Laparoscopic lavage an alternative to resection in perforated diverticulitis

Reuters Health – 05/01/2021 – fIn patients with perforated purulent diverticulitis, outcomes of laparoscopic peritoneal lavage eventually do not differ much from those following primary resection, researchers have found in JAMA Surgery.

As Dr. Najia Azhar of Skaane University Hospital Malmoe, in Sweden, told Reuters Health by email, “Long-term follow-up shows no difference in mortality or severe complications between the two groups, although the stoma rate is much higher in the resection group.”

“Some patients in the laparoscopic lavage group,” she added, “will eventually need resectional surgery, so laparoscopic lavage can be seen as a way to turn an acute situation into an elective one, and therefore shared decision-making taking both short- and long-term consequences into account with the patient is encouraged.”

Dr. Azhar and colleagues conducted a clinical trial in 21 hospitals in Sweden and Norway. They randomized 199 patients to undergo laparoscopic peritoneal lavage or colon resection. Perforated purulent diverticulitis was confirmed in 145 patients at the time of surgery. Median follow-up was close to five years.

The final analysis included 73 patients who had laparoscopic lavage and 69 who had resection. Twenty-six patients in the lavage group experienced severe complication compared to 24 of the resection group (36% vs. 35%, P=0.92), and 32% and 25% died (P=0.36), respectively.

Of the survivors, 8% of the lavage group had stomas compared to 36% who underwent resection (P=0.002). However, secondary operations, including stoma reversal were similarly prevalent (36% vs. 35%, respectively). Recurrence of diverticulitis was significantly higher in the lavage group (21%) than in resection patients (4%) and often led to sigmoid resection.

Total length of hospital stay, including the index admission, was similar in both groups, but unplanned reoperations were more frequent in the lavage group (26%) than the resection group (12%), as were unplanned readmissions.

There were no significant differences in quality of life between groups.

Dr. Brian S. Zuckerbraun, who coauthored a linked editorial, told Reuters Health by email, “My take-away from this study is that laparoscopic lavage and drain placement for diverticulitis with purulent peritonitis continues to be an alternative therapy to resection.”

“There are trade-offs with each approach, and further investigation may demonstrate clinical findings or specific populations that may benefit from one approach versus the other,” added Dr. Zuckerbraun, of the University of Pittsburgh Medical Center.

SOURCE: https://bit.ly/3n8xmva and https://bit.ly/3pP8GcR JAMA Surgery, online December 23, 2020.

By David Douglas