Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis

Abstract

IMPORTANCE Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available.OBJECTIVE To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis. DESIGN, SETTING, AND PARTICIPANTSThis international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-up was conducted between March 2018 and November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need and computed tomography-verified free air, were eligible. Those available for trial intervention (Hinchey stages <IV) were included in the long-term follow-up.INTERVENTIONS Patients were assigned to undergo laparoscopic peritoneal lavage or colon resection based on computer-generated, center-stratified block randomization. MAIN OUTCOMES AND MEASURESThe primary outcome was severe complications within 5 years. Secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life. RESULTSOf 199 randomized patients, 101 were assigned to undergo laparoscopic peritoneal lavage and 98 were assigned to colon resection. At the time of surgery, perforated purulent diverticulitis was confirmed in 145 patients randomized to lavage (n = 74) and resection (n = 71). The median follow-up was 59 (interquartile range, 51-78; full range, 0-110) months, and 3 patients were lost to follow-up, leaving a final analysis of 73 patients who had had laparoscopic lavage (mean [SD] age, 66.4 [13] years; 39 men [53%]) and 69 who had received a resection (mean [SD] age, 63.5 [14] years; 36 men [52%]). Severe complications occurred in 29% (n = 21) in the laparoscopic lavage group and 25% (n = 17) in the resection group (P = .58). Overall mortality was 32% (n = 23) in the laparoscopic lavage group and 25% (n = 17) in the resection group (P = .36). The stoma prevalence was 8% (n = 4) in the laparoscopic lavage group vs 33% (n = 17; P = .002) in the resection group among patients who remained alive, and secondary operations, including stoma reversal, were performed in 36% (n = 26) vs 35% (n = 24; P = .92), respectively. Recurrence of diverticulitis was higher following laparoscopic lavage (21% [n = 15] vs 4% [n = 3]; P = .004). In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection. There were no significant differences in the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores between the groups.CONCLUSIONS AND RELEVANCE Long-term follow-up showed no differences in severe complications. Recurrence of diverticulitis after laparoscopic lavage was more common, often leading to sigmoid resection. This must be weighed against the lower stoma...

Laparoscopic Lavage vs Resection for Purulent Diverticulitis

“…In this issue of JAMA Surgery , Azhar et al report on the long-term outcomes of patients from the Scandinavian Diverticulitis (SCANDIV) trial with a median follow-up of 5 years. The primary outcome was disease-related severe morbidity, including postoperative complications after not only the index operation, but also subsequent disease-related operations such as stoma reversal.…”

“…If outcomes are similar and stoma prevalence is decreased, should laparoscopic lavage be considered the favored approach? At this juncture, we agree with the conclusions by Azhar et al in that shared decision-making is necessary, with individualized care and comprehensive consideration of short-term vs long-term trade-offs.…”

Error in Results and Table

“…The Original Investigation, “Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial,” published in the February 2021 issue, contained errors in the Abstract, Results, and Table 2. In the Results subsection of the Abstract, the sentence “Severe complications occurred in 36% (n = 26) in the laparoscopic lavage group and 35% (n = 24) in the resection group ( P = .92)” should have read “Severe complications occurred in 29% (n = 21) in the laparoscopic lavage group and in 25% (n = 17) in the resection group ( P = .58).” The same erroneous values were in the Results section (with similar wording) and Table 2 (on the first line).…”

Long-term Outcomes of Laparoscopic Lavage for Perforated Diverticulitis Remain Unfavorable

“…Azhar et al report the 5-year results of the SCANDIV trial. Interestingly, the difference seen in severe complications at 90 days between laparoscopic lavage and sigmoid resection (26% vs 14%) has almost disappeared by 5 years (35% vs 36%) .…”

“…Azhar et al report the 5-year results of the SCANDIV trial. Interestingly, the difference seen in severe complications at 90 days between laparoscopic lavage and sigmoid resection (26% vs 14%) has almost disappeared by 5 years (35% vs 36%) . We can hypothesize that the change in severe complications in the laparoscopic lavage group from 26% to 35% is mostly due to unplanned reoperations (26% for laparoscopic lavage vs 12% for sigmoid resections) and readmissions (34% for laparoscopic lavage vs 11% for sigmoid resections) likely driven by recurrent diverticulitis (21% for laparoscopic lavage vs 4% for sigmoid resections).…”