Two-year results of the randomized clinical trial DILALA comparing laparoscopic lavage with resection as treatment for perforated diverticulitis

Abstract

BackgroundTraditionally, perforated diverticulitis with purulent peritonitis was treated with resection and colostomy (Hartmann's procedure), with inherent complications and risk of a permanent stoma. The DILALA (DIverticulitis – LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) and other randomized trials found laparoscopic lavage to be a feasible and safe alternative. The medium‐term follow‐up results of DILALA are reported here.MethodsPatients were randomized during surgery after being diagnosed with Hinchey grade III perforated diverticulitis at diagnostic laparoscopy. The primary outcome was the proportion of patients with one or more secondary operations from 0 to 24 months after the index procedure in the laparoscopic lavage versus Hartmann's procedure groups. The trial was registered as ISRCTN82208287.ResultsForty‐three patients were randomized to laparoscopic lavage and 40 to Hartmann's procedure. Patients in the lavage group had a 45 per cent reduced risk of undergoing one or more operations within 24 months (relative risk 0·55, 95 per cent c.i. 0·36 to 0·84; P = 0·012) and had fewer operations (ratio 0·51, 95 per cent c.i. 0·31 to 0·87; P = 0·024) compared with those in the Hartmann's group. No difference was found in mean number of readmissions (1·37 versus 1·50; P = 0·221) or mortality between patients randomized to laparoscopic lavage or Hartmann's procedure. Three patients in the lavage group and nine in the Hartmann's group had a colostomy at 24 months.ConclusionLaparoscopic lavage is a better option for perforated diverticulitis with purulent peritonitis than open resection and colostomy.

Epidemiology, Pathophysiology, and Treatment of Diverticulitis

“…144 The diverticulitis-laparoscopic lavage (DILALA) trial found fewer operations and improved stoma-free survival in the lavage group, and, in contrast to the 2 previous studies, concluded that the use of lavage was feasible and safe. 145 Unfortunately, lavage has been studied only as a substitute for resection (definitive treatment) rather than as a bridge to resection (damage control) with a primary anastomosis. 146 At this time, the use of laparoscopic lavage is not recommended outside of clinical trials, given its association with persistent and recurrent abdominal sepsis.…”

Long‐term follow‐up of a multicentre cohort study on laparoscopic peritoneal lavage for perforated diverticulitis

“…In our study, nine patients (24%) underwent sigmoidectomy during follow‐up. In previous reports on long‐term outcomes after LL, sigmoidectomy rates of 44.7% and 21% were reported . In the cohort presented by White et al .…”

“…In our cohort there was no intention to treat patients by elective sigmoidectomy unless otherwise indicated during follow-up. The sigmoidectomy rate reported at 2-year follow-up in the DILALA trial was 21% (n = 43) [13,29]. In the recently published LLO Study, the overall reoperation rate was 26% (56/212 patients) [33].…”

“…Current studies on LL predominantly report on outcomes up to 12 months after surgery [13,14,16,17,[24][25][26]. Reports on the long-term consequences of LL as therapy for perforated diverticulitis are scarce [27][28][29]. Therefore, further exploration of long-term outcomes is of importance, since leaving the diseased colonic segment in situ after LL potentially puts patients at increased risk for both uncomplicated and complicated diverticulitis recurrence, which might necessitate surgery [3,19,23].…”

The diminishing role of surgery for acute diverticulitis

“…In the SCANDIV (Scandinavian Diverticulitis) trial, a larger number of patients in the lavage group underwent unplanned reoperations, but the resection group needed more planned reoperations (stoma reversals). Not surprisingly, therefore, laparoscopic lavage is more cost‐effective than resection and follow‐up of the DILALA (DIverticulitis – LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) trial found a 45 per cent reduced risk of undergoing one or more operations in the lavage group.…”