COMMENTARY

Comparing Laparoscopic Lavage vs Resection for Perforated Diverticulitis

Albert B. Lowenfels, MD

Disclosures

September 26, 2018

How does laparoscopic lavage compare with resection for the initial treatment of perforated diverticulitis with purulent diverticulitis (Hinchey III)? In a paper published in the British Journal of Surgery , the authors report 2-year follow-up results after initiation of a Scandinavian trial (DILALA; DIverticulitis — LAparoscopic Lavage) comparing these alternative treatment options.[1]

Forty patients were treated with the conventional Hartmann approach (resection plus a diverting colostomy) and 43 patients were managed by laparoscopy and peritoneal lavage. Patients in the lavage group had fewer subsequent abdominal interventions (relative risk = 0.55, P = .024). At the end of 2 years, three patients in the lavage group had a colostomy compared with nine in the Hartmann's group.

Where Does This Study Leave Us?

Throughout the 20th century, nearly all patients with perforated purulent diverticulitis were treated with resection of the diseased colon and a diverting colostomy. More recently, laparoscopic peritoneal lavage has become an attractive option because, for many patients, it avoids an initial colostomy.

This randomized trial presents 2-year follow-up data from a randomized trial that supports the concept of a limited procedure.[1] However, the relative benefits of the two different approaches are still unclear. A recent review and meta-analysis concluded that initial colonic resection was the best option.[2] This trial and similar reviews excluded trials with feculent peritonitis (Hinchey IV) because resection would be the safest procedure for this group.

We still do not know whether any surgical procedure is necessary for purulent (nonfecal) diverticulitis; perhaps only antibiotic therapy without peritoneal lavage would be sufficient treatment.

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