Laparoscopic lavage versus primary resection in acute perforated diverticulitis

- a randomised multicenter study

Pseudo diverticula:

Prevalence

• Diverticulosis – >60 years of age: 30-50%

• Diverticulitis – 10-30% of those with diverticulosis:

• Conservative/medical treatment: 75-90%

• Surgical intervention: 10-30%

Hinchey grading

Complicated diverticulitis

• Obstruction

• Abscess formation

• Fistula formation

Perforation - Peritonitis– Mortality (historical): Purulent peritonitis 6%;

Faecal peritonitis 35%

(Nagorny et al 1985)

Incidence of acute perforated diverticulitis 3-5 /100.000

Surgical options

Three stage Transverse colostomy with lavage and suture of defect ’Sigmoid reection and anastomosisClosure of stoma

Hartmann Sigmoid resection with sigmoidostomy

Closed rectum (or mucous fistula)

Primary anastomosiswith or with out covering stoma

Lavage using the laparoscope

Hospital mortality after emergency surgery for perforated diverticulitis

Netherlands: Five teaching hospitals 291pts 1995 – 2005

Overall in-hospital mortality 29%

Ned Tijdschr Geeneskd. 2009;153:B195

Southeast England: One hosp 110pts 2002 – 2006

Mortality 10.9%

World J Emerg Surg. 2008 Jan 24;3-5

Hospital mortality after emergency surgery for perforated diverticulitis

England: ’Hospital Episode Statistics’ database between 1996 and 2006Emergency surgery for sigmoid diverticular disease

30 -day death 1923/10198 pts = 15.9%

Alim Pharm Therapeutics 2009;30: 1171-1182

Rationale

• E. Myers et. al., BJS 2008“Laparoscopic peritoneal lavage for generalizedperitonitis due to perforated diverticulitis”

Laparoscopy in 100 patients with perforated diverticulitis - laparoscopic lavage in 92 patients - 8 patients converted to Hartmann due to faecal peritonitis

Mortality 3%, morbidity 4%

• Similar results reported in other papers with fewer patients

No randomized studies

Primary endpoint

severe complications within 90 days (Clavien-Dindo >IIIa )

power analysis 30 % v.s. 10 % complications = 130 pts Aim = 150 patients

Secondary endpoints

-duration of procedure-time spent in hospital-complications individually-enterostoma one year after initial surgery- “Cleveland Global Quality of Life”-costs

Inclusion criteria :

- age >18 years - clinical signs of perforated diverticulitis and need for surgery - CT displays free gas and do not contradict the clinical diagnosis

- the patient tolerates general anesthesia - the patient has given written informed consent

Exclusion criteria: - pregnancy - bowel obstruction

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The patient will be informed on used technique only postoperatively

Techniques

In all cases, lavage with minimum 4 l saline, wound drain and Hinchey grading

Laparoscopic lavage usual port placement: umbilicus, suprapubic, right lower quadrant

faecal peritonitis (including visible hole) convert to Hartmann

adhesions to the sigmoid should not be dealt with

Sigmoid resection with or without stoma

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Case report forms

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Case report form, follow-up

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Patient information and consent

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