International Journal of Surgery 85 (2021) 1–9

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International Journal of Surgery

journal homepage: www.elsevier.com/locate/ijsu

Review

Hinchey Ia acute diverticulitis with isolated pericolic air on CT imaging; to

operate or not? A systematic review
Alexandros Karentzos a, *, Dimitrios Ntourakis b, Konstantinos Tsilidis c, Georgios Tsoulfas d,
Theodossis Papavramidis e
a
Department of Surgery, Torbay Hospital, Newton Rd, Torquay, TQ2 7AA, UK
b
European University Cyprus School of Medicine, 6 Diogenis Str 2404 Engomi, P.O. Box: 22006, 1516, Nicosia, Cyprus
c
University of Ioannina Faculty of Medicine, Department of Hygiene and Epidemiology, 45110, Ioannina, Greece
d
Aristotle University of Thessaloniki, 1st Department of Surgery, AHEPA University Hospital, Kiriakidi 1, Thessaloniki, Greece
e
Aristotle University of Thessaloniki, 3rd Department of Surgery, AHEPA University Hospital, Kiriakidi 1, Thessaloniki, Greece

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Colonic diverticulitis is one of the most common gastrointestinal pathologies and its prevalence
Perforated Hinchey Ia diverticulitis increases with the aging of the population in Western countries. Approximately 15% of patients with Hinchey Ia
Conservative treatment acute diverticulitis present with concomitant isolated pericolic air bubbles that denote intestinal perforation and
thus prompting a more “aggressive” treatment attitude, including emergency surgery, despite the absence of
evidence-based indications. This study is trying to delineate whether this approach is justified or whether a
conservative treatment would suffice for this group of patients.
Materials and methods: PubMed and Cochrane CENTRAL databases were systematically searched in order to
identify all studies that reported the need for emergency surgery and for percutaneous drainage in patients
presenting with Hinchey Ia colonic diverticulitis with extraluminal pericolic gas on CT imaging who were
initially treated conservatively. The last database search was performed on November 29, 2019 and no language
or study type restriction criteria were applied. The Newcastle-Ottawa scale was used to assess the risk of bias of
selected studies.
Results: Nine observational cohort studies with 411 patients reported the need for emergency surgery, with a
pooled rate of 5.1%. Among these studies, four studies comprising 165 patients reported the need for percuta­
neous drainage separately with a pooled rate of 1.2%.
Conclusion: Non-operative management of Hinchey Ia acute diverticulitis with isolated pericolic air is feasible
and safe with a success rate of 94.9%. Abscess formation requiring percutaneous drainage is present in only 1.2%
of patients, thus rendering the conservative initial treatment of these patients justified. Nevertheless, low quality
of included studies indicates further research to validate the outcomes of this review.

1. Introduction
Diverticular disease of the colon is a medical condition that is highly
related to the aging of the population in Western countries. It is esti­
mated that at the age of 40 years, diverticulosis affects approximately
10% of the population, whereas, at the age of 85 years, its prevalence
increases to more than two-thirds of the population [1]. Complications
of diverticulosis account for 300,000 hospital admissions and 1.5
million in-hospital-care days annually in the USA [2] and, among them,
acute diverticulitis is by far the most common, affecting about 4–7% of
these patients [3,4]. Different classification systems have been proposed
over the years in order to assess the severity of acute diverticulitis and in
an effort to provide a framework for the development of treatment al­
gorithms. The Hinchey classification, modified by Wasvary [5] in 1999
is the most frequently used nowadays but other classification systems
remain in use as well, notably the Ambrosetti classification [6], the
Hansen-Stock classification [7] and more recently the modified Neff
classification [8].

* Corresponding author.
E-mail addresses: alexandroskarentzos@yahoo.com (A. Karentzos), d.ntourakis@euc.ac.cy (D. Ntourakis), ktsilidis@gmail.com (K. Tsilidis), tsoulfasg@gmail.com
(G. Tsoulfas), papavramidis@hotmail.com (T. Papavramidis).

https://doi.org/10.1016/j.ijsu.2020.11.019
Received 31 August 2020; Received in revised form 10 November 2020; Accepted 18 November 2020
Available online 25 November 2020
1743-9191/© 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. This article is made available under the Elsevier license (http://www.elsevier.com/open-
access/userlicense/1.0/).
A. Karentzos et al.
The imaging modality of reference for acute colonic diverticulitis is
CT imaging since it identifies efficiently the segment of colon affected as
well as complications that may arise in the form of abscess formation,
purulent or fecal peritonitis, fistula formation and lumen stenosis. The
most severe episodes of diverticulitis complicated by diffuse peritonitis
(stages III or IV according to the modified Hinchey classification) have
been traditionally treated by surgery in the form of colectomy with
Fig. 1. Search strategy for identification of studies on PubMed.
2
International Journal of Surgery 85 (2021) 1–9
terminal colostomy (Hartmann’s procedure) or primary anastomosis [9,
10] and more recently by laparoscopic lavage/drainage. Episodes of
acute diverticulitis complicated by the formation of abscesses (stages Ib
and II according to the modified Hinchey classification) are treated by
percutaneous drainage when applicable with a size cut-off of 4–5 cm.
For acute uncomplicated diverticulitis presenting as confined pericolic
inflammation or phlegmon (stage Ia according to the modified Hinchey
A. Karentzos et al.
classification), nonoperative management with and recently even
without antibiotic therapy [11] is proposed. Nevertheless, approxi­
mately 15% of these patients present with concomitant pericolic extra­
luminal air [8], a radiological finding that is not taken into account by
the Hinchey classification. Despite the large number of patients
involved, especially if one takes into consideration that Hinchey Ia is the
most common manifestation of acute diverticulitis, there is no consensus
regarding the optimal treatment of these patients. The presence of per­
icolic extraluminal air obviously denotes perforation of this segment of
the colon (also termed “covered”, “micro-” or “localized” perforation)
and as a result, the question for a more “aggressive” approach in this
subgroup of patients arises.
A systematic review by van Dijk et al. [12] found an initial success
rate of 94% of non-operative treatment in left-sided colonic diverticulitis
patients presenting with pericolic extraluminal air, rendering a conser­
vative approach, including antibiotics, reasonable. This review included
a limited number of patients but, due to the increasing tendency for less
invasive treatments, new studies have been published ever since,
increasing the cumulative cohorts’ size and thus leading to better vali­
dated conclusions. The current systematic review tried to identify all
available studies regarding the feasibility of conservative treatment of
patients presenting with Hinchey Ia acute colonic diverticulitis and
pericolic air in order to provide solid-based recommendations for the
optimal treatment of this common condition.
2. Material and Methods
2.1. Search strategy
In order to identify eligible studies, a systematic search in the
Cochrane CENTRAL and the PubMed databases was undertaken. Search
terms were used to explicitly identify the population involved (diver­
ticulitis, acute diverticulitis, uncomplicated diverticulitis, Hinchey Ia,
Hinchey 1a, free air, free gas, extraluminal air, extraluminal gas, peri­
colic air, pericolic gas, pneumoperitoneum, covered perforation, intra­
peritoneal air, intraperitoneal gas, retroperitoneal air, retroperitoneal
gas, pneumoperitoneum, intestinal perforation) and they were com­
bined with search terms denoting potential treatments for the afore­
mentioned population (antibiotic treatment, conservative treatment,
surgical treatment, non-surgical treatment, non-operative treatment,
watchful waiting, Hartmann’s, Hartmann’s procedure, laparotomy,
laparoscopy, anti-bacterial agents, surgical procedures, operative). The
search strategy applied in the PubMed database is presented in Fig. 1. In
order to identify the maximum number of studies, no restriction criteria
regarding study type, language, publication status or year were applied.
The last search was performed on November 29, 2019. Additionally, the
reference lists of the full-text articles assessed for eligibility were scan­
ned in order to retrieve relevant studies.
2.2. Study selection
Only studies that included patients with Hinchey Ia colonic diver­
ticulitis with pericolic extraluminal air as concomitant radiological
finding, who were treated initially conservatively with or without an­
tibiotics, were considered for eligibility. Studies also had to report rates
of emergency surgery, percutaneous drainage or both as outcomes for
this specific cohort. Emergency surgery or percutaneous drainage had to
be performed within 30 days from the onset of symptoms in order to be
considered as a failure of conservative treatment in the acute phase of
diverticulitis. The staging of acute diverticulitis, as well as the presence
of pericolic air bubbles and the absence of other radiological features of
severity, had to be confirmed by CT scans. Although no specific
3
International Journal of Surgery 85 (2021) 1–9
definition of pericolic extraluminal air was required, its presence and
location had to be explicitly stated in the selected studies in order to
differentiate it from disseminated perforation. Potentially eligible
studies were randomized clinical trials as well as prospective and
retrospective cohort studies and they were screened independently by
two reviewers in order to select the ones that conformed to the afore­
mentioned criteria. Any disagreements were resolved through discus­
sion and studies were included only if consensus regarding their
eligibility was reached between the reviewers.
2.3. Risk of bias of individual studies assessment
The Newcastle-Ottawa Quality Assessment Form for cohort studies
[13] was used by the two reviewers to independently assess the quality
of the selected studies. Similar to study selection, any disagreements
were resolved through discussion.
2.4. Data extraction
A predefined data extraction form was used by the two reviewers in
order to extract independently the data of interest from the selected
studies. The two forms were compared and any disagreements were
resolved through discussion. All data were extracted and tabulated from
the relevant articles’ texts, tables, and figures. The data extracted from
eligible studies included the country and institution where the study was
conducted, study type, enrolment period, long-term follow-up duration,
patient selection criteria, comorbidities, segment of colon affected,
initial conservative treatment applied and the type of antibiotics used if
reported, the presence of control group and the reported failure outcome
(s). Moreover, data regarding the precise definition of pericolic extra­
luminal air in each selected study as well as the rationale for emergency
surgery in patients initially undergoing conservative treatment were
extracted. The corresponding authors of the selected studies were not
contacted since all relevant data of interest were adequately reported.
2.5. Outcomes of interest
The principal outcome measures were the need for emergency sur­
gery as well as the need for percutaneous drainage (when reported
separately) in the selected studies during the acute phase of diverticu­
litis, which was predefined as the 30-day period following the onset of
symptoms.
2.6. Synthesis of results
Due to the unavailability of raw data from the selected studies, it was
not possible to conduct a meta-analysis in order to identify risk factors
that might predispose to failure of conservative treatment in the form of
emergency surgery or percutaneous drainage. The extracted data were
tabulated and the cumulative rates of the outcomes of interest (need for
emergency surgery and percutaneous drainage) were calculated. The
work is reported in line with PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the
methodological quality of systematic reviews) Guidelines.
3. Results
3.1. Identification of eligible studies
Systematic search in the Cochrane CENTRAL and the PubMed da­
tabases identified 704 records initially. The titles and abstracts of these
records were screened and 683 citations were discarded because they
A. Karentzos et al. International Journal of Surgery 85 (2021) 1–9

did not meet the inclusion criteria. The full texts of the remaining 21 selection flowchart according to the PRISMA 2009 guidelines is depicted
citations were assessed for eligibility and 13 of them were excluded in Fig. 2.
because they did not meet the inclusion criteria as well; one study did
not provide distinct results for each outcome of interest (emergency
3.2. Study characteristics
surgery and percutaneous drainage), five studies did not report distinct
data for outcomes in patients specifically with pericolic air on CT im­
A summary of the characteristics of the nine selected studies([8,
aging, six citations involved irrelevant study types (five reviews and one
14–21]) is presented in Table 1. All of them were cohort studies that
case report study) and one citation involved a cohort of patients without
were published between 2011 and 2019 with presence of a control group
pericolic air on CT scans. Search of the reference lists of the full-text
in only one study [21]. One study was conducted in the United States of
articles that were assessed for eligibility permitted the identification of
America [16], one study in Israel [20] and the remaining seven studies
an additional study that met the inclusion criteria. Consequently, a total
were conducted in Europe (Netherlands, France, Finland, Switzerland,
of nine studies were included in the qualitative synthesis. The study
Spain, Sweden and Iceland). Two of the studies were multicentric [14,

Fig. 2. PRISMA 2009 flow diagram (modified).

4
 A. Karentzos et al.
Table 1
Summary of characteristics of included studies.
Cohort Study Bolkenstein et al., Costi et al., 2012 Dharmarajan Sallinien et al., 2014 Titos-Garcia Thorisson et al., Lahat et al. Mora Lopez et al., Meyer et al.
Author + Year 2019 et al., 2011 et al., 2017 2016 2013 2013 2019

Setting Country + Netherlands France USA Finland Spain Sweden + Iceland Israel Spain Switzerland
Institution multicentric UHTC UHTC UHTC UHTC multi-centric Medical center UHTC UHTC
Design Retro + data from Retro Retro Retro Retro Prospm Prosp Prosp Retro
RCTa
Enrolment period January January 1995–2008 2006–2010 2010–2015 2003–2010 January February January
2005–January 2017 2001–June 2010 2000–November 2006 2010–January 2013 2005–December 2009
Follow-up period 11 mo (IQR 2–24 71 mo (range Mean = 21,2 mo N/R N/R 1 year Mean = 88 mo 1 month 10 years
mo) 12–139 mo)
b k u v
Patient selection No sepsis/abscess/ Fit for surgery, Clinically no N/R First episode of AD
peritonitis HD stable generalized
peritonitis
d g t
Comorbidities ASA, BMI N/R ASA N/R None N/R
Localization N/R Left colon N/R N/R N/R Left colon N/R N/R Sigmoid colon
Initial conservative 48% Abx (N/R)/ Abxe Abx (N/R) Abx (Cef + Met) Abx (N/R) No Abx/Abxp Abx (N/R) Abx (Ceft + Met) AbxH
treatment 52% no Abx
Control group No No No No No No No No Yes
5

Failure outcome Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery
Drainage Drainage Drainage Drainage

Retro = retrospective cohort study; mo = months; IQR = interquartile range; N/R = not reported; Abx = antibiotics; UHTC = university hospital tertiary center; HD = hemodynamically, Cef = Cefuroxime; Met =
Metronidazole; Prosp = prospective cohort study; AD = acute diverticulitis; Ceft = Ceftriaxone.
ᵃ Data derived from the DIABOLO trial.
ᵇ Hemodynamically stable, no extradigestive stools/contrast medium extravasation after per rectum administration.
ᵈ ASA, BMI, dyslipidemia, hypertension, diabetes, tobacco, alcohol, use of steroid and non-steroid anti-inflammatory drugs.
ᵉ Amoxicillin and clavulanic acid only (+fluoroquinolones or aminosides).
ᵍ Corticosteroids, immunosuppression, chemotherapy.
ᵏ HD stable, no clinical or radiological evidence of diffuse peritonitis.
ᵐ Data derived from the AVOD trial.
ᵖ Initially, an intravenous combination of a second- or third-generation cephalosporin (cefuroxime or cefotaxime) and metronidazole, or with carbapenem antibiotics (ertapenem, meropenem or imipenem) or piperacillin-
tazobactam. Orally administrated antibiotics such as ciprofloxacin or cefadroxil combined with metronidazole were initiated subsequently on the ward or at discharge.
ᵗ Hypertension, hypothyroidism, COPD/asthma, diabetes, ischemic heart disease, hyperlipidemia, malignancy, Crohn’s disease, ulcerative colitis, chronic renal failure.

International Journal of Surgery 85 (2021) 1–9

ᵘ No comorbidities, no SIRS, no previous episode of AD.
ᵛ Hinchey Ia AD with extraluminal air without other features of advanced diverticulitis.
ᵸ Third-generation cephalosporin and metronidazole.
A. Karentzos et al. International Journal of Surgery 85 (2021) 1–9

19], whereas the remaining studies were conducted in a single hospital,
which in six cases was a university hospital that served as a tertiary
center. Six of the studies were retrospective and the remaining three had
a prospective design. One of the prospective studies [19] used data from
the AVOD study [11], which is a randomized clinical trial that was
conducted in Sweden and Iceland, and one of the retrospective studies
[14] partially used data from a randomized controlled trial as well
(DIABOLO trial [22]). The patients’ enrolment period was 5–13 years
and the post-discharge follow-up period was reported in seven studies,
ranging from one month to 139 months. Patient selection criteria were
reported in all but one study [19] and included only patients who did not
require emergency surgery or percutaneous drainage within the first 24
hours after the diagnosis of acute diverticulitis. In two of the studies [8,
20], only patients with their first episode of acute diverticulitis were
included which inevitably introduces a certain degree of selection bias.
Comorbidities of the patients that formed the studies’ cohorts were
explicitly reported in six citations. The study by Mora Lopez et al. [8]
included only patients without any comorbidities and without signs of
systemic inflammatory response syndrome which is again a source of
selection bias.
Although all selected studies involved patients with colonic diver­
ticulitis, the exact localization of the acute episode (left colon and sig­
moid colon) is reported in only three studies [15,19,21]. Further explicit
definition of pericolic air is reported in five studies [8,14,17,18,21].
Antibiotic treatment for patients with localized perforation was part of
the initial conservative treatment in all studies. Nevertheless, in two of
them [14,19] a proportion of the cohort did not receive any antibiotics
at all. The type of antibiotics is reported in five studies and includes
either monotherapy or combinations of antibiotics with the intention to
provide cover against gram-negative bacteria and anaerobes that
constitute standard colonic flora. Second- and third-generation cepha­
losporines, combination of Amoxicillin and clavulanic acid, fluo­
roquinolones, aminosides, metronidazole, carbapenems and
combination of piperacillin and tazobactam are the antibiotics reported
in the selected studies.
Regarding the outcomes of interests, need for emergency surgery
during the episode of acute diverticulitis is reported in all nine studies
whereas the need for percutaneous drainage is explicitly reported in
only four studies [8,14,16,20]. The rationale for emergency surgery is
not reported in two studies [8,20] since no patient required emergency
surgery in their cohorts, whereas in two other studies that included
patients who underwent emergency surgical treatment [18,21] no
reasoning for this decision is provided. In the remaining five studies,
surgical management was finally decided upon due to clinical deterio­
ration and increasing abdominal pain, unsuccessful conservative man­
agement of abdominal collections, absence of improvement after 4–5
days of maximal medical therapy, clinical progression of the disease
during intravenous antibiotic treatment and/or after percutaneous
drainage, CT scan imaging showing sigmoid perforation and following
diagnostic laparoscopy with findings of purulent peritonitis.
3.3. Risk of bias of selected studies
With the use of the Newcastle-Ottawa Quality Assessment Form for
cohort studies, the selected studies were critically appraised. The results
are shown in Table 2. The fact that all studies but one [21] lacked a
comparison cohort was a major issue undermining their quality but this
was an inherent characteristic of the vast majority of studies that could
not be altered. Nevertheless, the exposed cohorts were compatible with
the pre-specified selection criteria with a high degree of certainty
regarding the exposure. Moreover, the outcomes of interest were suffi­
ciently documented and reported as well. Also, the follow-up period in
the acute phase was sufficient in order for the outcomes of interest to
occur and the reported long-term follow-up of cohorts was adequate in
all but two [17,18] of the selected studies. As mentioned before, a
certain degree of patient selection bias was present in the studies by
Lahat et al. and Mora Lopez et al. due to the fact that only patients with
their first episode of acute diverticulitis were included in the cohorts.
Additionally, the study by Mora Lopez et al. [8] presented an additional
degree of patient selection bias, since it included only patients without
any comorbidities and without signs of systemic inflammatory response
syndrome (SIRS).
3.4. Outcomes of interest: need for emergency surgery and need for
percutaneous abscess drainage
The need for emergency surgery during the episode of acute diver­
ticulitis was reported in all nine studies selected for this systematic re­
view. These included a total of 411 patients presenting with Hinchey Ia
acute colonic diverticulitis with isolated pericolic air on initial CT im­
aging and without any other radiological criteria of disease severity such
as abscess formation or distant free air. A pooled rate of 5.1% (21/411)
of these patients required emergency surgery whereas 390/411 patients
(94.9%) underwent successful non-operative treatment. Patients who

Table 2
Risk of bias of selected observational cohort studies according to the Newcastle-Ottawa scale.
Cohort Study Representativeness Selection Ascertainment Demonstration of Comparability Assessment Appropriate Adequacy Total Quality
Author + Year of the exposed of the non- of exposure the absence of the of cohorts of outcome duration of of follow- stars assessment
cohort exposed outcome of follow-up up of (*)
cohort interest at the period cohorts
start of the study

Bolkenstein A(*) C A(*) A(*) – B(*) A(*) A(*) 6 Poor

et al., 2019
Costi et al., B(*) C A(*) A(*) – B(*) A(*) B(*) 6 Poor
2012
Dharmarajan B(*) C A(*) A(*) – B(*) A(*) B(*) 6 Poor
et al., 2011
Sallinien A(*) C A(*) A(*) – B(*) A(*) D 5 Poor
et al., 2014
Titos-Garcia B(*) C A(*) A(*) – B(*) A(*) D 5 Poor
et al., 2017
Thorisson A(*) C B(*) A(*) – B(*) A(*) B(*) 6 Poor
et al., 2016
Lahat et al., A(*) C A(*) A(*) – B(*) A(*) B(*) 6 Poor
2013
Mora Lopez A(*) C A(*) A(*) – B(*) A(*) A(*) 6 Poor
et al., 2013
Meyer et al., A(*) A(*) A(*) A(*) A(*) B(*) A(*) A(*) 8 Good
2019

6
A. Karentzos et al. International Journal of Surgery 85 (2021) 1–9

did not require emergency surgery were treated with as well as without Table 4
antibiotics and some of them benefited from percutaneous abscess Outcomes of studies reporting need for emergency surgery versus non-operative
drainage when indicated. The rate of successful non-operative man­ management, stratified into conservative treatment and percutaneous drainage,
agement of these patients in individual studies ranged from 0% to in patients with Hinchey Ia acute diverticulitis and pericolic air.
10.5%, so the cumulative rate of 5.1% is situated approximately in the Cohort Study Number of Non-operative Emergency
middle of this range. Author + Year participants management Surgery
Regarding the need for percutaneous drainage following abscess CT PD
formation, four of the selected studies explicitly reported relevant re­ Bolkenstein et al., 109 100/109 2/109 7/109 (6.4%)
sults [8,14,16,20]. The cumulative study population was 165 patients, 2019 (91.8%) (1.8%)
of which 93.3% (154/165 patients) were successfully managed with and Dharmarajan 19 17/19 0/19 2/19 (10.5%)
even without antibiotics. Of the remaining eleven patients, two required et al., 2011 (89.5%) (0%)
Lahat et al. 23 23/23 0/23 0/23 (0%)
percutaneous drainage following abscess formation and nine patients
2013 (100%) (0%)
required emergency surgery. As a result, the cumulative rates for Mora Lopez et al., 14 14/14 0/14 0/14 (0%)
percutaneous abscess drainage and emergency surgery were 1.2% and 2013 (100%) (0%)
5.5% respectively. Total 165 154/165 2/165 9/165 (5.5%)
Tables 3 and 4 display the outcomes of the individual studies as well (93.3%) (1.2%)

as the pooled outcomes of interest for this systematic review. CT = conservative treatment with/without antibiotics.
PD = percutaneous drainage for abscess.
4. Discussion
number of patients is more than double in comparison to the van Dijk
Based on the cumulative outcomes of this systematic review, 94.9% et al. review, when emergency surgery is the outcome that is queried,
of patients suffering from Hinchey Ia colonic diverticulitis with isolated thus increasing its validity. Other strengths of this review are the sys­
pericolic extraluminal air on initial CT scans can be managed non- tematic and broad citation search that was performed, with the appli­
operatively and even if an abscess requiring percutaneous drainage is cation of explicitly pre-defined criteria, as well as a rigorous selection
formed, this complication arises in only 1.2% of cases. This is a signif­ strategy of eligible studies.
icant finding since traditional surgical approach to patients presenting Nevertheless, it is clear that this systematic review has several lim­
with colonic perforation advocates surgical exploration with laparo­ itations which are to a great extent inherent to the nature of the studies
scopic lavage/drainage or even resection of the affected segment of selected. The exclusive use of observational cohort studies, even though
colon, with or without primary anastomosis, due to the fear of imminent two of them used data from randomized clinical trials, undermines the
clinical deterioration and development of diffuse peritonitis. Neverthe­ overall strength of evidence provided. Only one study [21] can be
less, this attitude is based solely on personal or expert opinion, without considered as good quality according to AHRQ (Agency for Healthcare
any evidence-based justification, thus raising doubts about the Research and Quality) standards, whereas the rest are of poor quality,
reasoning for continuing to follow it. Furthermore, the medical com­ mainly due to the lack of comparability of cohorts. Another problem is
plications, as well as socioeconomic burdens arising from the applica­ the introduction of patient selection bias in two(8,20) of the nine eligible
tion of this fairly “aggressive” policy, are hard to ignore and this has led studies as well as the limited number of participants in certain cohorts
to a gradual shift to a less invasive attitude towards patients presenting which diminish the validity of the corresponding studies. Another lim­
with what is known as “covered perforation” itation has to do with the search strategy applied and the use of only two
This systematic review has similar findings to the systematic review databases. The use of an additional one, notably the EMBASE database,
by van Dijk et al. [12] which found a 94% success rate of non-operative might enable the identification of additional studies, even though its use
treatment in patients presenting with isolated pericolic extraluminal air in the systematic review by van Dijk et al., in 2018 did not contribute
and left-sided colonic diverticulitis. The strength of this study is the further citations. Nevertheless, since access to the EMBASE database is
significant increase in the total number of citations identified, and by subscription only, it was not used in this systematic review. Finally,
subsequently in the number of patients involved. Actually, the total one weakness that needs to be addressed is the lack of uniformity among
the studies regarding the conservative treatment of Hinchey Ia patients
presenting with pericolic extraluminal air. In two of the selected studies
Table 3
[14,19], a proportion of patients did not receive any antibiotics at all,
Outcomes of studies reporting need for emergency surgery versus non-operative
whereas in a significant number of studies, data regarding antibiotic
management in patients with Hinchey Ia acute diverticulitis and pericolic air.
treatment, such as type of antibiotics and detailed protocol of adminis­
Cohort Study Number of Non-operative Emergency
tration, are not reported. Additionally, there is a marked difference in
Author + Year participants management Surgery
the type of antibiotics used in the studies when this kind of data is
Bolkenstein et al., 109 102/109 (93.6%) 7/109 (6.4%) available, which raises the question of whether the choice of antibiotic
2019
Costi et al. 31 28/31 (90.3%) 3/31 (9.7%)
had a role in the difference in rates of successful treatment with anti­
2012 biotics among these studies.
Dharmarajan et al., 19 17/19 (89.5%) 2/19 (10.5%) It is important to consider the fact that CT scan is an imaging mo­
2011 dality whose application has become widely available during the last
Sallinien et al. 82 81/82 (98.8%) 1/82 (1.2%)
decades, and even nowadays it is not an essential part of diagnostic al­
2014
Titos-Garcia et al., 51 46/51 (90.2%) 5/51 (9.8%) gorithms for abdominal pain in many parts of the developing world and
2017 in many smaller health institutions even in developed countries. CT
Thorisson et al. 26 25/26 (96.2%) 1/26 (3.8%) imaging, where applicated, has enabled clinicians to accurately define
2016 the stage of acute diverticulitis and depict with great detail its potential
Lahat et al. 23 23/23 (100%) 0/23 (0%)
complications, being an indispensable aid to treatment decision making.
2013
Mora Lopez et al., 14 14/14 (100%) 0/14 (0%) Nevertheless, there is no study that correlates the absence of formal
2013 diagnosis of Hinchey Ia diverticulitis, even with the presence of pericolic
Meyer et al. 56 54/56 (96.4%) 2/56 (3.6%) air bubbles, with increased morbidity and mortality. This is evidently
2019
due to the fact that common medical practice dictates the
Total 411 390/411 (94.9%) 21/411 (5.1%)

7
A. Karentzos et al.
hospitalization of patients presenting with abdominal pain and an in­
flammatory syndrome, usually with nil by mouth and empiric antibiotic
therapy, even in the absence of a formal diagnosis. As a result, even in
cases of missed diagnoses of Hinchey Ia diverticulitis, due to lack of
resources, the patients usually receive adequate medical care, and in
some cases can be even overtreated, since recent studies have concluded
that antibiotic therapy can usually be omitted and outpatient treatment
is feasible [23,24].
Ideally, an evidence-based protocol regarding the treatment of pa­
tients with Hinchey Ia colonic diverticulitis with pericolic air as an
isolated CT finding needs to be developed. This would require data from
studies that would assess the role of clinical findings, such as body
temperature, heart rate and signs of local or diffuse peritoneal irritation,
laboratory values, notably leukocytosis and C-reactive protein, and
radiological findings, such as the overall size of pericolic air-bubbles or
the segment of the colon affected, in the evolution of these patients to­
wards complete recovery, abscess formation or the development of
diffuse peritonitis requiring surgical intervention. Moreover, the ne­
cessity for antibiotic therapy and the optimal antibiotic regimens, if
indicated, for the treatment of these patients need to be delineated.
Answers to these queries would enable the development of evidence-
based guidelines for the optimal treatment of these patients and would
potentially even diminish the need for hospitalization, as in the case of
acute uncomplicated diverticulitis [23,24].
5. Conclusion
The findings of this systematic review confirm the benign course in
the majority of patients with Hinchey Ia acute diverticulitis with isolated
pericolic air which renders a priori emergency surgery unjustified and
supports the adoption of a “watchful waiting” attitude.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Ethical approval
No Ethical Approval required as this research project is a systematic
review of previous studies and no raw data of patients participating in
these studies were used.
Sources of funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Author contribution
Karentzos, Alexandros: conseptualization, study design, data
collection, data analysis, writing.
Ntourakis, Dimitrios: conceptualization, methodology.
Tsilidis, Konstantinos: conceptualization, methodology.
Tsoulfas, Georgios: conceptualization, methodology.
Papavramidis, Theodossis: conceptualization, study design, data
collection, supervision.
Research registration unique identifying number (UIN)
1. Name of the registry: Research Registry
2. Unique Identifying number or registration ID: reviewregistry981
3. Hyperlink to your specific registration (must be publicly accessible
and will be checked): https://www.researchregistry.com/browse
-the-registry#registryofsystematicreviewsmeta-analyses/registryofs
ystematicreviewsmeta-analysesdetails/5f4cc304f46ecb00
1568d82d/
8
International Journal of Surgery 85 (2021) 1–9
Guarantor
Alexandros Karentzos.
Declaration of competing interest
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ijsu.2020.11.019.
References
[1] P. Roberts, M. Abel, L. Rosen, W. Cirocco, J. Fleshman, E. Leff, et al., Practice
parameters for sigmoid diverticulitis. The standards task force American society of
colon and rectal surgeons, Dis. Colon Rectum 38 (2) (1995 Feb) 125–132.
[2] L.J. Kozak, C.J. DeFrances, M.J. Hall, National hospital discharge survey: 2004
annual summary with detailed diagnosis and procedure data, Vital Health Stat 13
(162) (2006 Oct) 1–209.
[3] K. Shahedi, G. Fuller, R. Bolus, E. Cohen, M. Vu, R. Shah, et al., Long-term risk of
acute diverticulitis among patients with incidental diverticulosis found during
colonoscopy, Clin. Gastroenterol. Hepatol. 11 (12) (2013 Dec) 1609–1613.
[4] R.J.L.F. Loffeld, Long-term follow-up and development of diverticulitis in patients
diagnosed with diverticulosis of the colon, Int. J. Colorectal Dis. 31 (1) (2016 Jan)
15–17.
[5] H. Wasvary, F. Turfah, O. Kadro, W. Beauregard, Same hospitalization resection for
acute diverticulitis, Am. Surg. 65 (7) (1999 Jul) 632–635, discussion 636.
[6] P. Ambrosetti, C. Becker, F. Terrier, Colonic diverticulitis: impact of imaging on
surgical management – a prospective study of 542 patients, Eur. Radiol. 12 (5)
(2002 May) 1145–1149.
[7] O. Hansen, F. Graupe, W. Stock, [Prognostic factors in perforating diverticulitis of
the large intestine], Chirurg 69 (4) (1998 Apr) 443–449.
[8] L. Mora Lopez, S. Serra Pla, X. Serra-Aracil, E. Ballesteros, S. Navarro, Application
of a modified Neff classification to patients with uncomplicated diverticulitis,
Colorectal Dis. 15 (11) (2013 Nov) 1442–1447.
[9] M.K. Schilling, C.A. Maurer, O. Kollmar, M.W. Buchler, Primary vs. secondary
anastomosis after sigmoid colon resection for perforated diverticulitis (Hinchey
Stage III and IV): a prospective outcome and cost analysis, Dis. Colon Rectum 44
(5) (2001 May) 695–699.
[10] L. Salem, D.R. Flum, Primary anastomosis or Hartmann’s procedure for patients
with diverticular peritonitis? A systematic review, Dis. Colon Rectum 47 (11)
(2004 Nov) 1953–1964.
[11] A. Chabok, L. Pahlman, F. Hjern, S. Haapaniemi, K. Smedh, Randomized clinical
trial of antibiotics in acute uncomplicated diverticulitis, Br. J. Surg. 99 (4) (2012
Apr) 532–539.
[12] S.T. van Dijk, S.A.N. Doelare, A.A.W. van Geloven, M.A. Boermeester, A systematic
review of pericolic extraluminal air in left-sided acute colonic diverticulitis, Surg.
Infect. 19 (4) (2018) 362–368.
[13] J.J. Deeks, J. Dinnes, R. D’Amico, A.J. Sowden, C. Sakarovitch, F. Song, et al.,
Evaluating non-randomised intervention studies, Health Technol. Assess. 7 (27)
(2003) 1–173, iii–x.
[14] H.E. Bolkenstein, S.T. van Dijk, E.C.J. Consten, B.G.F. Heggelman, C.M.A. Hoeks, I.
A.M.J. Broeders, et al., Conservative treatment in diverticulitis patients with
pericolic extraluminal air and the role of antibiotic treatment, J. Gastrointest. Surg.
23 (11) (2019 Nov) 2269–2276.
[15] R. Costi, F. Cauchy, A. Le Bian, J.F. Honart, N. Creuze, C. Smadja, Challenging a
classic myth: pneumoperitoneum associated with acute diverticulitis is not an
indication for open or laparoscopic emergency surgery in hemodynamically stable
patients. A 10-year experience with a nonoperative treatment, Surg. Endosc. 26 (7)
(2012) 2061–2071.
[16] S. Dharmarajan, S.R. Hunt, E.H. Birnbaum, J.W. Fleshman, M.G. Mutch, The
efficacy of nonoperative management of acute complicated diverticulitis, Dis.
Colon Rectum 54 (6) (2011) 663–671.
[17] V.J. Sallinen, P.J. Mentula, A.K. Leppäniemi, Nonoperative management of
perforated diverticulitis with extraluminal air is safe and effective in selected
patients, Dis. Colon Rectum 57 (7) (2014) 875–881.
[18] A. Titos-García, J.M. Aranda-Narváez, L. Romacho-López, A.J. González-Sánchez,
I. Cabrera-Serna, J. Santoyo-Santoyo, Nonoperative management of perforated
acute diverticulitis with extraluminal air: results and risk factors of failure, Int. J.
Colorectal Dis. 32 (10) (2017) 1503–1507.
[19] A. Thorisson, K. Smedh, M.R. Torkzad, L. Påhlman, A. Chabok, CT imaging for
prediction of complications and recurrence in acute uncomplicated diverticulitis,
Int J Colorectal Dis [Internet] 31 (2) (2016 Feb) 451–457, https://doi.org/
10.1007/s00384-015-2423-3. Available from:.
[20] A. Lahat, B. Avidan, E. Sakhnini, L. Katz, H.H. Fidder, S.B. Meir, Acute
diverticulitis: a decade of prospective follow-up, J. Clin. Gastroenterol. 47 (5)
(2013) 415–419.
[21] J. Meyer, A. Caruso, E. Roos, A. Balaphas, C. Toso, P.-A. Poletti, et al., The clinical
significance of extraluminal air in Hinchey 1a diverticulitis: results from a
A. Karentzos et al.
retrospective cohort study with 10-year follow-up, Int. J. Colorectal Dis. 34 (12)
(2019 Dec) 2053–2058.
[22] Ç. Ünlü, N. De Korte, L. Daniels, E.C. Consten, M.A. Cuesta, M.F. Gerhards, et al.,
A multicenter randomized clinical trial investigating the cost-effectiveness of
treatment strategies with or without antibiotics for uncomplicated acute
diverticulitis (DIABOLO trial), BMC Surg. 10 (2010) 1–10.
International Journal of Surgery 85 (2021) 1–9
[23] A.-M.E. Sirany, W.B. Gaertner, R.D. Madoff, M.R. Kwaan, Diverticulitis diagnosed
in the emergency room: is it safe to discharge home? J. Am. Coll. Surg. 225 (1)
(2017 Jul) 21–25.
[24] D. Isacson, A. Thorisson, K. Andreasson, M. Nikberg, K. Smedh, A. Chabok,
Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a
prospective study, Int. J. Colorectal Dis. 30 (9) (2015 Sep) 1229–1234.