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44 Locally Advanced Rectal Cancer

347

R-01 trial conrmed the importance of multimodality therapy, and in 1990 a National Institutes of Health (NIH) Consensus Development Conference on Adjuvant Therapy for Patients with Colon and Rectum Cancer recommended postoperative chemoradiation as standard treatment for patients with locally advanced rectal cancer.

The Swedish Rectal Cancer Trial, published in 1997, randomized patients to receive short-course radiation therapy using 5 Gy daily over 5days without chemotherapy followed by surgery 1week later versus surgery alone. This trial demonstrated the benets of short-course neoadjuvant radiation with local recurrence rates of 9% versus 26% in the surgery alone cohort. Furthermore, this has been the only study to demonstrate an overall survival advantage with multimodality therapy. This study has been criticized however because patients had not undergone TME.In 2001, a randomized study conducted by the Dutch Colorectal Cancer Group found that local recurrence rate was 8.2% after TME alone but only 2.4% after short-course radiation therapy followed by TME. Based on these studies, short-course radiation therapy is advocated in Northern Europe and

Scandinavia. However, in large part due to the GITSG and NSABP R-01, long-course chemoradiation therapy (conventional doses of radiation fractionated over 5 weeks to a total dose of 50.4Gy) with concurrent administration of 5-FU based chemotherapy has been favored in North America and some European countries.

In 2004, the German Rectal Cancer Study Group demonstrated that neoadjuvant chemoradiation was more effective than postoperative chemoradiation for reducing local recurrence rates (6% vs 13%), increasing rates of sphincter-preservation, and decreasing the incidence of signicant acute and long-term toxicities. Neoadjuvant use of long-course chemoradiation therapy or shortcourse radiation therapy followed by TME provides durable local control. Postoperative adjuvant chemoradiation remains an option for patients whose disease is understaged by preoperative imaging; reportedly as many as 22% of patients with locally advanced rectal cancer (Table44.2).

J. Because as many as 20–25% of patients will

eventually develop metastatic disease after curative resection of locally advanced rectal cancer, adjuvant chemotherapy has been used

Table 44.2 Summary of landmark randomized controlled trials inlocally advanced rectal cancer

Trial Treatment groups GITSG, 1985 1. Adjuvant

NSABP R-01, 1988

Swedish Trial, 1997

Dutch Trial, 2001

German Trial, 2004

GITSG Gastrointestinal Tumor Study Group, NSABP National Surgical Adjuvant Breast and Bowel Project, TME total mesorectal excision, DFS disease-free survival, OS overall survival

chemoradiation

2. Observation

1. Adjuvant chemotherapy

2. Adjuvant radiation

3. Observation

1. Preoperative short course radiation

2. Observation

1. Neoadjuvant short course radiation

2. TME

1. Neoadjuvant chemoradiation

2. Adjuvant chemoradiation

TME performed? Findings

No Adjuvant chemoradiation reduces local recurrence

55% to 33%

No Chemotherapy improved DFS and OS compared to

observation; Radiation therapy reduced local recurrence compared to observation

No Demonstrated overall survival advantage with

preoperative short course radiation

Yes Neoadjuvant short course radiation reduced local

recurrence by >50%

Yes Neoadjuvant chemoradiation associated with improved

local control (6% vs 13% recurrence)

348

D. W. Nelson and A. J. Bilchik

to eradicate systemic micrometastatic disease. Although the largest trial examining the role of adjuvant chemotherapy for locally advanced rectal cancer (European Organization for Research and Treatment of Cancer [EORTC] 22921) found no signicant improvement in disease-free survival or overall survival, only 43% of patients completed the full course of adjuvant chemotherapy. Despite inconclusive data, the National Comprehensive Cancer Network (NCCN) recommends adjuvant chemotherapy for all stage II and III rectal cancers regardless of nal pathological results. Acceptable regimens include 6 months of combination 5FU+leucovorin or capecitabine in combination with oxaliplatin or 5FU + leucovorin or capecitabine alone.

K. In an effort to address high rates of distant

metastatic disease recurrence and improve long term outcomes among patients with rectal cancer, recent trends have shifted focus of the role and timing of additional systemic treatments. Multiple trials have demonstrated promising outcomes using a total neoadjuvant approach where all planned radiation and systemic therapy are administered prior to surgery. Theoretical benets of this approach include improved compliance, decreased treatment-related toxicity, early elimination of micrometastatic disease, greater downstaging and potential for organ preservation options, assure complete (R0) resection, and possibly allow earlier reversal of diverting stoma. Conversely, a total neoad-

juvant approach may negatively impact patient performance status, potentiate risk of postoperative complications or overtreat patients that may be cured by surgery alone.

In a phase 2 trial, Garcia-Aguilar et al examined the effectiveness of the neoadjuvant approach by comparing four treatment arms stratied by the number of cycles of neoadjuvant chemotherapy following chemoradiation. Compliance was considerable with 77-82% of patients completing all therapy. Furthermore, the authors demonstrated that rates of pCR improved from 18% to 38% with increasing number of cycles of neoadjuvant chemotherapy. The Spanish GCR-3 phase II trial directly compared the total neoadjuvant approach with the traditional paradigm of neoadjuvant chemoradiation, followed by surgery and adjuvant chemotherapy. Compliance rates with a total neoadjuvant approach were 94% compared to just 57% in the adjuvant treatment group. Furthermore, the total neoadjuvant approach was associate with signicant reductions in toxicity-associated adverse events (19% vs. 54%). Despite these encouraging ndings, there was no difference in pCR rate between treatment arms and although not powered to detect long-term disease outcomes, 5-year disease-free survival rates were similar (62% vs. 64%) (Table 44.3).

Given promising initial results of the total neoadjuvant approach, the NCCN guidelines consider administration of 12-16 weeks of 5FU + leucovorin or capecitabine in combination with oxaliplatin followed by chemora-

Table 44.3 Summary of total neoadjuvant therapy trials inlocally advanced rectal cancer

Trial Treatment groups Findings Garcia-Aguilar etal., 2015 Four arms

Neoadjuvant chemoradiation followed by 0, 2, 4 or 6 cycles of mFOLFOX6

Spanish GCR-3, 2015 1. Neoadjuvant chemoradiation

followed by surgery and 4 cycles of adjuvant CAPOX

2. Neoadjuvant 4 cycles of CAPOX followed by chemoradiation and surgery

TNT total neoadjuvant therapy, pCR pathologic complete response, DFS disease-free survival

Compliance 77–82% pCR rates increased by 20% with 6 cycles of mFOLFOX6

Compliance 94% vs 57% in favor of TNT group TNT associated with reduced toxicity No difference in 5-Year DFS

44 Locally Advanced Rectal Cancer

349

diation and surgery an acceptable option in the treatment of locally advanced rectal cancer. Further research will be needed to elucidate long-term outcomes of this approach.

L. Surveillance after surgery includes ofce vis-

its at 3–6months for the rst 2 years and then every 6months for up to 5years. Ofce visits should include complete history and physical. A rising CEA level in the postoperative period may indicate recurrence. Proctoscopy is recommended every 6 months for 3–5years. Colonoscopy should be performed 1 year after surgery unless it was not performed preoperatively; in this case colonoscopy can be performed 3–6 months after surgery. Annual CT of the chest, abdomen and pelvis is also recommended for the rst 5years after surgery.

In summary, patients with locally advanced rectal cancer require multimodality treatment that includes neoadjuvant chemoradiation, TME, and postoperative chemotherapy. A thorough understanding of the anatomy, evaluation, staging and available treatment options is essential to formulating individualized clinical decision algorithms.

Colonic: Diverticulitis

MatthewT.Brady andJasonF.Hall

Refer to Algorithm in Fig. 45.1

Colonic diverticula are saccular outpouchings of the colon wall. While true diverticula contain all layers of the intestinal wall, diverticulosis of the colon generally refers to herniation of the mucosal, and muscularis mucosal layers of the colon. These diverticula arise from the sites at which the vasa recta penetrate the circular muscle layer of the colon wall to provide blood ow to the colonic mucosa. The sites, at which the vasa recta penetrate, are typically seen along the mesenteric borders of the anti-mesenteric taenia coli at the sites of perforating vessels. Diverticula can also arise, in the absence of a perforating vessel, at sites of pressure atrophy within the circular muscle layer. In the absence of infection and inammation these diverticula are soft, compressible, and in free communication with the lumen of the colon.

In Western societies, the presence of diverticulosis is rare under the age of 40 years, although that risk is thought to steadily thereafter, estimated to rise between 50–70% in patients 80years and

M. T. Brady Department ofSurgery, Boston Medical Center/Boston University School ofMedicine, Boston, MA, USA

J. F. Hall (*) Department ofSurgery, Boston Medical Center/Boston University School ofMedicine, Boston, MA, USA

Boston University School ofMedicine, Boston, MA, USA e-mail: Jason.Hall@bmc.org

older. While the true prevalence of diverticulosis is difcult to assess given its asymptomatic nature, post-mortem studies conrm its development is associated with increasing age. It is estimated that upwards of 25% of patients with diverticulosis will develop a complication related to their diverticular disease and 1–2% of those patients will require hospitalization.

Diverticular disease historically has been a disease of the twentieth century. An increased prevalence of diverticulosis and its associated disease states were seen in the early 1900s following the Industrial Revolution in the late 1800s which lead to an increased dietary intake of milled grains and rened sugars in industrialized nations. The increased availability of rened grain and sugars resulted in a concomitant decrease of dietary ber intake. The relationship between dietary ber and diverticulosis has been supported by numerous studies in the past century. Early studies by Painter and Burkitt compared dietary ber intake between populations in the United Kingdom and SubSaharan Africa and found decreased stool weight and stool transit times in the UK population. In westernized populations, those who consumed a diet high in vegetables and dietary ber have been found to have decreased rates of diverticulosis while those patients which diets rich in meats are found to have increased rates of diverticular disease, further supporting the dietary hypothesis. While life expectancy differences between African and the UK has been purported to confound the ndings of Painter and Burkitt, additional data has

https://doi.org/10.1007/978-3-319-65942-8_45

353

354

Fig. 45.1 Algorithm for colonic diverticulitis.

∗

Uncomplicated diverticulitis can typically be treated by antibiotic therapy alone. tis can present with acutely with a perforation or in a delayed manner with an associated stula or stricture. Perforated diverticulitis can be classied according to the Hinchey classication scale. 3 cm are unlikely to resolve with antibiotic management alone and should be drained percutaneously.

∗∗

Complicated diverticuli-

∗∗∗

Abscesses over

M. T. Brady and J. F. Hall

Patients who do not improve with antibiotics and percutaneous drainage, or those who present in extremis, should undergo operative intervention to resect the diseased colon. ticulitis will require elective colectomy after resolution of symptoms and the decision to undergo elective resection should be individualized. ing with acute diverticulitis should undergo colonoscopy following resolution of symptoms

Not all patients with a history of diver-

Patients present-

arisen that suggests as African countries the adoption of a more westernized diet in these regions is associated with increasing rates of diverticular disease. Historically, consumption of some foods such as nuts, seeds, and popcorn, was thought to lead to diverticular obstruction and incite episodes of diverticulitis in patients with diverticulosis. The belief of these types of foods cause of diverticulitis does not hold merit and dietary modication to avoid these foods in patients with a history of diverticulosis is not necessary.

Non-dietary theories also exist for the development of diverticulosis. Increased pressure in the sigmoid colon is associated with increase visualization of diverticula on cineradiography, suggesting that colonic segmentation as a result of circular muscle contraction within the sigmoid colon leads to high-pressure areas within the lumen. These elevated pressures, over time, can lead to the mucosal herniation and the develop-

ment of diverticula. Increased deposition of elastin within the taenia coli has also been associated with increased rates of diverticulosis when compared with normal colon. Colonic segments associated with diverticulitis are typically shortened, with a thicker muscularis propria, compared with normal colon. This shortening is suggested to be the result of deposition of elastin within the taenia coli. While the exact cause of the elastin deposition is unclear but patients with diverticulosis were identied to have a 200% increase in elastin content in the taenia coli of patients with diverticulosis compared with controls. Despite increases in circular muscle thickness, alterations in collagen within the colon wall lead to decreased compliance of the colon and increased rates of submucosal tears and mucosal herniation.

The precise mechanism of progression from diverticulosis to acute diverticulitis remains incompletely understood. Some suggest that it is

45 Colonic: Diverticulitis

355

similar to appendicitis in that diverticular obstruction leads to bacterial overgrowth, wall ischemia within the diverticulum, mucosal injury and perforation. The presentation of diverticulitis can range from localized inammation within a colonic segment to free perforation and frank fecal peritonitis. Infection from diverticulitis is often mixed aerobic and anaerobic pathogens of colonic origin. Typical aerobic bacteria isolated include, Escherichia coli, Klebsiella, and alpha- hemolytic Streptococci, while typical anaerobic isolates include Bacteroides, Peptostreptococcus, Clostridia, and Fusobacterium (Table45.1).

A–C.The clinical presentation of acute diverticulitis is highly dependent on the severity of disease at the time of diagnosis. Typically, patients are compiled into two broad categories, uncomplicated and complicated diverticulitis. Uncomplicated diverticulitis typically exhibits a milder presentation and is more likely to respond to medical therapy and can often be treated as an outpatient depending on disease severity. Complicated diverticulitis is used as an encompassing term for diverticulitis with associated free perforation, abscess, stula, obstruction, or stricture, which requires inpatient treatment. Typically, patients will present with varying degrees of abdominal pain, often localized to the left lower quadrant. These patients often will exhibit fevers as well as an associated leukocytosis. Occasionally a mass in the left lower quadrant can be palpated. The presence of fecaluria, pneumaturia or pyuria increases the suspicion for a colovesical stula. Patients with free perforation, and either purulent or feculent peritonitis, will exhibit severe tenderness with rebound tenderness and guarding.

Table 45.1 Modied Hinchey classication

Ia Conned pericolic inammation or phlegmon Ib Pericolic or mesocolic abscess II Pelvic, distant intraperitoneal, or retroperitoneal

abscess III Generalized purulent peritonitis IV Generalized feculent peritonitis

Wasvary H, Turfah F, Kadro O, Beauregard W.Same hospitalization resection for acute diverticulitis. The American surgeon. 1999;65(7):632–635

D.Computed tomography (CT) is the current gold standard for diagnosis of diverticulitis. CT imaging provides detailed cross sectional images, which allow for conrmation of the clinical diagnosis, staging of disease severity, and guidance of treatment. Signs of diverticulitis on CT imaging include the pericolic fat stranding and colonic wall thickening in the presence of diverticula. Signs of complicated diverticulitis include pericolic abscess formation, intraperitoneal uid and air suggestive of free perforation. The presence of complicated diverticulitis on CT imaging is associated with increased rates of recurrence, complications related to the disease, and requiring operative intervention.

E.The original Hinchey classication system used to describe severity of diverticulitis was based on both clinical and intraoperative ndings. This classication system has been modied to incorporate the detailed imaging information now available with the advent of CT imaging. Grade 0 refers to colonic wall thickening in the absence of pericolic fat stranding, Grade 1a refers to colonic wall thickening associated with pericolic fat stranding; Grade 1b includes the addition of a pericolic abscess. Grade 2 refers to a remote intraabdominal or pelvic abscess. Grades 3 and 4, which are difcult to distinguish by imaging ndings alone, refer to purulent and feculent peritonitis respectively. Patients presenting with more severe disease, an associated abscess, and/or perforation, are more likely to experience disease recurrence following a trial of nonoperative management. This knowledge is useful when considering treatment options for patients with Grade 2 or higher presentations of diverticulitis and is useful for patient counseling.

F. Acute uncomplicated diverticulitis commonly presents with left sided abdominal pain, fever, and leukocytosis. Occasionally a left sided abdominal mass can be palpated. The treatment of acute uncomplicated diverticulitis is dependent on disease severity. Recent studies have examined the utility of antibiotic therapy for patients presenting with an initial episode of mild acute uncomplicated diverticulitis and have found that it may not affect patient outcomes compared with intravenous uids alone. Outpatient management of mild

356

M. T. Brady and J. F. Hall

cases of uncomplicated diverticulitis is successful in many patients but should be attempted only in reliable patients with the ability to tolerate oral intake and oral antibiotics. For patients not able to be managed at home, inpatient hospital stay with intravenous uids, antibiotics, and bowel rest is recommended. Antibiotic regimens for the treatment of diverticulitis are often institution specic. Treatment is aimed at coverage of the aerobic and anaerobic ora most commonly identied in diverticular perforations is advocated, both single and multi- agent approaches are acceptable.

G.Patients presenting with complicated diverticulitis as manifested by presence of a segment inamed colon containing diverticula with an associated abscess, perforation, stula, obstruction, or stricture are typically admitted to the hospital and managed through a multimodal approach dependent on the level of disease severity.

H. Patients presenting with perforated diverticulitis and diverticular abscesses should be treated with bowel rest and intravenous antibiotics.

I.Patients who do not respond to antibiotics alone should be evaluated by interventional radiology for percutaneous abscess drainage. Larger abscesses, >3–4cm, are unlikely to resolve with antibiotic therapy alone. The utilization of a multimodal nonoperative management, incorporating antibiotics and image guided directed drainage catheters, is successful in resolving 91% of presentations with acute complicated diverticulitis. Patients who do not respond to antibiotics and catheter drainage should be considered for surgery.

J. Patients presenting with perforated diverticulitis and diffuse peritonitis, and those who fail to improve with nonoperative management, should be managed surgically. Up to 25% of patients hospitalized with complicated diverticulitis will fail non-operative treatment and require surgery for their diverticular disease. Sigmoid colectomy with end colostomy and rectal stump, or Hartmann’s procedure, has long been the standard for surgical treatment of perforated diverticulitis. This technique removes the diseased colon diverts the fecal stream in patients with

ongoing peritonitis who may not tolerate a primary anastomosis. Sigmoid resection with primary colorectal anastomosis and proximal diversion is also an acceptable option for management of perforated diverticulitis. This approach benets by obviating the need for repeated laparotomy for stoma reversal. When primary anastomosis is undertaken an intraoperative leak test should be performed. Both laparoscopic and open approaches can be undertaken and are largely dependent on patient characteristics and surgeon expertise. Laparoscopic lavage has been advocated as an option in the surgical treatment algorithm for perforated diverticulitis. This technique involves performing a laparoscopic lavage of the peritoneal cavity while leaving the diseased sigmoid colon in place. The DILALA trial described that laparoscopic lavage was safe and feasible in patients with Hinchey III diverticulitis and single center data suggest it is a viable option in Hinchey III diverticulitis in experienced hands. The main criticism of this technique is that it leaves behind the offending colon and source of sepsis. Additionally, this technique has higher rates of surgical reintervention when compared with sigmoid colectomy. Both the SCANDIV and LADIES trials demonstrated signicantly higher re-intervention rates in those patients being treated with laparoscopic lavage compared with sigmoid colectomy. Though, while reintervention rates appear to be higher, in patients with Hinchey III diverticulitis, mortality appears to be similar at 30 and 90days. Currently the use of laparoscopic lavage in purulent or feculent peritonitis would not be recommended in these scenarios.

K. Diverticular strictures can present as a complete or partial large bowel obstruction in patients with a history of diverticulitis. Diverticular strictures account for far fewer large bowel obstructions than colon cancer, though they are associated with a higher in hospital mortality rate. The most common location for these strictures is within the sigmoid colon. Stricture management is most dependent on whether a partial or complete obstruction exists. Patients presenting with partial obstruction will endorse continued atus and bowel movements despite

45 Colonic: Diverticulitis

357

abdominal distention and radiologic evidence of a relative obstruction in the colon. These patients can be managed with bowel rest, intravenous uids, and antibiotics if ongoing infection is present. If patients improve with these initial measures, and are able to be decompressed, they can undergo elective resection with primary anastomosis.

Self-expanding metallic stents (SEMS) can be used in situations of partial obstruction where a guidewire can be passed beyond the point of obstruction. Proponents of the use of SEMS in diverticular stricture quote high mortality rates for patients undergoing emergent colostomy or colon resection for obstruction as a justication for its use. Compared with malignant obstructions, deployment of SEMS for diverticular strictures can be technically challenging secondary to longer segments of diseased colon and increased tortuosity. SEMS have higher rates of stent migration in benign disease leading some to caution against their use in diverticular strictures. Ideally, surgical intervention should follow within a month of stent placement. Patients presenting with large bowel obstruction who do not improve with nonsurgical measures should proceed for operative interventions to resect the diseased colon.

L. Fistulas can develop as a result of perforated diverticulitis. Colovesical stulas, between the bladder and colon, are the most common presentation of stula associated with diverticulitis, accounting for 65% of diverticular stulas. Patients with colovesical stulas present with urinary symptoms and polymicrobial urinary tract infections. Additionally these patients may exhibit fecaluria and pneumaturia. A CT scan nding of air in the bladder, in the absence of instrumentation, is highly suggestive of a colovesical stula. Colovesical stulas should be managed surgically. Typically the sigmoid colon is adherent to the bladder. Often the stula opening into the bladder is small and can be suture repaired or more often left open. These small stulas usually heal within 1–2 weeks after surgery. A cystogram should be obtained to document healing prior to postoperative bladder catheter removal. Following sigmoid colectomy, a pri-

mary anastomosis is appropriate in these circumstances. Additional common stulous presentations include colovaginal, coloenteric, and colocutaneous stulas. Often, in each case, the omentum can be used if available to place between the new colonic anastomosis and the site of the stula repair.

M.Elective resection for diverticular disease has become a controversial topic. Following resolution of a nonoperatively managed episode of uncomplicated diverticulitis, somewhere between 13–30% of patients will have a repeated episode. Additionally the majority of recurrences happen within the rst year of initial presentation suggesting these early “recurrent” presentations may simply reect inadequate treatment of the primary occurrence. Risk factors for recurrence of diverticulitis include a family history of diverticulitis, length of involved colon being >5cm, and presence of a retroperitoneal abscess. Interestingly right-sided diverticulitis was unlikely to recur. Additionally, it is rare for patients to present with severe complicated diverticulitis following an episode of nonoperatively managed uncomplicated diverticulitis. The risk of requiring emergency surgery following a resolved episode of nonoperatively managed acute diverticulitis is low and estimated at 1 in 2000 patient years. Recurrent diverticular disease is unlikely to present requiring emergent colectomy and colostomy formation, past recommendations for elective colon resection after a patient’s second episode of diverticulitis are now outdated and have been replaced by a more individualized approached to patient selection for operative management. Increasing episodes do not appear to be a risk factor for increasing rates of diverticular related morbidity or mortality, as patients presenting with complicated diverticulitis are more likely to do so on their rst presentation.

Young patients, <50 year of age, were historically though to have a more virulent form of diverticulitis that mandated resection. In actuality, young patients respond similarly to older patients in response to antibiotic therapy. Additionally, recurrence rates are similar between young and older patients. Young patients should therefore be managed accord-

358

M. T. Brady and J. F. Hall

ing to their clinical presentation as opposed to their age.

Immunocompromised patients are at increased risk for poor outcomes related to diverticulitis. Transplant recipients on chronic immunosuppressive therapy have an increased rate of mortality associated with nonoperatively managed diverticulitis, approximately 50%. Immunocompromised patients more commonly present with free perforation, more frequently require emergency operations, and have a high postoperative an in-hospital mortality, estimated at 39%.

N. Endoscopic evaluation of the colon following an episode of diverticulitis is often recommended despite low rates of identifying colorectal cancer in patients following episodes of diverticulitis are low and mirror that of the general population. When performed, endoscopic examinations are deferred until at least 6weeks following an episode of acute diverticulitis given concern of injuring the diseased colon. Some more recently have questioned the need for delaying endoscopic examination citing low rates of perforation during acute episodes of diverticulitis despite technically difcult examinations with decreased rates of cecal intubation. These groups advocate for endoscopic examination for its potential to provide additional information, which can alter the management strategy.

O. Rates of colostomy reversal following Hartmann’s procedures are low compared with rates of reversal in patients with diverting ileostomy following sigmoid colectomy for diverticulitis. Hartmann’s procedure and sigmoid colectomy with primary anastomosis and diverting ileostomy have similar complication rates following the initial resection. Decreased complication rates related to stoma reversal may favor primary anastomosis and proximal diversion in select patients. P. Right-sided diverticulitis is an uncommon presentation in the United States though occurs frequently in Asian populations. Right sided diverticulitis can often be confused with appendicitis on the basis of history and physical examination and historically has created a uncertainty in operative decision making with regards to extent

of resection should diverticulitis be encountered. With the widespread availability of computed tomography, the ability to preoperatively diagnose right-sided diverticulitis can help guide clinical decision-making. Right-sided diverticulitis can be managed similarly to sigmoid diverticulitis. Those patients who do not exhibit peritonitis can be managed with IV antibiotics and bowel rest, with percutaneous drainage should it be necessary. Tan etal. showed very good long term outcomes for those patients with right sided diverticulitis who were treated nonoperatively at the time of initial diagnosis. Rates of operative intervention for right-sided diverticulitis are declining within the United States, possibly due to advancements in use of percutaneous drainage. Patients who do not respond to conservative therapy should undergo operative intervention through either a laparoscopic or open approach. Laparoscopic approaches are safe and feasible and associated with reduction in postoperative pulmonary complications in these patients. When the diagnosis right-sided diverticulitis is made intraoperatively in those patients who did not undergo preoperative imaging, treatment options include right colectomy or performing an appendectomy with subsequent medical treatment on the diverticulitis. Recurrence, as with other forms of diverticulitis does not in and of itself mandate resection, patients should be managed on an individual basis with regards to pursuit of acute or elective operative management.