Article Summary:

Laparoscopic Lavage Versus Primary Resection for Acute Perforated Diverticulitis

• Meta-analysis of 589 patients that compared clinical outcomes of laparoscopic lavage or colonic resection for purulent diverticulitis 
• randomized controlled trials, case-matched controlled studies or comparative studies, in which patients underwent LL or CR with categorization by Hinchey classification and included at least 10 cases per group. Primary resection consisted of either a Hartmann’s procedure or CR with or without defunctioning stoma and could be performed open or laparoscopically
• Operative and postoperative outcome measures included mortality (30 day, 90 day, and 12 months), stoma rates, cardiac and pulmonary complications, thromboembolic events, wound infection, intra abdominal sepsis, length of hospital stay, and unplanned readmissions. Patient characteristics included age, sex, BMI, ASA grade and Hinchey scores and compared between the 2 groups to make sure the influence of confounding variables was limited. 
• A total of 19 patients (9 LL group; 10 CR group) died within 30 days of surgery, whereas 51 patients (36 LL; 15 CR) required emergency reoperation within 30 days and 33 patients (20 LL; 13 CR) had unplanned readmissions within 90 days. The odds of developing postoperative intraabdominal abscess were almost 3 times greater in the LL group compared with the CR group (Fig. 2A), and had higher rates of peritonitis after the primary surgery (Fig. 2B). Emergency reoperations between >30 days to 1 year after the first operation are also significantly more frequent with a POR of 3.321 in the LL group. The LL group had a significantly shorter operative time, fewer cardiac complications after surgery, and fewer wound infections, and shorter length of hospital stay (Table 3). Overall, 90% of patients had a stoma after CR as either an end colostomy or defunctioning ileostomy; 74% of whom underwent stoma reversal within 12 months. Approximately, 14% of patients in the LL group also required a stoma, with 48% return of gut continuity within 12 months, whereas another 36% underwent elective sigmoidectomy
• Conclusion: Laparoscopic lavage for Hinchey III diverticulitis may offer certain benefits and avoids stoma formation in most patients, but also appears to be associated with increased risk of prolonged intraabdominal sepsis. LL is associated with approximately 3 times greater risk of persistent peritonitis, intraabdominal abscesses and the need for emergency surgery compared with CR. Primary resection, on the other hand, removes the diseased segment and potential cancer if present, but does require a further operation to reverse the stoma.

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diverticulitis