Acute diverticulitis is one of the most common gastrointestinal disorders, with an
estimated lifetime risk ranging from 10 to 25%. Notably this condition predominantly
affects the left side of the colon (Acute Left Colon Diverticulitis - ALCD). Over the
years, advancements in radiological imaging techniques have led to the modification of
the original Hinchey classification, and in 2015 the World Society of Emergency Surgery
(WSES) introduced a novel classification based on computer tomography (CT) findings. The
prevalence of ALCD is on the rise in Western countries, with a marked increase of 132%
observed between 1980 and 2007, especially among individuals aged 40 to 49 years. This
trend is also evident in Italy, where there was a substantial rise in admission rates
between 2008 and 2015, increasing from 8.8 to 11.8 cases per 100,000 inhabitants,
primarily among those under 60 years old. Consequently, this surge in ALCD cases has led
to elevated healthcare costs, particularly when surgical intervention is not required.
Notably, only around 5% of patients with ALCD experience complicated episodes, indicating
that uncomplicated ALCD (U-ACLD) is more common than complicated ACLD (C-ALCD). However,
current clinical practice still demonstrates high admission rates for both U-ACLD and
C-ALCD, particularly among the elderly with comorbidities. Given that surgery is not
always warranted, patients are often admitted to non-surgical departments, although no
specific guidelines exist to determine which facility is the most suitable.
There remains a dearth of knowledge regarding the comparative management of ALCD between
surgical and non-surgical wards in cases of non-operative management (NOM). Some studies
demonstrated similar outcomes among patients admitted to both surgical and non-surgical
units.
In this context, the primary objective of the current study is to compare ALCD patients
admitted for NOM to the surgical ward with those admitted to a non-surgical ward.
Specifically, the study aims to assess clinical outcomes (such as gastrointestinal
disorders and the restoration of a regular diet), hospitalization length (Length of Stay
- LOS), and post-admission follow-up.
The following data were collected: age, sex, body mass index (BMI), American Society of
Anesthesiologists (ASA) scores, previous ALCD episodes (requiring or not requiring
hospitalization), C-reactive protein (CRP) levels on admission, type of management (i.e.
no treatment, antimicrobial therapy, percutaneous drainage), LOS, post-discharge
colonoscopy, follow-up visits, and ALCD recurrence. Follow-up data were retrieved from
the electronic records covering two years after the episodes. ALCD was classified using
the Hinchey classification modified by Wasvary et al. based on CT findings on admission.
According to the admission department, the study population was divided into two groups:
a surgical group (SG) and a non-surgical group (NSG). The ward of hospitalization was
decided by the emergency doctor according to bed availability: if there were beds in the
surgical ward, patients were preferably hospitalized there, otherwise, a non-surgical
environment was chosen. The non-surgical wards were mainly the two wards of Internal
Medicine. Criteria considered for discharge include resolution of fever, pain reduction
with no need for constant use of painkillers, free oral feeding, normalization of white
blood cell count, and more than a 50% decrease in the serum levels of CRP. Recurrence was
defined as a new ALCD episode confirmed by a CT scan not earlier than 2 months after the
first episode.
To compare ALCD management in non-surgical and surgical environments, SG subjects were
propensity-score matched (PSM) to NSG subjects on ALCD grade according to the
classification modified by Wasvary et al., to reduce the bias related to ALCD grade.
This decision was made also to study which factors of patients' baseline characteristics
(age, sex, BMI, ASA score, CRP levels) mainly differ between the two Groups. The
Shapiro-Wilk test was used to analyze quantitative variables. Nominal variables are
expressed as numbers and percentages, non-normal quantitative variables as median and
range, and normal variables as mean and standard deviation (SD). Chi-squared and Fisher's
exact test were used to compare nominal variables, whereas the Mann-Whitney U test was
used for non-normal quantitative variables and the T-student test for normal quantitative
variables. A multivariate logistic regression analysis was conducted to evaluate if age,
sex, ASA score, and hospitalization ward were independent predictors in readmission, the
lack of follow-up, and receiving a colonoscopy. Data are represented in odds ratio (ORs)
and Confidence Interval (CI) of 95%. P values < 0.05 were considered statistically
significant.