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

AIM: Laparoscopic peritoneal lavage has increasingly been investigated as a promising alternative to sigmoidectomy for perforated diverticulitis with purulent peritonitis. Most studies only reported outcomes up to 12 months. Therefore, the objective of this study was to evaluate long-term outcomes of patients treated with laparoscopic lavage. METHODS: Between 2008 and 2010, 38 patients treated with laparoscopic lavage for perforated diverticulitis in 10 Dutch teaching hospitals were included. Long-term follow-up data on patient outcomes, e.g. diverticulitis recurrence, reoperations and readmissions, were collected retrospectively. The characteristics of patients with recurrent diverticulitis or complications requiring surgery or leading to death, categorized as 'overall complicated outcome', were compared with patients who developed no complications or complications not requiring surgery. RESULTS: The median follow-up was 46 months (interquartile range 7-77), during which 17 episodes of recurrent diverticulitis (seven complicated) in 12 patients (32%) occurred. Twelve patients (32%) required additional surgery with a total of 29 procedures. Fifteen patients (39%) had a total of 50 readmissions. Of initially successfully treated patients (n = 31), 12 (31%) had recurrent diverticulitis or other complications. At 90 days, 32 (84%) patients were alive without undergoing a sigmoidectomy. However, seven (22%) of these patients eventually had a sigmoidectomy after 90 days. Diverticulitis-related events occurred up to 6 years after the index procedure. CONCLUSION: Long-term diverticulitis recurrence, re-intervention and readmission rates after laparoscopic lavage were high. A complicated outcome was also seen in patients who had initially been treated successfully with laparoscopic lavage with relevant events occurring up to 6 years after initial surgery.

Early experience with laparoscopic lavage for perforated diverticulitis.

BACKGROUND: Laparoscopic lavage has recently emerged as a promising alternative to sigmoid resection in the treatment of perforated diverticulitis. This study examined an early experience with this technique. METHODS: The files of all patients with complicated diverticulitis were searched in 34 teaching hospitals of the Netherlands. Patients with perforated diverticulitis treated with laparoscopic lavage between 1 January 2008 and 31 December 2010 were included. RESULTS: Treatment with laparoscopic lavage was performed in only 38 patients in ten hospitals. Lavage was successful in controlling sepsis in 31 of the 38 included patients, with 32 per cent morbidity (10 of 31 patients) and fast recovery. Overall, 17 of 38 patients developed complications, of whom two had a missed overt sigmoid perforation. Two patients died from multiple organ failure and one from aspiration pneumonia; one other patient died after palliative management of inoperable lung carcinoma. Three patients in whom lavage was successful underwent subsequent sigmoid resection for recurrent diverticulitis. Patients in whom lavage was unsuccessful tended to have more co-morbidities, a higher preoperative C-reactive protein concentration and a higher Mannheim Peritonitis Index. CONCLUSION: Laparoscopic lavage for perforated diverticulitis was feasible in the majority of patients, but identification of an overt sigmoid perforation and patient selection are of critical importance.

Systematic review of trocar-site hernia.

BACKGROUND: Broad implementation of laparoscopic surgery has made trocar-related complications clinically important. Trocar-site hernia (TSH) is an uncommon, but potentially serious, complication that occasionally requires emergency surgery. This systematic review was conducted to establish the prevalence and risk factors for TSH. METHODS: The review was conducted according to the PRISMA guidelines. MEDLINE, Embase, Web of Science and the Cochrane Library were searched to 7 June 2010 for studies on TSH. RESULTS: Twenty-two articles were included. One study was a randomized clinical trial, five were prospective cohort studies and 16 were retrospective cohort studies. The prevalence of TSH is low, with a median pooled estimate of 0·5 (range 0-5·2) per cent. No meta-analysis on risk factors could be performed. Pyramidal trocars, 12-mm trocars and a long duration of surgery were identified as the most important technical risk factors for TSH. Older age and a higher body mass index were observed to be patient-related risk factors. CONCLUSION: TSH is an uncommon complication of laparoscopic surgery. The most important technical risk factors are the design and size of the trocars. The scientific evidence for recommendations to avoid TSH is sparse.

Is routine histopathological examination of appendectomy specimens useful? A systematic review of the literature.

AIM: Histopathological examination of the appendix after appendectomy is routinely performed. The object of this systematic review is to determine whether routine histopathological examination of the appendix is justified. METHOD: PubMed, EMBASE, Web of Science and the Cochrane library were searched without language restriction up to 1 October 2009. All articles that reported on the incidence of histopathologically proven aberrant appendiceal pathology were included. RESULTS: Nineteen case series reported the incidence of a benign neoplasm [0.5%, weighted mean (WM)], malignant neoplasm (0.2%, WM) and other pathology (0-14%). Nine articles reported the sensitivity of the intra-operative findings to detect aberrant diagnoses. Parasitic infection was detected in 0-19%, endometriosis in 0% and granulomatosis in 0-11% of cases. Five articles addressed the consequences of aberrant pathology. Most patients with parasite infection, granulomatosis and malignant neoplasms underwent additional investigation or treatment, in contrast to patients with a benign neoplasm. CONCLUSION: The incidence of unexpected findings in appendectomy specimens is low and the intra-operative diagnosis alone appears insufficient for identifying unexpected disease. The benefit of histopathology is studied inadequately. From the present available evidence, routine histopathology cannot be judged as useless.

Short- and long-term results of open versus laparoscopic appendectomy.

BACKGROUND: Clinical advantages of laparoscopic appendectomy have been shown in numerous trials and reviews. Most of these advantages are small and of limited clinical relevance, while laparoscopic operation costs are reported to be higher. The present study compares short- and long-term results of conventional appendectomy with or without diagnostic laparoscopy (OA), and laparoscopic appendectomy (LA). METHODS: All adult patients who underwent appendectomy in our institution from 1995 to 2005 were included retrospectively. Patient data were retrieved from medical records, questionnaires sent by mail, and records of general practitioners. Primary outcome parameters were long-term complications, readmissions, and reinterventions (>30 days postoperatively). Secondary outcome parameters were short-term complications, readmissions, and reinterventions (≤30 days postoperatively). RESULTS: A total of 755 patients were included, 545 of whom underwent OA, with the remaining 210 undergoing LA. In the long term there were few complications noted, and there were no significant differences in complications between the two groups. Within 30 days postoperatively, LA was associated with a significantly higher incidence of abdominal abscesses with consequent diagnostic investigations, interventions, and readmissions. CONCLUSIONS: Although laparoscopic appendectomy is known to deliver clinical advantages, it is associated with a higher incidence of abdominal abscesses. Because the procedure is about to become the standard of care, future research must be directed at solving this issue. The expected lower incidence of incisional hernia and small bowel obstruction after laparoscopic appendectomy was not shown in the present study.