ORIGINAL CONTRIBUTION
Laparoscopic Peritoneal Lavage for Hinchey III Diverticulitis: Is It as Effective as It Is Applicable? Gustavo L. Rossi, M.D. • Ricardo Mentz, M.D. • Santiago Bertone, M.D. Guillermo Ojea Quintana, M.D. • Soledad Bilbao, M.D. • Victor M. Im, M.D. Carlos A. Vaccaro, M.D., Ph.D. Section of Colorectal Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
BACKGROUND: Over the past few years, the laparoscopic peritoneal lavage has emerged as a therapeutic alternative to standard resection procedures. However, its effectiveness and applicability remain debatable. OBJECTIVE: The aim of this study was to assess laparoscopic lavage in controlling abdominal sepsis secondary to purulent peritonitis. DESIGN: This study was conducted as a retrospective analysis of prospectively collected data. SETTING: This study was conducted at a single tertiary care institution. PATIENTS: Patients requiring emergency surgery for perforated diverticulitis and generalized peritonitis between June 2006 and June 2013 were identified from a prospective database. Laparoscopic assessment was considered in all of the hemodynamically stable patients, and laparoscopic lavage was performed according to intraoperative strict criteria. MAIN OUTCOME MEASURES: Primary outcomes were the effectiveness and applicability of laparoscopic lavage. Secondarily, feasibility, morbidity, and mortality were also assessed. RESULTS: Seventy-five patients required emergency
surgery for generalized peritonitis secondary to perforated diverticulitis. Forty-six patients who underwent laparoscopy presented a purulent generalized Financial Disclosure: None reported. Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Hollywood, FL, May 17 to 21, 2014. Correspondence: Gustavo L. Rossi, M.D., Section of Colorectal Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. E-mail: [email protected] Dis Colon Rectum 2014; 57: 1384–1390 DOI: 10.1097/DCR.0000000000000252 © The ASCRS 2014
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(Hinchey III) peritonitis and were examined under the intention-to-treat basis to perform a laparoscopic lavage. Thirty-two patients (70.0%; 95% CI 56.2–82.7) had no previous episodes of diverticulitis. Thirty-six patients (78.0%; 95% CI 66.3–90.1) had free air on a CT scan. The conversion rate was 4% (95% CI 0–10). The feasibility of the method was 96.0% (95% CI 90.4–100), and its applicability was 59.0% (95% CI 44.8–73.2). Median operative time was 89 minutes (range, 40–200 minutes). Postoperative morbidity was 24.0% (95% CI 11.7–36.3), and the mortality rate was 0%. We registered 5 failures, and all of them underwent reoperation. The effectiveness of the procedure was 85% (95% CI 76–93). LIMITATIONS: This was a single-institution retrospective
study. CONCLUSIONS: The effectiveness of laparoscopic lavage seems to be high. Although its applicability is lower, it could be applied in more than half of patients requiring emergency surgery. This alternative strategy should be considered when laparoscopic assessment reveals Hinchey III diverticulitis. KEY WORDS: Applicability; Effectiveness; Hinchey III diverticulitis; Laparoscopic lavage.
I
n recent decades, the treatment of acute diverticulitis in all of its stages has evolved toward a more conservative approach.1,2 This gradual change has been in part because of advances in antibiotic therapy, imaging, percutaneous drainage techniques, and critical care, which have resulted in a nonoperative strategy able to convert an emergent situation into an elective one in a high percentage of cases. This trend has been reported recently, showing that ≈90 % of patients are being managed nonoperatively.3 However, in those patients who present with diverticular peritonitis (purulent or feculent), surgery continues to play a critical role in treatment. Until recently, the only 2 treatment options were resection of the affected segment Diseases of the Colon & Rectum Volume 57: 12 (2014)
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Diseases of the Colon & Rectum Volume 57: 12 (2014)
of the colon and the creation of an end colostomy as a modified Hartmann procedure or resection and primary anastomosis with or without diversion. Nevertheless, these resective procedures remain associated with an appreciable morbidity rate and a mortality of ≈15%.4,5 On the other hand, in the mid-1990s, a nonresective procedure was described in a small series of 8 patients, with a high rate of success, for the treatment of peritonitis attributed to a perforated diverticulitis.6 This new alternative, known as laparoscopic peritoneal lavage, aims to control abdominal sepsis (generally in Hinchey stage III) by performing a meticulous washout of all quadrants through a minimally invasive approach, leaving the sigmoid colon in place, and avoiding the construction of a stoma. Thereafter, a few groups, mainly from Europe, reported their experiences with this attractive organ-preserving procedure with a rate of success in general >80% and a low mortality rate.7–12 However, despite these promising results, some authors have questioned the usefulness and applicability of this therapeutic tool, arguing that there is scant and low-quality evidence13 or a questionable selection of patients.14 Recently, The American Society of Colon and Rectal Surgeons, in the last edition of its Practice Parameters for the Treatment of Sigmoid Diverticulitis,15 has stated that operative therapy without resection in patients with purulent or feculent peritonitis is generally not an appropriate alternative to colectomy. This statement is mainly based on the few available data from low-quality research, which include heterogeneous populations and different inclusion criteria. Thus, the primary aim of this study was to examine the effectiveness and applicability of laparoscopic lavage to resolve abdominal sepsis in a selected and homogeneous (Hinchey III) population of patients with a standardized intraoperative strategy, and, secondarily, to evaluate morbidity and mortality.
METHODS Patients and Data Collection
A prospectively maintained, practice-specific database was used to identify all of the patients with emergency admissions for acute sigmoid diverticulitis from June 2006 to June 2013 at the Hospital Italiano de Buenos Aires. Among patients who required emergency surgery, those hemodynamically stable cases in which a laparoscopic approach was feasible were deemed eligible. After laparoscopic exploration, subjects with Hinchey II or IV disease, with intraoperative evidence of perforation, or those who underwent laparoscopic resection were excluded from the study population. Data were prospectively recorded in an institutional review board–approved database including demographic data, comorbidities, number of previous episodes, clinical/CT and radiographic findings, intraop-
erative findings, operative times, length of stay, morbidity, and mortality. Procedures
After clinical assessment and laboratory test, all of the patients were resuscitated with intravenous fluids and antibiotics (500 mg of ciprofloxacin and 1000 mg of ornidazole). All of the patients were evaluated with CT at admission. The criterion for emergency surgery, defined as procedures performed within 12 hours of admission, was based on a clinical assessment (generalized peritonitis). Tomographic findings added additional information. Patients were placed in a modified lithotomy position with nasogastric decompression and a vesical catheter. After the insertion of the camera through a 12-mm umbilical port, two 5-mm trocars were placed on the right upper and lower quadrants. A third additional trocar was used according to the surgeon’s preference on the left lower quadrant. Once inside the abdominal cavity, a meticulous exploration was performed to rule out other causes of peritonitis. Pelvic structures and bowel loops were mobilized away from the pelvis using blunt dissection. Laparoscopic lavage was started by the pelvis to expose the sigmoid phlegmon and wash the pouch of Douglas. The sigmoid colon was left in place without any additional mobilization, and a careful revision was performed to identify the presence of an overt perforation. If there was no evidence of an overt perforation, a hydropneumatic test was performed to detect any unsuspected communication with the colon lumen. For this assessment, we insufflated the colon through the rectum with a rigid proctoscope, clamping the descending colon proximal to the affected segment and irrigating the pelvis with saline. If any perforation was detected, resection was mandatory and excluded from the analyzed population. In these cases, the decision to continue the surgery laparoscopically or open was based on the individual surgeon’s experience and preference. If no perforation was detected, we proceeded to complete the laparoscopic lavage, systematically including both parietocolic and subphrenic spaces. No specific amount of saline was used; irrigation continued until we obtained a clear fluid. The average volume used was between 3 and 6 L. Once laparoscopic lavage was finished, suction silastic drains were placed in the pelvis. Patients went to the intensive care unit as required. Intravenous antibiotics were continued for 5 to 7 days. Thereafter, the continuity of antibiotic treatment was established with the division of infectious diseases. Enteral feeding was initiated according to clinical progress. Total parenteral nutrition was only used in cases of prolonged bowel rest. Outcomes
The main outcomes were effectiveness, defined as the percentage of patients in whom the abdominal sepsis was resolved with no need for further treatment including drainage pro-
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cedures, ≤30 days from admission; and applicability, defined as the percentage of patients requiring emergency surgery for perforated diverticulitis who were treated with laparoscopic lavage and drainage. In this study, the decision to perform laparoscopic lavage was taken according to intraoperative strict criteria, including 4 quadrants of purulent peritonitis without an overt perforation or a positive hydropneumatic test. The feasibility of the method was defined as the percentage of patients in which, after laparoscopy was completed, lavage of the abdominal cavity could be performed. Based on our policy, all of the hemodynamically stable patients with an acute abdomen requiring surgical exploration without excessive distension were systematically approached by laparoscopy. Morbidity and mortality rates were also assessed and categorized according to the Clavien-Dindo score.16 Categorical variables were expressed as a percentage and 95% CI and continuous variables as the median and range.
Rossi et al: Laparoscopic Lavage for Hinchey III
Admisson for acute diverticulitis N = 455 Nonoperative treatment n = 380 Emergency surgery n = 75 Open surgery n =16
Laparoscopic approach n = 59
n=7
- Abdominal distension
n=4
- Both
n=5
Excluded n =13
RESULTS In the studied period, 455 consecutive patients were admitted with a primary diagnosis of acute diverticulitis, of which 75 (16%) required emergency surgery for an acute abdomen. Fifty-nine patients were initially approached by laparoscopy, and 13 met the exclusion criteria. Thus, 46 patients presented a purulent generalized (Hinchey III) peritonitis and represent the population analyzed. Figure 1 shows the distribution of patients according to the Strengthening the Reporting of Observational Studies in Epidemiology statement.17 Patient demographics are outlined in Table 1. Thirtytwo patients (70.0%; 95% CI 56.2–82.7) had no previous episodes of diverticulitis. Thirty-six patients (78.0%; 95% CI 66.3–90.1) had free air on CT scan, with 29 (63.0%; 95% CI 49.0–79.5) as a distant pneumoperitoneum and 7 (13.0%; 95% CI 3.3–22.7) as bubbles around a phlegmonous sigmoid. Figure 2 displays the findings on the CT scan of a patient who successfully underwent laparoscopic lavage. Of the 46 patients whose intention to treat was to perform a laparoscopic lavage, 2 required conversion (4%; 95% CI 0–10), representing a feasibility of 96.0% (95% CI 90.4–100) for the method. Reasons for conversion were excessive intestinal distension in one case and firm adhesions that made it impossible to adequately visualize the operative field in the other. These converted cases were managed with a sigmoidectomy, primary anastomosis without diversion, and a Hartmann procedure. We were able to carry out laparoscopic lavage in 44 of the 75 patients who required emergency surgery, so that the applicability of the method was 59.0% (95% CI 44.8–73.2). The median operative time was 89 minutes (range, 40–200 minutes). We had no intraoperative complications. The median number of drains placed was 2 (range, 1–4). Global postoperative morbidity
- Hemodynamic instability
Laparoscopic lavage (intention to treat)
- Hinchey II
n=3
- Hinchey IV
n=5
- Hydropneumatic test (+)
n=3
- Macroscopic perforation
n=2
n = 46
Figure 1. Diagram depicting the distribution of patients.
was 24.0% (95% CI 11.7–36.3). Eleven patients presented 13 complications. Details of the complications according to the Clavien-Dindo classification are TABLE 1. Demographic and clinical characteristics (N = 46) Variable Women, n (%; 95% CI) Age, mean (range), y BMI, mean (range), kg/m2 ASA score, n (%; 95% CI) I II III IV Previous abdominal surgery, n (%; 95% CI) Type of surgery Appendectomy Cesarean section Cholecystectomy Hysterectomy Gastrectomy Nephrectomy Eventroplasty plus mesh Dermolipectomy Previous episodes of diverticulitis, n (%; 95% CI) 0 1 2 3
27 (59; 44.8–73.2) 66 (31–95) 25.6 (20.0–33.4) 2 (4.7; 0–10.8) 23 (50; 35.5–64.4) 21 (45.6; 31.2–60.0) 0 15 (32.6; 19.1–46.1)
5 1 3 3 1 3 1 1
32 (70.0; 56.2–82.7) 9 (19.5; 8.0–31.0) 4 (8.3; 0.4–16.2) 1 (2.2; 0–6.4)
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The effectiveness of laparoscopic lavage was 85% (95% CI 76–93). In addition to the 2 patients who required conversion, 5 of 44 washouts failed to adequately control abdominal sepsis (Fig. 3). All of them were reassessed with a second CT scan. In 1 patient, a paravesical residual abscess was identified and drained percutaneously; however, despite the drainage, he persisted with fever and abdominal pain. All 5 of these patients were reoperated and resected. A laparotomy was performed in 4 of them, and 1 patient was approached laparoscopically. In 3 patients, the re-exploration revealed a feculent peritonitis near a visible perforation, and the other 2 patients showed fibrinous residual purulent peritonitis, mainly in the pelvis. Two of the patients with feculent peritonitis underwent a Hartmann procedure, and the other a sigmoid resection, primary anastomosis, and colostomy. The other 2 cases were resolved with sigmoid resection and primary anastomosis without diversion. Three patients in the entire series required diversion (6.5%; 95% CI 0–13.6), and all of them were subsequently reconstructed. Of those patients with full recovery, none of them required additional drainage. Four had a prolonged antibiotic course, although none of them presented complications associated with this treatment. One month after surgery, all of the patients who were treated with successful laparoscopic lavage were assessed with a double-contrast barium enema or colonoscopy. All of them presented with diverticular disease, and no malignancy was found.
Figure 2. CT scan of the oldest patient in this series (95 years old). A, Perihepatic free fluid and pneumoperitoneum. B, Diverticular phlegmon in the pelvis.
shown in Table 2. The median length of stay was 6 days (range, 3–30 days), and only 2 patients had intensive care unit admissions. The procedural mortality rate was 0%. TABLE 2. Complications according to Clavien-Dindo score16 Stratification of complications Grade II Pneumonia Ileus Hypertension Grade IIIb Failure Wound infection Grade IVa Acute myocardial infarction Pneumonia Grade IVb Failure Atrial fibrillation with respiratory failure
N 1 2 1 4 1 1 1 1 1
DISCUSSION One of the main findings of this study is the high effectiveness of this method to control abdominal sepsis and to restore the status of health, with a value within the previously reported range (77%–100%).8,10 This not only implies avoiding a sigmoid resection in an unfavorable scenario, which has been associated with a high mortality rate, but also the low colostomy rate reported in all of the series, including this one. Such a strategy allows for proper assessment of these patients once the peritonitis has been resolved, because they usually do not know that they have a diverticular disease. Moreover, coincidentally with other series,7,12 we observed that the majority of the patients had no previous episodes of diverticulitis, and the clinical presentation with peritonitis was the debut of the disease. This study also showed that laparoscopic lavage can be successfully applied in a considerably high proportion of patients requiring emergency surgery for purulent generalized peritonitis. Studies that attempt to assess the place of an alternative procedure should address this issue. To date, only 2 previous series have reported 44%10 and 17%11 applicability, which is much lower than the applicability found in this series.
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Rossi et al: Laparoscopic Lavage for Hinchey III
Laparoscopic lavage (intention to treat) N = 46
Conversion to open surgery n=2
Full laparoscopic lavage n = 44
Complete recovery n = 39
Failures and reintervention n = 5 - Open PA without diversion n=2 - Open HP n=2 - Laparoscopic PA with diversion n = 1
Figure 3. Flow chart of surgical outcomes. PA = primary anastomosis; HP = Hartmann procedure.
The strength of this study is based on 2 important aspects. First is, the prospective nature of data collection meant that no information was missed, which may otherwise have interfered with the analysis, and second is the homogeneous nature of the population analyzed because of strict exclusion criteria. All of the included patients had an acute abdomen requiring immediate surgical exploration, and all presented 4-quadrant purulent (Hinchey III) peritonitis. With respect to this topic, many other series have included different timings of surgery (from 3 days) and stages of the disease.7–11 Recently, 3 different systematic reviews that included more than 200 laparoscopic lavages revealed that ≈20% and 4% of patients had Hinchey II and IV diverticulitis; this issue must be taken into account when interpreting the results.18–20 A weakness of the present study is mainly its retrospective design, and, as such, it is unable to assess the true role of this new surgical strategy. However, on one hand, it represents a real scenario and shows the place that laparoscopic lavage could occupy within the therapeutic armamentarium; on the other hand, as mentioned above, prospective data collection may somehow mitigate this issue. Second, despite stressing the importance of performing a meticulous intraoperative assessment, we were unable to detect an unsuspected perforation in 5 patients, which surely influenced the postoperative course. Third, because only 5 patients experienced treatment failure, we were also unable to discriminate the factors associated with the onset of this event. Regarding morbidity and mortality, our results are consistent with other published studies. It is noteworthy
that our overall morbidity of 25% is not low; nevertheless, only 7 patients presented severe complications, which included the 5 failures requiring re-exploration and resection, and no patients in the series died. The first multicenter randomized trial recently published comparing the outcome of 2 classic alternatives to the treatment for perforated left-sided diverticulitis (Hartmann procedure versus primary anastomosis with diverting ileostomy) revealed high mortality rates of 13% and 9% and morbidity rates of 67% and 75%.21 However, despite being a randomized trial, there was some selection bias, because, as the authors stated very honestly, 52 patients were not assessed for eligibility because of surgeon preference. For this reason, and because some authors speculate that many of the patients who underwent a laparoscopic lavage could have been treated with a nonoperative strategy,22 we must ask ourselves how many could have been washed instead of resected. Laparoscopic lavage itself includes 2 opposing concepts. Some critics stress that selection bias is intrinsically related to this method and adversely affects its credibility. Nevertheless, there is consensus that intraoperative selection of candidates is of utmost importance to get the most benefit. There also seems to be agreement that, when an overt perforation is detected, resection should be mandatory.10,23 The challenge is to identify those patients with no perforations in whom laparoscopic lavage is supposed to successfully control the sepsis and those with occult perforation which, if not detected, may jeopardize the results. Regarding this issue, a recent retrospective review showed that 63% (17/27) of resected
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patients with Hinchey III diverticulitis had no perforation on review of histology.24 In our experience, although a hydropneumatic test allowed us to identify 3 patients with an unsuspected perforation and exclude them from lavage, there were 5 failures of the initial treatment that required reoperation and resection. O’Leary and Myers,25 in a recent editorial for this journal, considered that these additional measures should decrease the failure rate of laparoscopic lavage and estimated that such cases account for ≈30% of all cases. Finally, they speculated that this percentage will appear in the 4 ongoing randomized trials.26–29 In our opinion, although prospective studies unquestionably represent the highest level of evidence, we agree with authors who, in this particular case, are likely to highlight this failure.
CONCLUSION Our results suggest that laparoscopic peritoneal lavage is safe and highly effective to resolve purulent generalized (Hinchey III) peritonitis in hemodynamically stable patients. Although its applicability was low, it could be used in more than half of all patients requiring emergency surgery for acute diverticulitis, thereby avoiding a resective procedure in an unfavorable scenario. Intraoperative selection seems to be critical to detect some inadvertent perforations. However, despite this measure, we would expect ≈15% therapeutic failure, which needs to be considered when informing patients about this attractive surgical strategy. ACKNOWLEDGMENTS The authors thank Dr Victoria Ardiles for her help and support in conducting this study. REFERENCES 1. Dharmarajan S, Hunt SR, Birnbaum EH, Fleshman JW, Mutch MG. The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum. 2011;54:663–671. 2. Costi R, Cauchy F, Le Bian A, Honart JF, Creuze N, Smadja C. Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients–a 10year experience with a nonoperative treatment. Surg Endosc. 2012;26:2061–2071. 3. Masoomi H, Buchberg BS, Magno C, Mills SD, Stamos MJ. Trends in diverticulitis management in the United States from 2002 to 2007. Arch Surg. 2011;14:400–406. 4. Faiz O, Warusavitarne J, Bottle A, et al. Nonelective excisional colorectal surgery in English National Health Service Trusts: a study of outcomes from Hospital Episode Statistics Data between 1996 and 2007. J Am Coll Surg. 2010;210:390–401. 5. Ince M, Stocchi L, Khomvilai S, Kwon DS, Hammel JP, Kiran RP. Morbidity and mortality of the Hartmann procedure for diver-
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ticular disease over 18 years in a single institution. Colorectal Dis. 2012;14:e492–e498. 6. O’Sullivan GC, Murphy D, O’Brien MG, Ireland A. Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg. 1996;171:432–434. 7. Bretagnol F, Pautrat K, Mor C, Benchellal Z, Huten N, de Calan L. Emergency laparoscopic management of perforated sigmoid diverticulitis: a promising alternative to more radical procedures. J Am Coll Surg. 2008;206:654–657. 8. Franklin ME Jr, Portillo G, Treviño JM, Gonzalez JJ, Glass JL. Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg. 2008;32:1507–1511. 9. 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. 10. White SI, Frenkiel B, Martin PJ. A ten-year audit of perforated sigmoid diverticulitis: highlighting the outcomes of laparoscopic lavage. Dis Colon Rectum. 2010;53:1537–1541. 11. Rogers AC, Collins D, O’Sullivan GC, Winter DC. Laparoscopic lavage for perforated diverticulitis: a population analysis. Dis Colon Rectum. 2012;55:932–938. 12. Swank HA, Mulder IM, Hoofwijk AG, Nienhuijs SW, Lange JF, Bemelman WA; Dutch Diverticular Disease Collaborative Study Group. Early experience with laparoscopic lavage for perforated diverticulitis. Br J Surg. 2013;100:704–710. 13. Santaniello M, Bergamaschi R. Perforated diverticulitis: should the method of surgical access to the abdomen determine treatment? Colorectal Dis. 2007;9:494–495. 14. Horgan A. Laparoscopic lavage for perforated diverticulitis: a panacea? Another view. Dis Colon Rectum. 2013;56:388. 15. Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014;57:284–294. 16. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–196. 17. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453–1457. 18. Alamili M, Gögenur I, Rosenberg J. Acute complicated diverticulitis managed by laparoscopic lavage. Dis Colon Rectum. 2009;52:1345–1349. 19. Toorenvliet BR, Swank H, Schoones JW, Hamming JF, Bemelman WA. Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis. 2010;12:862–867. 20. Gaertner WB, Kwaan MR, Madoff RD, et al. The evolving role of laparoscopy in colonic diverticular disease: a systematic review. World J Surg. 2013;37:629–638. 21. Oberkofler CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012;256:819–826. 22. Mutch MG. Complicated diverticulitis: are there indications for laparoscopic lavage and drainage? Dis Colon Rectum. 2010;53:1465–1466.
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23. McDermott FD, Collins D, Heeney A, Winter DC. Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis. Br J Surg. 2014;101:e90–e99. 24. O’Leary DP, Myers E, O’Brien O, Andrews E, McCourt M, Redmond HP. Persistent perforation in non-faeculant diverticular peritonitis–incidence and clinical significance. J Gastrointest Surg. 2013;17:369–373. 25. O’Leary DP, Myers E. Laparoscopic lavage for perforated diverticulitis: a panacea? Dis Colon Rectum. 2013;56:385–387. 26. Øresland T, Schultz JK, Yaqub S, Rashidi M, Nilsen FR. Scandinavian Diverticulitis Trial: SCANDIV–a randomized prospective multicenter trial. http://www.scandiv.com/Scandiv/SCANDIV_files/Scandiv%20protokoll%20110110.pdf. Accessed September 12, 2014.
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27. Thornell A, Angenete E, Gonzales E, et al.; Scandinavian Surgical Outcomes Research Group, SSORG. Treatment of acute diverticulitis laparoscopic lavage vs. resection (DILALA): study protocol for a randomised controlled trial. Trials. 2011;12:186. 28. ClinicalTrials.gov. LapLAND laparoscopic lavage for acute non-faeculent diverticulitis. http://clinicaltrials.gov/show/ NCT01019239. Accessed September 12, 2014. 29. Swank HA, Vermeulen J, Lange JF, et al.; Dutch Diverticular Disease (3D) Collaborative Study Group. The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg. 2010;10:29.
Laparoscopic Peritoneal Lavage for Hinchey III Diverticulitis: Is It as Effective as It Is Applicable? Gustavo L. Rossi, M.D. • Ricardo Mentz, M.D. • Santiago Bertone, M.D. Guillermo Ojea Quintana, M.D. • Soledad Bilbao, M.D. • Victor M. Im, M.D. Carlos A. Vaccaro, M.D., Ph.D. Section of Colorectal Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
BACKGROUND: Over the past few years, the laparoscopic peritoneal lavage has emerged as a therapeutic alternative to standard resection procedures. However, its effectiveness and applicability remain debatable. OBJECTIVE: The aim of this study was to assess laparoscopic lavage in controlling abdominal sepsis secondary to purulent peritonitis. DESIGN: This study was conducted as a retrospective analysis of prospectively collected data. SETTING: This study was conducted at a single tertiary care institution. PATIENTS: Patients requiring emergency surgery for perforated diverticulitis and generalized peritonitis between June 2006 and June 2013 were identified from a prospective database. Laparoscopic assessment was considered in all of the hemodynamically stable patients, and laparoscopic lavage was performed according to intraoperative strict criteria. MAIN OUTCOME MEASURES: Primary outcomes were the effectiveness and applicability of laparoscopic lavage. Secondarily, feasibility, morbidity, and mortality were also assessed. RESULTS: Seventy-five patients required emergency
surgery for generalized peritonitis secondary to perforated diverticulitis. Forty-six patients who underwent laparoscopy presented a purulent generalized Financial Disclosure: None reported. Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Hollywood, FL, May 17 to 21, 2014. Correspondence: Gustavo L. Rossi, M.D., Section of Colorectal Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. E-mail: [email protected] Dis Colon Rectum 2014; 57: 1384–1390 DOI: 10.1097/DCR.0000000000000252 © The ASCRS 2014
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(Hinchey III) peritonitis and were examined under the intention-to-treat basis to perform a laparoscopic lavage. Thirty-two patients (70.0%; 95% CI 56.2–82.7) had no previous episodes of diverticulitis. Thirty-six patients (78.0%; 95% CI 66.3–90.1) had free air on a CT scan. The conversion rate was 4% (95% CI 0–10). The feasibility of the method was 96.0% (95% CI 90.4–100), and its applicability was 59.0% (95% CI 44.8–73.2). Median operative time was 89 minutes (range, 40–200 minutes). Postoperative morbidity was 24.0% (95% CI 11.7–36.3), and the mortality rate was 0%. We registered 5 failures, and all of them underwent reoperation. The effectiveness of the procedure was 85% (95% CI 76–93). LIMITATIONS: This was a single-institution retrospective
study. CONCLUSIONS: The effectiveness of laparoscopic lavage seems to be high. Although its applicability is lower, it could be applied in more than half of patients requiring emergency surgery. This alternative strategy should be considered when laparoscopic assessment reveals Hinchey III diverticulitis. KEY WORDS: Applicability; Effectiveness; Hinchey III diverticulitis; Laparoscopic lavage.
I
n recent decades, the treatment of acute diverticulitis in all of its stages has evolved toward a more conservative approach.1,2 This gradual change has been in part because of advances in antibiotic therapy, imaging, percutaneous drainage techniques, and critical care, which have resulted in a nonoperative strategy able to convert an emergent situation into an elective one in a high percentage of cases. This trend has been reported recently, showing that ≈90 % of patients are being managed nonoperatively.3 However, in those patients who present with diverticular peritonitis (purulent or feculent), surgery continues to play a critical role in treatment. Until recently, the only 2 treatment options were resection of the affected segment Diseases of the Colon & Rectum Volume 57: 12 (2014)
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Diseases of the Colon & Rectum Volume 57: 12 (2014)
of the colon and the creation of an end colostomy as a modified Hartmann procedure or resection and primary anastomosis with or without diversion. Nevertheless, these resective procedures remain associated with an appreciable morbidity rate and a mortality of ≈15%.4,5 On the other hand, in the mid-1990s, a nonresective procedure was described in a small series of 8 patients, with a high rate of success, for the treatment of peritonitis attributed to a perforated diverticulitis.6 This new alternative, known as laparoscopic peritoneal lavage, aims to control abdominal sepsis (generally in Hinchey stage III) by performing a meticulous washout of all quadrants through a minimally invasive approach, leaving the sigmoid colon in place, and avoiding the construction of a stoma. Thereafter, a few groups, mainly from Europe, reported their experiences with this attractive organ-preserving procedure with a rate of success in general >80% and a low mortality rate.7–12 However, despite these promising results, some authors have questioned the usefulness and applicability of this therapeutic tool, arguing that there is scant and low-quality evidence13 or a questionable selection of patients.14 Recently, The American Society of Colon and Rectal Surgeons, in the last edition of its Practice Parameters for the Treatment of Sigmoid Diverticulitis,15 has stated that operative therapy without resection in patients with purulent or feculent peritonitis is generally not an appropriate alternative to colectomy. This statement is mainly based on the few available data from low-quality research, which include heterogeneous populations and different inclusion criteria. Thus, the primary aim of this study was to examine the effectiveness and applicability of laparoscopic lavage to resolve abdominal sepsis in a selected and homogeneous (Hinchey III) population of patients with a standardized intraoperative strategy, and, secondarily, to evaluate morbidity and mortality.
METHODS Patients and Data Collection
A prospectively maintained, practice-specific database was used to identify all of the patients with emergency admissions for acute sigmoid diverticulitis from June 2006 to June 2013 at the Hospital Italiano de Buenos Aires. Among patients who required emergency surgery, those hemodynamically stable cases in which a laparoscopic approach was feasible were deemed eligible. After laparoscopic exploration, subjects with Hinchey II or IV disease, with intraoperative evidence of perforation, or those who underwent laparoscopic resection were excluded from the study population. Data were prospectively recorded in an institutional review board–approved database including demographic data, comorbidities, number of previous episodes, clinical/CT and radiographic findings, intraop-
erative findings, operative times, length of stay, morbidity, and mortality. Procedures
After clinical assessment and laboratory test, all of the patients were resuscitated with intravenous fluids and antibiotics (500 mg of ciprofloxacin and 1000 mg of ornidazole). All of the patients were evaluated with CT at admission. The criterion for emergency surgery, defined as procedures performed within 12 hours of admission, was based on a clinical assessment (generalized peritonitis). Tomographic findings added additional information. Patients were placed in a modified lithotomy position with nasogastric decompression and a vesical catheter. After the insertion of the camera through a 12-mm umbilical port, two 5-mm trocars were placed on the right upper and lower quadrants. A third additional trocar was used according to the surgeon’s preference on the left lower quadrant. Once inside the abdominal cavity, a meticulous exploration was performed to rule out other causes of peritonitis. Pelvic structures and bowel loops were mobilized away from the pelvis using blunt dissection. Laparoscopic lavage was started by the pelvis to expose the sigmoid phlegmon and wash the pouch of Douglas. The sigmoid colon was left in place without any additional mobilization, and a careful revision was performed to identify the presence of an overt perforation. If there was no evidence of an overt perforation, a hydropneumatic test was performed to detect any unsuspected communication with the colon lumen. For this assessment, we insufflated the colon through the rectum with a rigid proctoscope, clamping the descending colon proximal to the affected segment and irrigating the pelvis with saline. If any perforation was detected, resection was mandatory and excluded from the analyzed population. In these cases, the decision to continue the surgery laparoscopically or open was based on the individual surgeon’s experience and preference. If no perforation was detected, we proceeded to complete the laparoscopic lavage, systematically including both parietocolic and subphrenic spaces. No specific amount of saline was used; irrigation continued until we obtained a clear fluid. The average volume used was between 3 and 6 L. Once laparoscopic lavage was finished, suction silastic drains were placed in the pelvis. Patients went to the intensive care unit as required. Intravenous antibiotics were continued for 5 to 7 days. Thereafter, the continuity of antibiotic treatment was established with the division of infectious diseases. Enteral feeding was initiated according to clinical progress. Total parenteral nutrition was only used in cases of prolonged bowel rest. Outcomes
The main outcomes were effectiveness, defined as the percentage of patients in whom the abdominal sepsis was resolved with no need for further treatment including drainage pro-
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cedures, ≤30 days from admission; and applicability, defined as the percentage of patients requiring emergency surgery for perforated diverticulitis who were treated with laparoscopic lavage and drainage. In this study, the decision to perform laparoscopic lavage was taken according to intraoperative strict criteria, including 4 quadrants of purulent peritonitis without an overt perforation or a positive hydropneumatic test. The feasibility of the method was defined as the percentage of patients in which, after laparoscopy was completed, lavage of the abdominal cavity could be performed. Based on our policy, all of the hemodynamically stable patients with an acute abdomen requiring surgical exploration without excessive distension were systematically approached by laparoscopy. Morbidity and mortality rates were also assessed and categorized according to the Clavien-Dindo score.16 Categorical variables were expressed as a percentage and 95% CI and continuous variables as the median and range.
Rossi et al: Laparoscopic Lavage for Hinchey III
Admisson for acute diverticulitis N = 455 Nonoperative treatment n = 380 Emergency surgery n = 75 Open surgery n =16
Laparoscopic approach n = 59
n=7
- Abdominal distension
n=4
- Both
n=5
Excluded n =13
RESULTS In the studied period, 455 consecutive patients were admitted with a primary diagnosis of acute diverticulitis, of which 75 (16%) required emergency surgery for an acute abdomen. Fifty-nine patients were initially approached by laparoscopy, and 13 met the exclusion criteria. Thus, 46 patients presented a purulent generalized (Hinchey III) peritonitis and represent the population analyzed. Figure 1 shows the distribution of patients according to the Strengthening the Reporting of Observational Studies in Epidemiology statement.17 Patient demographics are outlined in Table 1. Thirtytwo patients (70.0%; 95% CI 56.2–82.7) had no previous episodes of diverticulitis. Thirty-six patients (78.0%; 95% CI 66.3–90.1) had free air on CT scan, with 29 (63.0%; 95% CI 49.0–79.5) as a distant pneumoperitoneum and 7 (13.0%; 95% CI 3.3–22.7) as bubbles around a phlegmonous sigmoid. Figure 2 displays the findings on the CT scan of a patient who successfully underwent laparoscopic lavage. Of the 46 patients whose intention to treat was to perform a laparoscopic lavage, 2 required conversion (4%; 95% CI 0–10), representing a feasibility of 96.0% (95% CI 90.4–100) for the method. Reasons for conversion were excessive intestinal distension in one case and firm adhesions that made it impossible to adequately visualize the operative field in the other. These converted cases were managed with a sigmoidectomy, primary anastomosis without diversion, and a Hartmann procedure. We were able to carry out laparoscopic lavage in 44 of the 75 patients who required emergency surgery, so that the applicability of the method was 59.0% (95% CI 44.8–73.2). The median operative time was 89 minutes (range, 40–200 minutes). We had no intraoperative complications. The median number of drains placed was 2 (range, 1–4). Global postoperative morbidity
- Hemodynamic instability
Laparoscopic lavage (intention to treat)
- Hinchey II
n=3
- Hinchey IV
n=5
- Hydropneumatic test (+)
n=3
- Macroscopic perforation
n=2
n = 46
Figure 1. Diagram depicting the distribution of patients.
was 24.0% (95% CI 11.7–36.3). Eleven patients presented 13 complications. Details of the complications according to the Clavien-Dindo classification are TABLE 1. Demographic and clinical characteristics (N = 46) Variable Women, n (%; 95% CI) Age, mean (range), y BMI, mean (range), kg/m2 ASA score, n (%; 95% CI) I II III IV Previous abdominal surgery, n (%; 95% CI) Type of surgery Appendectomy Cesarean section Cholecystectomy Hysterectomy Gastrectomy Nephrectomy Eventroplasty plus mesh Dermolipectomy Previous episodes of diverticulitis, n (%; 95% CI) 0 1 2 3
27 (59; 44.8–73.2) 66 (31–95) 25.6 (20.0–33.4) 2 (4.7; 0–10.8) 23 (50; 35.5–64.4) 21 (45.6; 31.2–60.0) 0 15 (32.6; 19.1–46.1)
5 1 3 3 1 3 1 1
32 (70.0; 56.2–82.7) 9 (19.5; 8.0–31.0) 4 (8.3; 0.4–16.2) 1 (2.2; 0–6.4)
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The effectiveness of laparoscopic lavage was 85% (95% CI 76–93). In addition to the 2 patients who required conversion, 5 of 44 washouts failed to adequately control abdominal sepsis (Fig. 3). All of them were reassessed with a second CT scan. In 1 patient, a paravesical residual abscess was identified and drained percutaneously; however, despite the drainage, he persisted with fever and abdominal pain. All 5 of these patients were reoperated and resected. A laparotomy was performed in 4 of them, and 1 patient was approached laparoscopically. In 3 patients, the re-exploration revealed a feculent peritonitis near a visible perforation, and the other 2 patients showed fibrinous residual purulent peritonitis, mainly in the pelvis. Two of the patients with feculent peritonitis underwent a Hartmann procedure, and the other a sigmoid resection, primary anastomosis, and colostomy. The other 2 cases were resolved with sigmoid resection and primary anastomosis without diversion. Three patients in the entire series required diversion (6.5%; 95% CI 0–13.6), and all of them were subsequently reconstructed. Of those patients with full recovery, none of them required additional drainage. Four had a prolonged antibiotic course, although none of them presented complications associated with this treatment. One month after surgery, all of the patients who were treated with successful laparoscopic lavage were assessed with a double-contrast barium enema or colonoscopy. All of them presented with diverticular disease, and no malignancy was found.
Figure 2. CT scan of the oldest patient in this series (95 years old). A, Perihepatic free fluid and pneumoperitoneum. B, Diverticular phlegmon in the pelvis.
shown in Table 2. The median length of stay was 6 days (range, 3–30 days), and only 2 patients had intensive care unit admissions. The procedural mortality rate was 0%. TABLE 2. Complications according to Clavien-Dindo score16 Stratification of complications Grade II Pneumonia Ileus Hypertension Grade IIIb Failure Wound infection Grade IVa Acute myocardial infarction Pneumonia Grade IVb Failure Atrial fibrillation with respiratory failure
N 1 2 1 4 1 1 1 1 1
DISCUSSION One of the main findings of this study is the high effectiveness of this method to control abdominal sepsis and to restore the status of health, with a value within the previously reported range (77%–100%).8,10 This not only implies avoiding a sigmoid resection in an unfavorable scenario, which has been associated with a high mortality rate, but also the low colostomy rate reported in all of the series, including this one. Such a strategy allows for proper assessment of these patients once the peritonitis has been resolved, because they usually do not know that they have a diverticular disease. Moreover, coincidentally with other series,7,12 we observed that the majority of the patients had no previous episodes of diverticulitis, and the clinical presentation with peritonitis was the debut of the disease. This study also showed that laparoscopic lavage can be successfully applied in a considerably high proportion of patients requiring emergency surgery for purulent generalized peritonitis. Studies that attempt to assess the place of an alternative procedure should address this issue. To date, only 2 previous series have reported 44%10 and 17%11 applicability, which is much lower than the applicability found in this series.
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Rossi et al: Laparoscopic Lavage for Hinchey III
Laparoscopic lavage (intention to treat) N = 46
Conversion to open surgery n=2
Full laparoscopic lavage n = 44
Complete recovery n = 39
Failures and reintervention n = 5 - Open PA without diversion n=2 - Open HP n=2 - Laparoscopic PA with diversion n = 1
Figure 3. Flow chart of surgical outcomes. PA = primary anastomosis; HP = Hartmann procedure.
The strength of this study is based on 2 important aspects. First is, the prospective nature of data collection meant that no information was missed, which may otherwise have interfered with the analysis, and second is the homogeneous nature of the population analyzed because of strict exclusion criteria. All of the included patients had an acute abdomen requiring immediate surgical exploration, and all presented 4-quadrant purulent (Hinchey III) peritonitis. With respect to this topic, many other series have included different timings of surgery (from 3 days) and stages of the disease.7–11 Recently, 3 different systematic reviews that included more than 200 laparoscopic lavages revealed that ≈20% and 4% of patients had Hinchey II and IV diverticulitis; this issue must be taken into account when interpreting the results.18–20 A weakness of the present study is mainly its retrospective design, and, as such, it is unable to assess the true role of this new surgical strategy. However, on one hand, it represents a real scenario and shows the place that laparoscopic lavage could occupy within the therapeutic armamentarium; on the other hand, as mentioned above, prospective data collection may somehow mitigate this issue. Second, despite stressing the importance of performing a meticulous intraoperative assessment, we were unable to detect an unsuspected perforation in 5 patients, which surely influenced the postoperative course. Third, because only 5 patients experienced treatment failure, we were also unable to discriminate the factors associated with the onset of this event. Regarding morbidity and mortality, our results are consistent with other published studies. It is noteworthy
that our overall morbidity of 25% is not low; nevertheless, only 7 patients presented severe complications, which included the 5 failures requiring re-exploration and resection, and no patients in the series died. The first multicenter randomized trial recently published comparing the outcome of 2 classic alternatives to the treatment for perforated left-sided diverticulitis (Hartmann procedure versus primary anastomosis with diverting ileostomy) revealed high mortality rates of 13% and 9% and morbidity rates of 67% and 75%.21 However, despite being a randomized trial, there was some selection bias, because, as the authors stated very honestly, 52 patients were not assessed for eligibility because of surgeon preference. For this reason, and because some authors speculate that many of the patients who underwent a laparoscopic lavage could have been treated with a nonoperative strategy,22 we must ask ourselves how many could have been washed instead of resected. Laparoscopic lavage itself includes 2 opposing concepts. Some critics stress that selection bias is intrinsically related to this method and adversely affects its credibility. Nevertheless, there is consensus that intraoperative selection of candidates is of utmost importance to get the most benefit. There also seems to be agreement that, when an overt perforation is detected, resection should be mandatory.10,23 The challenge is to identify those patients with no perforations in whom laparoscopic lavage is supposed to successfully control the sepsis and those with occult perforation which, if not detected, may jeopardize the results. Regarding this issue, a recent retrospective review showed that 63% (17/27) of resected
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patients with Hinchey III diverticulitis had no perforation on review of histology.24 In our experience, although a hydropneumatic test allowed us to identify 3 patients with an unsuspected perforation and exclude them from lavage, there were 5 failures of the initial treatment that required reoperation and resection. O’Leary and Myers,25 in a recent editorial for this journal, considered that these additional measures should decrease the failure rate of laparoscopic lavage and estimated that such cases account for ≈30% of all cases. Finally, they speculated that this percentage will appear in the 4 ongoing randomized trials.26–29 In our opinion, although prospective studies unquestionably represent the highest level of evidence, we agree with authors who, in this particular case, are likely to highlight this failure.
CONCLUSION Our results suggest that laparoscopic peritoneal lavage is safe and highly effective to resolve purulent generalized (Hinchey III) peritonitis in hemodynamically stable patients. Although its applicability was low, it could be used in more than half of all patients requiring emergency surgery for acute diverticulitis, thereby avoiding a resective procedure in an unfavorable scenario. Intraoperative selection seems to be critical to detect some inadvertent perforations. However, despite this measure, we would expect ≈15% therapeutic failure, which needs to be considered when informing patients about this attractive surgical strategy. ACKNOWLEDGMENTS The authors thank Dr Victoria Ardiles for her help and support in conducting this study. REFERENCES 1. Dharmarajan S, Hunt SR, Birnbaum EH, Fleshman JW, Mutch MG. The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum. 2011;54:663–671. 2. Costi R, Cauchy F, Le Bian A, Honart JF, Creuze N, Smadja C. Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients–a 10year experience with a nonoperative treatment. Surg Endosc. 2012;26:2061–2071. 3. Masoomi H, Buchberg BS, Magno C, Mills SD, Stamos MJ. Trends in diverticulitis management in the United States from 2002 to 2007. Arch Surg. 2011;14:400–406. 4. Faiz O, Warusavitarne J, Bottle A, et al. Nonelective excisional colorectal surgery in English National Health Service Trusts: a study of outcomes from Hospital Episode Statistics Data between 1996 and 2007. J Am Coll Surg. 2010;210:390–401. 5. Ince M, Stocchi L, Khomvilai S, Kwon DS, Hammel JP, Kiran RP. Morbidity and mortality of the Hartmann procedure for diver-
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ticular disease over 18 years in a single institution. Colorectal Dis. 2012;14:e492–e498. 6. O’Sullivan GC, Murphy D, O’Brien MG, Ireland A. Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg. 1996;171:432–434. 7. Bretagnol F, Pautrat K, Mor C, Benchellal Z, Huten N, de Calan L. Emergency laparoscopic management of perforated sigmoid diverticulitis: a promising alternative to more radical procedures. J Am Coll Surg. 2008;206:654–657. 8. Franklin ME Jr, Portillo G, Treviño JM, Gonzalez JJ, Glass JL. Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg. 2008;32:1507–1511. 9. 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. 10. White SI, Frenkiel B, Martin PJ. A ten-year audit of perforated sigmoid diverticulitis: highlighting the outcomes of laparoscopic lavage. Dis Colon Rectum. 2010;53:1537–1541. 11. Rogers AC, Collins D, O’Sullivan GC, Winter DC. Laparoscopic lavage for perforated diverticulitis: a population analysis. Dis Colon Rectum. 2012;55:932–938. 12. Swank HA, Mulder IM, Hoofwijk AG, Nienhuijs SW, Lange JF, Bemelman WA; Dutch Diverticular Disease Collaborative Study Group. Early experience with laparoscopic lavage for perforated diverticulitis. Br J Surg. 2013;100:704–710. 13. Santaniello M, Bergamaschi R. Perforated diverticulitis: should the method of surgical access to the abdomen determine treatment? Colorectal Dis. 2007;9:494–495. 14. Horgan A. Laparoscopic lavage for perforated diverticulitis: a panacea? Another view. Dis Colon Rectum. 2013;56:388. 15. Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014;57:284–294. 16. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–196. 17. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453–1457. 18. Alamili M, Gögenur I, Rosenberg J. Acute complicated diverticulitis managed by laparoscopic lavage. Dis Colon Rectum. 2009;52:1345–1349. 19. Toorenvliet BR, Swank H, Schoones JW, Hamming JF, Bemelman WA. Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis. 2010;12:862–867. 20. Gaertner WB, Kwaan MR, Madoff RD, et al. The evolving role of laparoscopy in colonic diverticular disease: a systematic review. World J Surg. 2013;37:629–638. 21. Oberkofler CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012;256:819–826. 22. Mutch MG. Complicated diverticulitis: are there indications for laparoscopic lavage and drainage? Dis Colon Rectum. 2010;53:1465–1466.
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23. McDermott FD, Collins D, Heeney A, Winter DC. Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis. Br J Surg. 2014;101:e90–e99. 24. O’Leary DP, Myers E, O’Brien O, Andrews E, McCourt M, Redmond HP. Persistent perforation in non-faeculant diverticular peritonitis–incidence and clinical significance. J Gastrointest Surg. 2013;17:369–373. 25. O’Leary DP, Myers E. Laparoscopic lavage for perforated diverticulitis: a panacea? Dis Colon Rectum. 2013;56:385–387. 26. Øresland T, Schultz JK, Yaqub S, Rashidi M, Nilsen FR. Scandinavian Diverticulitis Trial: SCANDIV–a randomized prospective multicenter trial. http://www.scandiv.com/Scandiv/SCANDIV_files/Scandiv%20protokoll%20110110.pdf. Accessed September 12, 2014.
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27. Thornell A, Angenete E, Gonzales E, et al.; Scandinavian Surgical Outcomes Research Group, SSORG. Treatment of acute diverticulitis laparoscopic lavage vs. resection (DILALA): study protocol for a randomised controlled trial. Trials. 2011;12:186. 28. ClinicalTrials.gov. LapLAND laparoscopic lavage for acute non-faeculent diverticulitis. http://clinicaltrials.gov/show/ NCT01019239. Accessed September 12, 2014. 29. Swank HA, Vermeulen J, Lange JF, et al.; Dutch Diverticular Disease (3D) Collaborative Study Group. The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg. 2010;10:29.
