Laparoscopic Lavage Worse Than Resection in Diverticulitis

Jenni Laidman

October 08, 2015

Laparoscopic lavage for acute perforated diverticulitis in patients requiring emergency surgery was no better than primary resection in reducing severe postoperative complications. Further, laparoscopic lavage was associated with a higher rate of reoperation than resection in a randomized trial of 144 patients published in the October 6 issue of JAMA.

Johannes Kurt Schultz, MD, from the Department of Gastrointestinal Surgery, Akershus University Hospital, Lörenskog, and the Faculty of Medicine at the University of Oslo, Norway, and colleagues randomly assigned patients with suspected perforated diverticulitis, clinical indication for emergency surgery, and evidence of free air on an abdominal computer tomography scan to either laparoscope lavage or resection at 21 medical centers in Sweden and Norway from 2010 to 2014. The primary study outcome was the presence of severe postoperative complications, defined as a Clavin-Dindo score higher than IIIa within 90 days of treatment.

Slightly more than 30% of the laparoscopic lavage group and 26.0% in the colon resection group experienced severe postoperative complications. The 4.7% difference between the two procedures failed to meet statistical significance (95% confidence interval [CI], −7.9% to 17.0%; P = .53). Nor did the difference in mortality at 90 days reach significance (P = .67), with 14 deaths (13.9%) in the laparoscopic lavage group and 11 (11.5%) in the colon resection group.

However, the rate of reoperation among patients without fecal peritonitis was significantly higher in the laparoscopy lavage group, with 15 (20.3%) of 74 patients requiring another operation compared with 4 (5.7%) of 70 patients in the resection group, for a difference of 14.6% (95% CI, 3.5% - 25.6%; P = .01). Further, four sigmoid carcinomas were not detected with laparoscopic lavage.

Operating time was significantly reduced in the laparoscopic lavage group, but postoperative hospital stay and quality of life were not significantly different between the two groups.

The authors note that these results are in contrast to reports from nonrandomized trials that showed an advantage for laparoscopic lavage. "However, the series showing this were likely affected by selection bias, ie, with optimal patients selected for the new procedure and more severely ill patients being treated with open colon resections, making the laparoscopic approach appear to have better outcomes," the authors write.

In an accompanying editorial, Scott A. Strong, MD, and Nathaniel J. Soper, MD, both from Northwestern University Feinberg School of Medicine in Chicago, Illinois, note that the two groups of patients in the trial had similar characteristics. However, they note, "significantly fewer of the lavage procedures were performed by a specialty-trained surgeon."

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Still, the results in this trial are similar to those in another Scandinavian randomized trial comparing laparoscopic lavage with an open Hartmann procedure for Hinchey III disease, the editorialists note. That study found similar rates of severe complications, 30-day reoperation, and mortality as the newly reported trial. Further, a Dutch study with four intervention groups had to terminate the laparoscopic lavage group early because of safety concerns, they write.

Therefore, the editorialists say the role of laparoscope lavage for complicated diverticulitis with peritonitis remains unclear. "[T]he best resection operation has not been determined."

"The utility of less intrusive strategies and minimally invasive approaches will undoubtedly expand as technologies evolve, but they must be responsibly incorporated into surgical practice based on evidence rather than subjective reasons," the editorial authors conclude.

The authors and editorialists have disclosed no relevant financial relationships.

JAMA. 2015;314:1343-1345, 1364-1375. Article abstract, Editorial extract

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