Severe complications at 5 years were no different for patients with perforated purulent diverticulitis who underwent laparoscopic peritoneal lavage or colon resection, according to data from 199 individuals treated at 21 hospitals in Norway and Sweden. But it may yet prove appropriate in the right patient.
Acute perforated diverticulitis with peritonitis remains a challenging complication with high morbidity and mortality among patients with diverticular disease, and bowel resection remains the standard of treatment, Najia Azhar, MD, of Skåne University Hospital, Malmö, Sweden, and colleagues wrote.
Short-term data suggest that laparoscopic lavage with drainage and antibiotics might be a viable alternative, but long-term data are lacking, they said.
In the Scandinavian Diverticulitis (SCANDIV) trial, published in JAMA Surgery, researchers randomized 101 patients to laparoscopic peritoneal lavage and 98 to colon resection. With 3 patients lost to follow-up, the final analysis included 73 patients who underwent laparoscopic lavage and 69 who underwent resection. The mean age of the lavage patients was 66.4 years, and 39 were men. The mean age of the resection patients was 63.5 years, and 36 were men. The primary outcome was severe complications – excluding stoma reversals and elective sigmoid resections because of recurrence – at an average of 5 years’ follow-up. Secondary outcomes included stoma prevalence, diverticulitis recurrence, and secondary sigmoid resection.
Severe complications were similar for the lavage and resection groups (36% and 35%, respectively), as were the overall mortality rates (32% and 25%, respectively).
The prevalence of stoma was significantly lower in the lavage group, compared with the resection group (8% vs. 33%, P = .002). However, secondary operations (including reversal of stoma) were similar between the lavage and resection groups, performed in 26 lavage patients (36%) versus 24 resection patients (35%).
Diverticulitis recurrence was significantly more common in the lavage, compared with the resection group (21% vs. 4%, P = .004), the researchers noted.
In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection; all but one of these occurred within a year of the index procedure, the researchers wrote. In addition, overall length of hospital stay was similar for both groups.
No significant differences in quality of life were noted between the groups, based on the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores.
Balance secondary pros and cons
Laparoscopic lavage is not common practice today in the United States, the researchers noted. In clinical practice guidelines issued in 2020, the American Society of Colon and Rectal Surgeons strongly recommend colectomy over laparoscopic lavage for the treatment of left-sided colonic diverticulitis. However, the European Society of Coloproctology’s guidelines state that laparoscopic lavage is feasible for patients with peritonitis at Hinchey stage III.
The findings of the current study were limited primarily by the exclusion of 50% of eligible patients because of challenges associated with conducting randomized trials in emergency settings, the researchers noted. However, the number of excluded patients and their baseline characteristics after exclusion were very similar in the two groups, and the study represents the largest randomized trial to date to examine long-term outcomes in patients with perforated diverticulitis.
“Laparoscopic lavage is faster and cost-effective but leads to a higher reoperation rate and recurrence rate, often requiring secondary sigmoid resection,” the researchers emphasized. Consequently, patients undergoing lavage should have consented for resection surgery.
The similar rates of severe complications and quality of life scores support laparoscopic lavage as an option for perforated purulent diverticulitis, but shared decision-making will be essential for better optimal patient management, the researchers concluded.