Laparoscopic lavage versus resection in perforated diverticulitis with purulent peritonitis: a meta-analysis of randomized controlled trials

Marco Ceresoli, Federico Coccolini, Giulia Montori, Fausto Catena, Massimo Sartelli, Luca Ansaloni, Marco Ceresoli, Federico Coccolini, Giulia Montori, Fausto Catena, Massimo Sartelli, Luca Ansaloni

Abstract

Objective: Purulent peritonitis from acute left colon diverticulitis is a relatively common presentation of diverticular disease; historically the treatment was the Hartmann procedure. Laparoscopic peritoneal lavage has been proposed as a lesser invasive treatment option with great interest and debate among surgeons and with contrasting results. The aim of this meta-analysis was to compare the results of sigmoid resection with laparoscopic lavage.

Methods: A systematic review was performed to select randomized controlled trials comparing laparoscopic lavage versus resection in Hinchey III diverticulitis. Studies' selection, data extraction and risk of bias assessment were done by two independent authors; results were shown as OR with 95 % C.I.

Results: Three RCT were selected for the meta-analysis including 315 patents. Laparoscopic lavage was associated with significantly more reoperations (OR 3.75, p = 0.006) and more intra-abdominal abscesses (OR 3.50, p = 0.0003) with no differences in mortality (OR 0.93, p = 0.92). At 12 months follow up laparoscopic lavage was associated with lesser reoperations (OR 0.32, p = 0.0004); there were no differences in term of stoma presence (OR 0.44 p = 0.27) and mortality (OR 0.74 p = 0.51).

Conclusions: The present meta-analysis shows that in acute perforated diverticulitis with purulent peritonitis laparoscopic lavage is comparable to sigmoid resection in term of mortality but it is associated with a significantly higher rate of reoperations and a higher rate of intra-abdominal abscess. No differences in term of mortality were demonstrated at follow-up. Further studies are needed to better define the safety and appropriateness of this treatment.

Keywords: Acute diverticulitis; Acute perforated diverticulitis; Laparoscopic lavage; Meta-analysis; Purulent peritonitis.

Figures

Fig. 1
Fig. 1
PRISMA flow diagram
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Fig. 2
Reoperation at index admission
Fig. 3
Fig. 3
Mortality at index admission
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Fig. 4
Intra-abdominal abscess
Fig. 5
Fig. 5
12 months reoperations

References

    1. Weizman AV, Nguyen GC. Diverticular disease: epidemiology and management. Can J Gastroenterol. 2011;25:385–9. doi: 10.1155/2011/795241.
    1. Schoetz DJ. Diverticular disease of the colon: a century-old problem. Dis Colon Rectum. 1999;42:703–9. doi: 10.1007/BF02236921.
    1. Delvaux M. Diverticular disease of the colon in Europe: epidemiology, impact on citizen health and prevention. Aliment Pharmacol Ther. 2003;18(Suppl 3):71–4. doi: 10.1046/j.0953-0673.2003.01720.x.
    1. Shahedi K, Fuller G, Bolus R, Cohen E, Vu M, Shah R, et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol. 2013;11:1609–13. doi: 10.1016/j.cgh.2013.06.020.
    1. Ambrosetti P, Grossholz M, Becker C, Terrier F, Morel P. Computed tomography in acute left colonic diverticulitis. Br J Surg. 1997;84:532–4. doi: 10.1046/j.1365-2168.1997.02576.x.
    1. Sartelli M, Moore FA, Ansaloni L, Di Saverio S, Coccolini F, Griffiths EA, et al. A proposal for a CT driven classification of left colon acute diverticulitis. World J Emerg Surg. 2015;10:3. doi: 10.1186/1749-7922-10-3.
    1. Neff CC, vanSonnenberg E. CT of diverticulitis. Diagnosis and treatment. Radiol Clin North Am. 1989;27:743–52.
    1. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. [Internet]. Adv Surg. 1978;85–109. Available from: .
    1. Li D, Baxter NN, McLeod RS, Moineddin R, Wilton AS, Nathens AB. Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis. Dis Colon Rectum. 2014;57:1397–405. doi: 10.1097/DCR.0000000000000224.
    1. Krukowski ZH, Matheson NA. Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg. 1984;71:921–7. doi: 10.1002/bjs.1800711202.
    1. Constantinides VA, Tekkis PP, Athanasiou T, Aziz O, Purkayastha S, Remzi FH, et al. Primary resection with anastomosis vs. Hartmann’s procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. Dis Colon Rectum. 2006;49:966–81. doi: 10.1007/s10350-006-0547-9.
    1. Myers E, Hurley M, O’Sullivan GC, Kavanagh D, Wilson I, Winter DC. Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg. 2008;95:97–101. doi: 10.1002/bjs.6024.
    1. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. doi: 10.1136/bmj.d5928.
    1. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–88. doi: 10.1016/0197-2456(86)90046-2.
    1. Demets DL. Methods for combining randomized clinical trials: strengths and limitations. Stat Med. 1987;6:341–50. doi: 10.1002/sim.4780060325.
    1. Schultz JK, Yaqub S, Wallon C, Blecic L, Forsmo HM, Folkesson J, et al. Laparoscopic lavage vs primary resection for acute perforated diverticulitis: the SCANDIV randomized clinical trial. JAMA. 2015;314:1364–75. doi: 10.1001/jama.2015.12076.
    1. Vennix S, Musters GD, Mulder IM, Swank HA, Consten EC, Belgers EH, et al. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: A multicentre, parallel-group, randomised, open-label trial. Lancet. 2015;386:1269–77. doi: 10.1016/S0140-6736(15)61168-0.
    1. Thornell A, Angenete E, Bisgaard T, Bock D, Burcharth J, Heath J, et al. Laparoscopic lavage for perforated diverticulitis with purulent peritonitis. Ann Intern Med [Internet]. 2016;1–10. Available from: .
    1. Angenete E, Thornell A, Burcharth J, Pommergaard H-C, Skullman S, Bisgaard T, et al. Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis: the first results from the randomized controlled trial DILALA. Ann Surg. 2014;00:1–6.
    1. Abbas S. Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis. 2007;22:351–7. doi: 10.1007/s00384-005-0059-4.
    1. Cirocchi R, Trastulli S, Desiderio J, Listorti C, Boselli C, Parisi A, et al. Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis. Int J Colorectal Dis. 2013;28:447–57. doi: 10.1007/s00384-012-1622-4.
    1. O’Sullivan GC, Murphy D, O’Brien MG, Ireland A, Pain J, Cahill J, et al. Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg. 1996;171:432–4. doi: 10.1016/S0002-9610(97)89625-0.
    1. Cirocchi R, Trastulli S, Vettoretto N, Milani D, Cavaliere D, Renzi C, et al. Laparoscopic peritoneal lavage: a definitive treatment for diverticular peritonitis or a “bridge” to elective laparoscopic sigmoidectomy?: a systematic review. Medicine (Baltimore) 2015;94:e334. doi: 10.1097/MD.0000000000000334.
    1. Benoist S. What is the role of laparoscopic peritoneal lavage for perforated diverticulitis with purulent peritonitis in 2016? J Visc Surg. 2016;153(3):159–60. doi: 10.1016/j.jviscsurg.2016.04.004.
    1. Afshar S, Kurer MA. Laparoscopic peritoneal lavage for perforated diverticulitis: are we any further forward? Colorectal Dis. 2016. [cited 2016 Jul 26]; Available from: .
    1. Gervaz P, Ambrosetti P. Critical appraisal of laparoscopic lavage for Hinchey III diverticulitis. World J Gastrointest Surg. 2016;8:371–5. doi: 10.4240/wjgs.v8.i5.371.
    1. Winter DC, Hogan AM RK. LapLAND laparoscopic lavage for acute non-faeculent diverticulitis. . 2009; Accessed 26 Aug 2016.

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