Surgery xxx (2020) 1e6

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Surgery
journal homepage: www.elsevier.com/locate/surg

Treating acute colonic diverticulitis with extraluminal pericolic air:

An Acute Care Surgery in the Netherlands (ACCSENT) multicenter
retrospective cohort study
Sanne Vogels, MDa,*, Martine Frouws, MD, PhDb, Annelien N. Morks, MDc,
Daphne Roos, MD, PhDd, Jephta van den Bremer, MDa, Sacha M.P. Koch, MD, PhDa,
Robin H.M. Smithuis, MDe, Rigo Hoencamp, MD PhDa,f,g,h,
Gwendolyn M. van der Wilden, MD, PhDa
a
Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands
b
Department of Surgery, Groene Hart Hospital, Gouda, The Netherlands
c
Department of Surgery, Haga Hospital, The Hague, The Netherlands
d
Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
e
Department of Radiology, Alrijne Hospital, Leiderdorp, The Netherlands
f
Department of Surgery, Leiden University Medical Center, The Netherlands
g
Trauma Research Unit, Department of Trauma Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
h
Defense Healthcare Organization, Ministry of Defense, The Hague, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Background: Owing to improved quality of computed tomography, a new category of complicated acute
Accepted 26 October 2020 diverticulitis, including patients with pericolic air but without abscess formation, can be defined (Hin-
Available online xxx chey 1a). Recent studies question whether this new category of acute diverticulitis could be treated as
uncomplicated cases. The aim of our study is to report on the clinical course of acute diverticulitis
Hinchey 1a in current clinical practice.
Methods: For this multicenter retrospective cohort study, patients presenting at the emergency
department with Hinchey 1a acute diverticulitis as demonstrated by computed tomography scan, were
identified. The primary outcome measure was successful conservative treatment with observation alone,
antibiotics, and/or hospital admission. Readmissions, percutaneous drainage of abscesses, and emer-
gency operations were considered as failure.
Results: Between October 2016 and October 2018, 1,199 patients were clinically suspected for acute
diverticulitis, of whom 101 (8.4%) were radiologically diagnosed to have type 1a acute diverticulitis
(average age 57 (±13) years, 45% female) and started with conservative treatment. This was successful in
86 (85%) patients. One of the 15 unsuccessfully treated patients (1%) received percutaneous drainage of
an abdominal abscess. Surgery was required in 9 cases (9%) after a median time of 6 days (range, 3 to 69
days). Although a difference in the volume of extraluminal air on computed tomography scan was found,
this was not shown to be a risk factor for the clinical course.
Conclusion: Patients with type 1a acute diverticulitis can be treated successfully by conservative therapy
in the majority of cases (85%). More research is required to define predictive factors for successful
conservative management.
© 2020 Published by Elsevier Inc.

Introduction

Acute diverticulitis (AD) is a growing health care problem in

Western countries, accounting for a significant proportion of
* Reprint requests: Sanne Vogels, MD, Alrijne Hospital, Department of Surgery,
Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands. annual presentations at the emergency department (106 per
E-mail address: svogels@alrijne.nl (S. Vogels). 100,000 visits in the US population1) and a growing number of

https://doi.org/10.1016/j.surg.2020.10.032
0039-6060/© 2020 Published by Elsevier Inc.
2 S. Vogels et al. / Surgery xxx (2020) 1e6
Table I
Modified Hinchey classification by Wasvary et al15
0 Mild clinical diverticulitis
Ia Confined pericolic inflammation or phlegmon
Ib Pericolic or mesocolic abscess
II Pelvic, distant intra-abdominal, or retroperitoneal abscess
III Generalized purulent peritonitis
IV Generalized fecal peritonitis
admissions to the hospital.2e5 The extent of complexity in AD
ranges from uncomplicated colonic inflammation that can be
treated in an outpatient setting to complicated diverticulitis with
the formation of abscesses, fistulas, strictures, perforations with
extraluminal air, and/or purulent or fecal peritonitis. Most cases of
complicated AD require the use of antimicrobial regimens or
interventional treatment, like percutaneous drainage (18%e28%) or
emergency surgery (4%e26%).6 The latter is associated with high
morbidity (up to 52%) and mortality (10%e25%) rates.7e10
The various stages of diverticulitis were initially categorized
preoperatively by Hinchey et al in 1978, mainly using ultrasonog-
raphy.11 Yet, with computed tomography (CT) imaging becoming
the new gold standard for diagnosis, the extent of diverticulitis is
estimated more accurately. Therefore, various modifications of
Hinchey’s staging or new classifications were proposed in recent
literature, mostly based on CT findings.12e14 Sartelli et al introduced
a new category of complicated diverticulitis where next to the in-
flammatory process merely pericolic air was found on the
abdominal CT scan, without abscess formation or signs of perito-
nitis.12 This pericolic air is thought to result from micro-, covered,
or localized perforations due to the inflammation of diverticula and
can be categorized within the modified Hinchey classification as
complicated diverticulitis category 1a (Table I).15
Evidence regarding the exact natural course of AD with pericolic
air is limited; however, most studies suggest that intervention is
required.16e19 Current guidelines recommend conservative treat-
ment for this group of AD patients, including observation and an-
tibiotics based on the clinical presentation.16,20e23 Consensus on
optimal treatment is lacking, whereby patients are often treated
based on expert opinions. Subsequently, this could lead to over or
undertreatment among this group of patients. A cautious approach
might also cause additional health care costs like unnecessary
hospital admissions and the administration of intravenous (IV)
antibiotics.
Studies question whether this newly defined stage of acute
diverticulitis could actually be regarded as a mild uncomplicated
diverticulitis, rather than a complicated diverticulitis that needs
aggressive treatment.16e18 Evidence justifying a more conservative
treatment is limited to some small cohort studies.19,24 To further aid
the establishment of an evidence-based treatment, the current
study aimed to illustrate the clinical course of patients with AD
with extraluminal pericolic air, ie, Hinchey 1a, and tried to identify
factors associated with successful conservative treatment.
Methods
Study design
A multicenter retrospective observational cohort study was
conducted in 4 nonacademic teaching hospitals. The study protocol
was reviewed by medical ethics committee Leiden-Den Haag-Delft
in Leiden and approved under number G19.107. The study protocol
complied with the Declaration of Helsinki.
Study population
A search for the International Classification of Diseases, 10th
revision, code “K57; diverticular disease of intestine” was per-
formed in the electronic patient files of patients visiting the
emergency department between October 2016 and October 2018.
Patients diagnosed with acute diverticulitis were selected. Only
patients evaluated by the use of an abdominal CT scan that revealed
AD with pericolic extraluminal air were included (Hinchey 1a). All
patients presenting with a different Hinchey category or radiologic
findings like distant air, abscess formation, or signs of peritonitis
were excluded.
Data collection
Electronic patient files were analyzed for patient characteristics,
medical history, use of medication, and previous episodes of AD.
Additionally, information concerning the onset and type of symp-
toms of the current AD episode, previous use of antibiotics, and
other clinical signs associated with malaise were recorded. The
biochemical laboratory results (hemoglobin, C-reactive protein
[CRP], white cell count [WBC] levels, and erythrocyte sedimenta-
tion rate) and urine samples retrieved on presentation were
documented.
In all patients, a spiral CT scan (64 slice scanner) was performed
in supine position and by administration of IV contrast (Ultravist,
300/500; Bayer, Amsterdam, The Netherlands). Both axial and
coronal images were conducted, spaced with either 0.3 mm or 0.5
mm and with a 512 matrix.
The report of the abdominal CT scan was analyzed for terms like
pericolic free air, air bubbles, air pockets, extraluminal air, or
covered perforation. All scans were reanalyzed by 2 investigators
(SV and GW) for the presence of pericolic air as previously defined
by Sartelli et al.12 This study states that the air collection should be
within 5 centimeters of the inflamed bowel segment. Therefore,
distance of the free air bubble to the inflamed segment was
determined, as was the largest diameter in either the axial or the
coronal plane. The latter serves as an estimation of the bubble’s
volume. In order to adhere to the classification by Sartelli et al,12
patients with extraluminal air more than 5 centimeters from the
affected segment (category 2B) were excluded from analysis. Any
disagreement or doubt was resolved by consultation of a
radiologist.
Subsequently, the extent of the conservative treatment
regimen started in accordance with the expert opinion of the
surgeon on duty, after presentation at the emergency room,
was recorded in the database. This included the use of antibi-
otics, admission to the hospital and the duration of stay, a
second presentation at the emergency room, performance of
radiologic interventions, and/or the performance of a surgical
procedure.
Definition of outcomes
The primary outcome was successful conservative treatment,
defined as outpatient observation without interventions, admission
to the hospital for observation, and/or administration of antibiotics.
This also included treatment for patients who warranted admission
later in the course of illness.
 S. Vogels et al. / Surgery xxx (2020) 1e6 3

Fig. 1. Flow chart of study patients.

Any adverse events, including readmission, radiologic in- analyze potential risk factors. Subsequently, a multivariable
terventions, surgical intervention, and mortality were considered model was set up including all univariably associated factors
failure of conservative treatment. with P < .20. Odds ratios were presented with 95% confidence
intervals.

Statistical analysis Results

Statistical analysis was performed using SPSS statistics,
version 24 (IBM Corporation, Armonk, NY). Descriptive statistics
were provided for all previously mentioned variables. Results
were reported as means with corresponding standard deviations
(SD). Differences between groups were analyzed using an un-
paired t test, a 1-way analysis of variance, a Kruskal-Wallis test,
or Mann-Whitney U test for numerical data. A Pearson c2 test or
a Fisher exact test was used to analyze categorical data. A uni-
variable logistic regression analysis was performed in order to
Patient demographics study population
A total of 1,199 patients were diagnosed with AD at the emer-
gency room (Fig 1). Six hundred and thirty-four patients were
evaluated by an abdominal CT scan, of whom 101 met all inclusion
criteria of Hinchey 1a (8.4% of total). Demographics of the patients
who were admitted to the hospital with only observation (n ¼ 13),
observation and antibiotics (n ¼ 78), and those who required
radiologic or surgical intervention (n ¼ 10) are shown in Table II.
The mean age of included patients was 57 (±13) years. Female
4 S. Vogels et al. / Surgery xxx (2020) 1e6

Table II
Analysis of patients who did not receive any treatment (observation), who were started on antibiotic treatment, or who received any form of intervention (drainage or
emergency operation)

All patients Observation Antibiotic Intervention P value

(n ¼101) (n ¼ 13) treatment (n ¼ 78) (n ¼ 10)

Average age (y, SD) 57 (±13) 59 (±11) 56 (±12) 60 (±14) .44*

Female sex (n,%) 45 (45) 10 (77) 33 (42) 2 (20) .02y
History of diverticulitis (n,%) 15 (15) 3 (23) 11 (14) 1 (8) .61y
Charlson comorbidity index (mean, SD) 1.7 (±1.7) 1.7 (±1.7) 1.6 (±1.7) 2.4 (±2.2) .34*
Abdominal examination on initial presentation (n,%)
Involuntary guarding 8 (8) 0 (0) 5 (6) 3 (30) .04y
Rebound tenderness 36 (36) 5 (45) 28 (36) 3 (30) .94z
Vital parameters upon initial presentation (mean, SD)
Temperature (in degrees Celsius) 37.6 (±0.8) 37.4 (±0.7) 37.6 (±0.8) 37.6 (±0.9) .56*
Systolic blood pressure (in mm Hg) 137 (±18) 140 (±12) 136 (±18) 138 (±24) .76*
Diastolic blood pressure (in mm Hg) 81 (±12) 84 (±10) 82 (±12) 78 (±15) .58*
Pulse rate 89 (±16) 91 (±10) 89 (±17) 84 (±18) .65*
Respiratory rate 16 (±2) 14 (±1) 16 (±2) 16 (±1) .47*
Saturation (%) 97 (±2) 98 (±2) 97 (±2) 97 (±3) .83*
Biochemical analysis upon initial presentation (mean, SD)
Hemoglobin 7.9 (±0.9) 8.0 (±0.6) 9.0 (±0.9) 8.9 (±0.8) .00*
CRP 128 (±78) 141 (±67) 127 (±80) 114 (±78) .70*
WBC count 13.4 (±4.2) 12.2 (±4.9) 13.7 (±4.2) 12.8 (±4.0) .42*
Erythrocyte sedimentation rate 35 (±23) 45 (±25) 35 (±22) 22 (±16) .10*
Pericolic air on abdominal CT scan (median, IQR)
Diameter (in mm) 10 (8) 7 (8) 10 (8) 13 (9) .10x
Distance to colon (in mm) 2 (6) 0 (4) 2 (6) 2 (7) .44x

IQR, interquartile range; n, number of patients.

*
One-way analysis of variance.
y
Fisher exact test.
z
c2 test.
x
Kruskal-Wallis test.

patients were significantly more represented in the observation this group was 12 (±7) days, and the mean duration of hospitali-
group compared to the antibiotic or intervention group. The mean zation was 14 (±6) days.
duration of hospitalization was 6 (±5) days, with a maximum One patient, who was admitted twice, received a percutaneous
duration of 26 days. drainage during both admissions due to intra-abdominal abscess
formation, respectively 12 and 27 days after initiation of conser-
vative treatment with IV antibiotics.
Primary outcome: successful conservative treatment
Emergency surgery due to clinical deterioration was performed
in 9 patients, indicating that initial conservative treatment con-
Eighty-six patients (85%) were treated successfully in an
sisting of admission and IV antibiotics failed. The surgery took place
outpatient setting or by hospitalization with or without using an-
during initial admission in 5 cases, whereas 4 patients were oper-
tibiotics (Table III). Fourteen of these 86 patients (17%) were pre-
ated on readmission. A second abdominal CT scan was performed
sented for a second time at the emergency room. No change in
preoperatively in 3 of these patients, which confirmed the
conservative treatment regimen was required in 10. Three patients
impairment of the AD. The procedures performed in this emer-
who initially followed an outpatient observational approach dete-
gency setting were Hartmann’s procedure (n ¼ 5), a laparoscopic
riorated and were admitted for IV antibiotics. One patient, who was
assisted sigmoidectomy with diverting ileostomy (n ¼ 1), a lapa-
admitted and treated with IV antibiotics after the first presentation,
roscopic (n ¼ 1) or laparotomic (n ¼ 1) abdominal lavage, and a
received a new regimen of oral antibiotics for a newly diagnosed
laparotomy to repair the perforation with an omental patch (n ¼ 1).
urinary tract infection.
The latter procedure was complicated by abscess formation that
In sum, 69 of the 101 subjects (68%) were successfully treated
resolved after percutaneous drainage during a readmission. The
with IV antibiotics and 4 patients (4%) with oral antibiotics in an
median time between the diagnosis of Hinchey type 1a AD and the
outpatient setting. All received broad-spectrum antibiotics with a
emergency surgery was 6 days, ranging from 3 to 69 days. One
mean duration of treatment of 8 (±4) days. Thirteen patients (13%)
patient receiving a Hartmann procedure in the initial admission
were observed in the hospital (n ¼ 11, 11%) or in an outpatient
died during follow-up due to respiratory insufficiency secondary to
setting without antibiotics (n ¼ 2, 2%). The mean overall hospital
a bilateral pneumonia.
stay in this group was 5 (±3) days. Various months after this
episode of AD, 4 patients received an elective sigmoidectomy for
frequent recurrence (n ¼ 2) or diverticular stenosis (n ¼ 2).
Factors associated with successful conservative management

Secondary outcome: failure of conservative treatment
Conservative treatment failed in 15 out of 101 included patients
(15%), as readmission (n ¼ 10), radiologic intervention (n ¼ 1), or
emergency surgery (n ¼ 9) was required. Of the readmissions, 5
patients were observed and/or treated with IV antibiotics due to
clinical deterioration. The mean duration of antibiotic treatment in
Sex, the presence of involuntary guarding on physical exami-
nation, levels of CRP, and a larger diameter of extraluminal air on
the abdominal CT scan were identified as potential risk factors in
the univariate analysis. However, no relevant risk factors for suc-
cessful conservative treatment could be identified in the multi-
variate analyses, as none of the odds ratios showed to be
statistically significant (Table III).
 S. Vogels et al. / Surgery xxx (2020) 1e6 5

Table III
Patients receiving successful conservative treatment compared to patients who required readmission, drainage, or emergency operation (failure of conservative treatment)

Successful conservative Failure of conservative P value Unadjusted OR Adjusted OR

treatment (n ¼ 86) treatment (n ¼ 15) (95%CI)* (95%CI)y

Average age (y, SD) 56 (±12) 59 (±14) .39z 1.02 (0.98e1.07) -

Female sex (n,%) 41 (48) 4 (27) .17x 0.40 (0.12e1.35) 0.46 (0.13e1.70)
History of diverticulitis (n,%) 12 (14) 3 (20) .69x 1.54 (0.38e6.28) -
Charlson comorbidity index (mean, SD) 1.6 (±1.6) 2.1 (±2.3) .24z 1.19 (0.89e1.58) -
Abdominal examination upon initial presentation (n,%)
Involuntary guarding 5 (6) 3 (20) .09x 4.05 (0.86e19.17) 4.68 (0.92e23.85)
Rebound tenderness 31 (36) 5 (33) 1.00|| 0.89 (0.28e2.83) -
Vital parameters upon initial presentation (mean, SD)
Temperature (in degrees Celsius) 37.6 (±0.8) 37.7 (±0.9) .57z 1.23 (0.62e2.44) -
Systolic blood pressure (in mm Hg) 136 (±17) 138 (±25) .75z 1.00 (0.98e1.04) -
Diastolic blood pressure (in mm Hg) 82 (±12) 78 (±14) .28z 0.98 (0.93e1.02) -
Pulse rate 89 (±16) 88 (±19) .94z 0.99 (0.97e1.03) -
Respiratory rate 16 (±2) 15 (±2) .77z 0.94 (0.64e1.39) -
Saturation (%) 97 (±2) 97 (±3) .95z 0.99 (0.76e1.30) -
Biochemical analysis upon initial presentation (mean, SD)
Hemoglobin 8.8 (±0.9) 8.9 (±0.8) .89z 1.05 (0.57e1.93) -
CRP 133 (±78) 97 (±74) .10z 0.99 (0.99e1.00) 0.99 (0.98e1.00)
WBC count 13.5 (±4.3) 13.4 (±3.6) .93z 0.99 (0.87e1.13) -
Erythrocyte sedimentation rate 35 (±23) 35 (±25) .93z 0.99 (0.97e1.03) -
Pericolic air on abdominal CT scan (median, IQR)
Diameter (in mm) 10 (8) 13 (7) .06¶ 1.04 (0.98e1.10) 1.04 (0.97e1.11)
Distance to colon (in mm) 2 (5) 3 (8) .68¶ 1.01 (0.92e1.11) -

IQR, interquartile range; n, number of patients.

*
OR in univariable analysis.
y
OR in multivariable analysis.
z
Independent sample t test.
x
Fisher exact test.
||
c2 test.
¶
Mann-Whitney U test.

Discussion interobserver variation, which strengthens the assumption that

The current study describes the clinical course of patients
treated for a Hinchey type 1a AD with pericolic extraluminal air in 4
hospitals in the Netherlands. Of the included patients, 85% were
treated successfully with a conservative treatment regimen.
Therefore, nonsurgical management of Hinchey type 1a AD appears
to be safe in the majority of cases. Factors associated with successful
conservative treatment could not be identified.
All patients in the current cohort started with conservative
treatment after presentation at the emergency room, consisting of
either an outpatient observational management or admission to the
hospital or the use of oral or IV antibiotics. This treatment regimen
was considered unsuccessful after adverse events like readmission,
percutaneous drainage, or emergency surgery. With this definition,
86 of the included patients were treated successfully, resulting in a
success rate of 85%. There are multiple studies reporting on suc-
cessful conservative management with success rates of 91%,19
92%,24 and 90%.17 However, Bolkenstein et al24 did not use read-
mission as criterion for failure of treatment, and the other 2 studies
did not specify the role of a readmission. Readmission was
considered a failure in our study in order to illustrate financial ef-
ficacy as well. Excluding readmissions as failure of conservative
treatment gives a 90% success rate, which is comparable to previous
studies.
Clinical predictors for failure of conservative treatment in this
group of patients are currently undefined. Previous studies sug-
gested that volume and distance of pericolic air could potentially
serve as predictive factors for clinical outcome.17,24 Whereas the
diameter of the pericolic air in our study was found to be smaller in
the group that was successfully treated with conservative man-
agement (Table II), the predictive value of this parameter could not
be confirmed (odds ratio [OR] 1.04, 95% confidence interval [CI]
0.97e1.11; Table III). Also, exact determination of the volume of
pericolic air on a CT scan remains difficult and is susceptible to
usage of this parameter as clinical predictor should be done with
great caution.
Other clinical factors identified in previous literature were the
presence of increased inflammatory parameters and multiple
comorbidities. Some authors claim that an increased CRP and WBC
count predicted failure of conservative treatment.24 Titos García
et al identified a classification as American Society of Anesthesiol-
ogist III or IV as relevant risk factor.17 The discriminative value of
these predictors was not confirmed by our data (Charlson comor-
bidity index OR 1.19, 95% CI 0.89e1.58; CRP OR 0.99, 95% CI
0.98e1.00; WBC OR 0.87 95% CI 0.87e1.13; Table III). However, next
to these clinical factors, general impression and findings on phys-
ical examination often determine treatment approach in daily
practice yet are often excluded from analysis. Future research will
be required to define the predictive value of various clinical
parameters.
Aside from the nonrandomized retrospective character, this
study was limited by the small numbers of patients who could be
included in the group that was observed without antibiotic treat-
ment. We believe this represents the current lack of consensus and/
or knowledge on optimal management for this patient group,
whereby less aggressive treatment is not encouraged. Also, 565 out
of the 1,199 AD patients who presented at the emergency room did
not receive an abdominal CT scan, whereby prevalence of the
Hinchey type 1a AD may be underestimated in our cohort. This
methodological bias potentially resulted in the exclusion of type 1a
AD patients with a mild clinical presentation, whereas these were
also our subjects of interest. Nevertheless, the clinical course of the
11 included patients who received observational management
turned out to be promising and does imply the presence of over-
treatment as was already suggested in previous literature.24
In conclusion, the clinical implications of isolated pericolic air on
abdominal CT scans remain debatable and consensus on optimal
treatment is currently not available. Almost 90% of patients with
6 S. Vogels et al. / Surgery xxx (2020) 1e6
type 1a AD can be treated conservatively and some even without
hospital admission and/or IV antibiotics. More research is required
to define predictive factors for successful conservative or observa-
tional management.
Conflict of interest/Disclosure
The authors have no conflict of interest to declare.
Funding/Support
This study had no study sponsors.
Acknowledgments
Dr R.F. Schmitz and Dr J.W.S. Merkus are acknowledged for
supporting the arrangement of permission for execution of this
study at their hospital.
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