Similar outcomes, but unanswered questions
Even though the primary outcome of disease-related morbidity was similar for both groups, “the issue still remains regarding when and how, if ever, this therapeutic approach should be considered for purulent peritonitis,” Kellie E. Cunningham, MD, and Brian S. Zuckerbraun, MD, both of the University of Pittsburgh, wrote in an accompanying editorial.
Although laparoscopic lavage has the obvious advantages of avoiding a laparotomy and stoma, previous studies have shown a higher rate of early reoperations and recurrent diverticulitis, despite lower stoma prevalence and equal mortality rates, they said. In addition, “patients who are immunosuppressed or would be expected to have a higher mortality rate with failure to achieve definitive source control should likely not be offered this therapy.”
A “philosophical” argument could be made in favor of laparoscopic lavage based on the potential consequences of early treatment failure, they wrote.
“Although one may consider the need for early reoperation a complication, some would argue it affects the minority of patients, thus avoiding the more morbid procedure with creation of a stoma at the index operation in the majority of patients,” they noted. “Additionally, patients who underwent lavage that subsequently proceed to colectomy would have otherwise been offered this therapy initially at the time of the index operation.”
More research is needed to answer questions such as which, if any, operative findings are associated with failure. In addition, an analysis of long-term cost benefits between the two options should be explored, the authors wrote.
Based on current evidence, shared decision-making is necessary, with individualized care and short and long-term trade-offs taken into account, they wrote.
Gastroenterologist perspective: Study fills gap in follow-up data
In an interview, David A. Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia School of Medicine, Norfolk, said the study is important because data have been lacking on outcomes of a laparoscopic lavage without a resection.
The findings represent “a major shift” in the growing consensus among surgeons that laparoscopic lavage is a viable option in appropriate patients, he said.
A key issue is the high rate of morbidity in patients who undergo traditional diverticulitis surgery. Complications can include wound infection and poor quality of life associated with stoma, Dr. Johnson said. Consequently, “a nonoperative approach from a patient perspective is certainly refreshing.”
Dr. Johnson said he was surprised by how well the patients fared after lavage given the severity of the diverticulitis in the patient population. However, this may be in part because of the relatively small numbers of patients at highest risk for complications, such as those with diabetes or immunocompromising conditions.
Dr. Johnson also said he was struck by the fact that the adenocarcinomas in the lavage group were diagnosed within the first year after the procedure. “The cancer diagnosis shouldn’t reflect on the lavage group,” but emphasizes the importance of having an earlier colonoscopy, he noted.
Next steps for research might include identifying a standardized endpoint for lavage, and determining how expanded use of the procedure might impact community practice, Dr. Johnson said. In addition, more research is needed to more clearly define patients most likely to benefit from laparoscopic lavage.
The study was supported in part by the department of surgery at Skåne University Hospital, Akershus University Hospital, and a fellowship to one of the study coauthors from the Southeastern Norway Regional Health Authority. Lead author Dr. Azhar disclosed grants from the department of surgery of Skåne University Hospital. Dr. Cunningham and Dr. Zuckerbraun had no financial conflicts to disclose. Dr. Johnson had no relevant financial disclosures.