Laparoscopic lavage effective for perforated diverticulitis peritonitis

Last Updated: 2016-01-19

By Will Boggs MD

NEW YORK (Reuters Health) - Laparoscopic lavage is an effective alternative to the Hartmann procedure for treating patients with perforated diverticulitis with purulent peritonitis, researchers from Sweden and Denmark report.

"Our results are clear, i.e., we find that laparoscopic lavage was safe and beneficial in terms of less need for subsequent surgical procedures," Dr. Eva Haglind from University of Gothenburg, Gothenburg, Sweden told Reuters Health by email. "As two other randomized controlled trials have published results that are not completely in agreement with ours, I would suggest to wait for the inevitable meta-analysis of all three."

The Hartmann procedure, which includes colon resection and colostomy or resection of the affected colon with primary anastomosis with or without diverting ileostomy, has been the preferred treatment for diverticulitis complicated by purulent peritonitis, but some studies have shown reduced morbidity and mortality when laparoscopic lavage was used instead.

Dr. Haglind and colleagues from nine hospitals in Sweden and Denmark compared laparoscopic lavage and the Hartmann procedure with regard to the percentage of patients with one or more reoperations within 12 months. Their study included 83 patients with Hinchey grade III diverticulitis, with 43 randomly assigned to laparoscopic lavage and 40 to Hartmann procedure.

Within 12 months, significantly fewer patients in the laparoscopic group (27.9%) than in the Hartmann group (62.5%) had one or more reoperations (p=0.004), according to the January 19 Annals of Internal Medicine online report.

On average, the laparoscopic group had 59% fewer reoperations than the Hartmann group in the adjusted analysis and 72% fewer reoperations in the per-protocol analysis.

Hospital stay within 12 months was shorter for the laparoscopic group (mean, 14 days) than for the Hartmann group (mean, 18 days), and there were fewer infectious adverse events in the laparoscopic group than in the Hartmann group.

Global quality of life did not differ between the groups at any time point.

"Ours is the first randomized, controlled trial, to our knowledge, to show that laparoscopic lavage can be used as a definitive treatment of perforated diverticulitis with purulent peritonitis," the researchers note.

"This technique, laparoscopic lavage, needs to be studied from a pathophysiologic perspective," Dr. Haglind said. "At present we do not know the mechanism(s) -- is it simply 'cleaning up' in the abdomen or are other mechanisms responsible for the effect? The importance of clarifying mechanisms is, of course, that the principle may work in purulent peritonitis in general and/or in serious infections of a purulent type but in other locations."

Dr. Tim W. Eglinton and Dr. Frank A. Frizelle, from the University of Otago, Christchurch, New Zealand, contrast the results of the current trial (DILALA) with those from two other trials (LOLA and SCANDIV) that did not support the use of laparoscopic lavage in their related editorial.

"The seemingly contradictory findings of these two recent studies and DILALA reflect the variable end points used to assess the procedures," they wrote. "Unlike the two previously reported trials, DILALA categorized reversal of the Hartmann procedure, but not percutaneous abscess drainage, as a reoperation. Therefore, the results from the three studies are actually quite similar."

"The risk for ongoing intra-abdominal sepsis clearly is higher when the diseased segment is not resected, but this is at the expense of requiring subsequent reversal of the Hartmann procedure," they explained. "What is not clear from any of the studies is which patients with purulent peritonitis (Hinchey grade III) actually require surgery at all."

"Despite the issue of resection of the inflammatory focus, perhaps the next trial required should not focus on laparoscopic lavage versus the Hartmann procedure, but rather computed tomography, antibiotics, and watchful waiting compared with surgical intervention by either laparoscopic lavage or resection," the editorial concluded.

A number of organizations supported this research. Three coauthors reported disclosures.

SOURCE: http://bit.ly/1niYMQB

Ann Intern Med 2016.