The Hinchey classification wasproposed in1978 based on clinical and surgicalfindings, and has since beenused as an importantdeterminant of risk factors for clinical decision-making(6, 7). Several studiesreportthat either medical treatment, drainage, orcolectomy are required based on classification. For class 2, medical treatment is still considered amajor approach, and surgery is regarded as asalvage strategy (8). Hinchey class 3 and 4 are considered to indicate surgical treatment(2), withHartman’s operation or colectomy with primary resection both representing common choices(9).Still, emergent surgery for diverticulitis is riskier, and Hartmann’s operation for this condition has a lower likelihood of closure ostomy(10).
Since CT is widely used as noninvasive diagnostic tool in the ER(11),diagnosis ofacute diverticulitis hasbecome more accurateand safe. In particular,when patients exhibitsigns ofinfection, CT can provide more data regarding the intra-abdominal condition, including the presence of abscesses or free air (12). Modified Hinchey classifications wereintroduced in1997 by Sher et al.(7), and 1999 byWasvary et al.(13); both were modified according toclinical findings. According to the literature, the severity of diverticulitis determined via CTis a good predictive factor for medical failure (14), especially when abscesses, extraluminal free air,or contrast were observed. A study in 2005 listed a more detailed classification using CT, which wasused as decision making tool; only 22% of patients with abscessesrequiredurgent surgery (15).
The WSES guidelines have been suggested since 2016 withincreasing evidence for emergent treatment using CT findings (16). The guidelines indicatemedical treatment for pericolic air or small fluid collection, and distant air without diffuse fluid accumulation can also betreated medically initially. These guidelines were revised in 2020 to guideright-sided diverticulitis treatment (17). The principles of diagnosis and treatment for both sides are the same; however, stool type is different in the right and left colon. Diverticulitis pattern is also different between sides, including formation,etiology (18–20).
Our data mimics that of previous literature within theAsian population where the right side is predominant (Table 1); additionally, we observed thatwhite blood count (WBC) wasnot a good index (Table 2).AlthoughourCRP data wasnot statistically different between right-and left-sided diverticulitis, the difference in mean value wasstill obvious (6 vs. 9); still, CRP wassignificantly higher in patients who underwentsurgery. Our data showed that the likelihood ofsurgerywashigher in patients with left-sided diverticulitis (Table 3).Previous research also demonstrates more emergent operations are performed for complicated left-sided diverticulitis; however, no reasons werereported (21).
Not all patients with free air requireoperation (Table 4), especially when air is limiting in the pericolic region. Most cases of colon diverticulitisappear within limited locations(22),and the relationship between the colon and surrounding organs is not symmetrical.There arealsodifferencesin the proportion of mesocolon coverage to colon lumen,as well asstool type, which may haveproducedthese results. Thus, we doubt thatmajor inflammation of thelumen will affect patients’ appearance and treatment.
Inour study, we classified the major inflammation sitesusingCT scan in the ER. Location 1 included the medial side to anterior region,as this portion generally has no fixed organs or tissue to help the external-adhesion process. The small intestine and omentum arecommonlyknown torandomlyattach to perforation or severe inflammation. Location 2 included thelateral side of body, which is easily sealedbythe abdominal wall or retroperitoneal region. Inthis region, inflammation doesnot spread easily; however, abscess formation along the abdominal muscle mayoccasionally occur. Drainage in this area is less risky forthe small intestine, and multiple drainage may also be performed. Location 3 wasdefined as the region near the mesocolon.The tenia mesocolica and mesocolon promote muscular support and resistance against minor inflammation, and this region can be observed via CT (23).
In our data analyses, we observedmore cases with right-sided diverticulitis in locations 1 and 3;conversely, location 3 in left-sided diverticulitis wasrare (Table 5). Thus, we evaluated thelocation and likelihoodof emergent operation (Table 6). Although there was no significant difference between location and surgery, we still found that no surgeries were performed for location 3,and few surgeries were performed in location 1. Additionally, emergent surgerywas found to be riskierfordiverticulitis on thelateral side of the lumen. We consider thatthese results maybe be limitedby the limited number of surgery cases, and additionalresearch with a larger cohort is requiredto understand whether abdominal wall adhesion is a good or poorprognostic factor for medical success.We further analyzed our data regarding location, age, and inflammatorycondition. Our data demonstratedno significant differences regarding region, age, WBC, or CRP (Table 7); however, we found that the mean CRP was minor for location 1.