Kasparek MS, Becker HD, Jehle EC, Zittel TT, et al. Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol. 2005;17(6):649–654. doi: 10.1097/00042737-200506000-00009.
    1. Frileux P, Dubrez J, Burdy G, Roullet-Audy JC, Dalban-Sillas B, Bonnaventure F, et al. Sigmoid diverticulitis. Longitudinal analysis of 222 patients with a minimal follow up of 5 years. Colorectal Dis. 2010;12(7):674–680. doi: 10.1111/j.1463-1318.2009.01866.x.
    1. Lopez-Borao J, Kreisler E, Millan M, Trenti L, Jaurrieta E, Rodriguez-Moranta F, et al. Impact of age on recurrence and severity of left colonic diverticulitis. Colorectal Dis. 2012;14(7):e407–e412. doi: 10.1111/j.1463-1318.2012.02976.x.
    1. Binda GA, Arezzo A, Serventi A, Bonelli L. Italian study group on complicated D, Facchini M, et al multicentre observational study of the natural history of left-sided acute diverticulitis. Br J Surg. 2012;99(2):276–285. doi: 10.1002/bjs.7723.
    1. Biondo S, Borao JL, Kreisler E, Golda T, Millan M, Frago R, et al. Recurrence and virulence of colonic diverticulitis in immunocompromised patients. Am J Surg. 2012;204(2):172–179. doi: 10.1016/j.amjsurg.2011.09.027.
    1. Unlu C, van de Wall BJ, Gerhards MF, Wiezer M, Draaisma WA, Consten EC, et al. Influence of age on clinical outcome of acute diverticulitis. J Gastrointest Surg. 2013;17(9):1651–1656. doi: 10.1007/s11605-013-2240-3.
    1. Buchs NC, Konrad-Mugnier B, Jannot AS, Poletti PA, Ambrosetti P, Gervaz P. Assessment of recurrence and complications following uncomplicated diverticulitis. Br J Surg. 2013;100(7):976–979. doi: 10.1002/bjs.9119.
    1. Trenti L, Kreisler E, Galvez A, Golda T, Frago R, Biondo S. Long-term evolution of acute colonic diverticulitis after successful medical treatment. World J Surg. 2015;39(1):266–274. doi: 10.1007/s00268-014-2773-y.
    1. Brochmann ND, Schultz JK, Jakobsen GS, Oresland T. Management of acute uncomplicated diverticulitis without antibiotics: a single-centre cohort study. Colorectal Dis. 2016;18(11):1101–1107. doi: 10.1111/codi.13355.
    1. Meyer J, Caruso A, Roos E, Balaphas A, Toso C, Poletti PA, et al. The clinical significance of extraluminal air in Hinchey 1a diverticulitis: results from a retrospective cohort study with 10-year follow-up. Int J Colorectal Dis. 2019;34(12):2053–2058. doi: 10.1007/s00384-019-03424-w.
    1. Balk EM, Adam GP, Bhuma MR, Konnyu KJ, Saldanha IJ, Beland MD, et al. Diagnostic imaging and medical management of acute left-sided colonic diverticulitis: a systematic review. Ann Intern Med. 2022;175(3):379–387. doi: 10.7326/M21-1645.
    1. Desai M, Fathallah J, Nutalapati V, Saligram S. Antibiotics versus no antibiotics for acute uncomplicated diverticulitis: a systematic review and meta-analysis. Dis Colon Rectum. 2019;62(8):1005–1012. doi: 10.1097/DCR.0000000000001324.

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