Laparoscopic peritoneal lavage versus sigmoidectomy for perforated diverticulitis with purulent peritonitis: three-year follow-up of the randomised LOLA trial.

BACKGROUND: This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial. METHODS: Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group. RESULTS: Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan-Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy. CONCLUSION: Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.

Damage control strategy in perforated diverticulitis with generalized peritonitis.

BACKGROUND: The best treatment for perforated colonic diverticulitis with generalized peritonitis is still under debate. Concurrent strategies are resection with primary anastomosis (PRA) with or without diverting ileostomy (DI), Hartmann's procedure (HP), laparoscopic lavage (LL) and damage control surgery (DCS). This review intends to systematically analyze the current literature on DCS. METHODS: DCS consists of two stages. Emergency surgery: limited resection of the diseased colon, oral and aboral closure, lavage, vacuum-assisted abdominal closure. Second look surgery after 24-48 h: definite reconstruction with colorectal anastomosis (-/ + DI) or HP after adequate resuscitation. The review was conducted in accordance to the PRISMA-P Statement. PubMed/MEDLINE, Cochrane central register of controlled trials (CENTRAL) and EMBASE were searched using the following term: (Damage control surgery) AND (Diverticulitis OR Diverticulum OR Peritonitis). RESULTS: Eight retrospective studies including 256 patients met the inclusion criteria. No randomized trial was available. 67% of the included patients had purulent, 30% feculent peritonitis. In 3% Hinchey stage II diverticulitis was found. In 49% the Mannheim peritonitis index (MPI) was greater than 26. Colorectal anastomosis was constructed during the course of the second surgery in 73%. In 15% of the latter DI was applied. The remaining 27% received HP. Postoperative mortality was 9%, morbidity 31% respectively. The anastomotic leak rate was 13%. 55% of patients were discharged without a stoma. CONCLUSION: DCS is a safe technique for the treatment of acute perforated diverticulitis with generalized peritonitis, allowing a high rate of colorectal anastomosis and stoma-free hospital discharge in more than half of the patients.

Epidemiology, Pathophysiology, and Treatment of Diverticulitis.

Diverticulitis is a prevalent gastrointestinal disorder that is associated with significant morbidity and health care costs. Approximately 20% of patients with incident diverticulitis have at least 1 recurrence. Complications of diverticulitis, such as abdominal sepsis, are less likely to occur with subsequent events. Several risk factors, many of which are modifiable, have been identified including obesity, diet, and physical inactivity. Diet and lifestyle factors could affect risk of diverticulitis through their effects on the intestinal microbiome and inflammation. Preliminary studies have found that the composition and function of the gut microbiome differ between individuals with vs without diverticulitis. Genetic factors, as well as alterations in colonic neuromusculature, can also contribute to the development of diverticulitis. Less-aggressive and more-nuanced treatment strategies have been developed. Two multicenter, randomized trials of patients with uncomplicated diverticulitis found that antibiotics did not speed recovery or prevent subsequent complications. Elective surgical resection is no longer recommended solely based on number of recurrent events or young patient age and might not be necessary for some patients with diverticulitis complicated by abscess. Randomized trials of hemodynamically stable patients who require urgent surgery for acute, complicated diverticulitis that has not improved with antibiotics provide evidence to support primary anastomosis vs sigmoid colectomy with end colostomy. Despite these advances, more research is needed to increase our understanding of the pathogenesis of diverticulitis and to clarify treatment algorithms.

Drains, Germs, or Steel: Multidisciplinary Management of Acute Colonic Diverticulitis.

The medical and surgical management of uncomplicated diverticulitis has changed over the last several years. Although immunocompetent patients or those without comorbidities can be treated with antibiotics as an outpatient, the efficacy of high-fiber intake or drugs such as mesalamine or rifaximin is not yet clearly established in the treatment of acute episodes and in the prevention of recurrences. On the other hand, the choice between antibiotic treatment and percutaneous drainage is not always obvious in diverticulitis complicated by abscess formation, especially for larger abscesses; although the results of studies comparing the two approaches remain controversial, surgery must be pursued for abscesses > 8 cm. For emergency surgery, the debate is still ongoing regarding laparoscopic lavage and surgical resection followed by primary anastomosis, since for both approaches the published reports are not in agreement regarding possible benefits. Therefore, these approaches are recommended only for selected patients under the care of experienced surgeons. Also, the contribution of elective surgery toward the overall approach has been revised; currently, it is reserved primarily for patients with a high risk of recurrence and whenever more conservative treatments were not effective.

Laparoscopic peritoneal lavage versus laparoscopic sigmoidectomy in complicated acute diverticulitis: a multicenter prospective observational study.

PURPOSE: Laparoscopic peritoneal lavage (LPL) is feasible in selected patients with pelvic abscess and generalized purulent peritonitis caused by acute diverticulitis. We aimed to compare LPL and laparoscopic sigmoidectomy (LS) in complicated acute diverticulitis. METHODS: This prospective, observational, multicenter study included patients with a pelvic abscess not amenable to conservative management and patients with Hinchey III acute diverticulitis, from 2015 to 2018. Sixty-six patients were enrolled: 28 (42%) underwent LPL and 38 (58%) underwent LS. In LS, patients had a primary anastomosis, with or without ileostomy, or an end colostomy (HA). Major outcomes were mortality, morbidity, failure of source control, reoperation, length of stay, and diverticulitis recurrence. RESULTS: Patient demographics were similar in the two groups. In LPL, ASA score > 2 and Mannheim Peritonitis Index were significantly higher (p = 0.05 and 0.004). In LS, 24 patients (63%) had a PA and 14 (37%) an HA. No death was recorded. Overall, morbidity was 33% in LPL and 18% in LS (p = 0.169). However, failure to achieve source control of the peritoneal infection and the need to return to the operating room were more frequent in LPL (p = 0.002 and p = 0.006). Mean postoperative length of stay was comparable (p = 0.08). Diverticular recurrence was significantly higher in LPL (p = 0.003). CONCLUSION: LPL is related to a higher reoperation rate, more frequent postoperative ongoing sepsis, and higher recurrence rates. Therefore, laparoscopic lavage for perforated diverticulitis carries a high risk of failure in daily practice.

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.

Meta-analysis of surgical strategies in perforated left colonic diverticulitis with generalized peritonitis.

PURPOSE: Surgical strategies for perforated diverticulitis (Hinchey stages III and IV) remain controversial. This systematic review aimed to compare the outcome of primary anastomosis, Hartmann procedure and laparoscopic lavage. METHODS: A systematic literature search was conducted through Medline, Embase, Cochrane Central Register and Health Technology Assessment Database to identify randomized and non-randomized controlled trials involving patients with perforated left-sided colonic diverticulitis comparing different surgical strategies. The methodological quality of the included studies was assessed systematically (Grading of Recommendations, Assessment, Development and Evaluation) and a meta-analysis was performed. RESULTS: After screening 4090 titles and abstracts published between 1958 and January 2018, 148 were selected for full text assessment. Sixteen trials (7 RCTs, 9 non-RCTs) with 1223 patients were included. Mortality rates were not significantly different between Hartmann procedure and primary anastomosis for Hinchey III and IV, neither in the meta-analysis of three RCTs (RR 2.03 (95% CI 0.79 to 5.25); p = 0.14, moderate quality of evidence) nor in the meta-analysis of six observational studies (RR 1.53 (95% CI 0.89 to 2.65); p = 0.13, very low quality of evidence). However, stoma reversal rates were significantly higher in the primary anastomosis group (RR 0.73 (95% CI 0.58 to 0.98); p = 0.008, moderate quality of evidence). Meta-analysis of four RCTs showed no significant difference between laparoscopic lavage for Hinchey III compared to sigmoid resection neither for mortality (RR 1.07 (95% CI 0.65 to 1.76); p = 0.79, moderate quality of evidence) nor for major complications (RR 0.86 (95% CI 0.69 to 1.08); p = 0.20, moderate quality of evidence). CONCLUSIONS: This systematic review suggests similar rates of complications but higher rates of colonic restoration after primary anastomosis compared to Hartmann procedure in perforated diverticulitis with generalized peritonitis (Hinchey III and IV). Results in laparoscopic lavage for Hinchey III are not superior to primary resection. However, further studies with a careful interpretation of the meaning of re-interventions are required.

Surgical treatment of diverticulitis and its complications: A systematic review and meta-analysis of randomized control trials.

PURPOSE: The surgical interventions of diverticulitis vary according to its grade and severity. There is a controversy about the best of these different surgical procedures. We aimed to systematically review and meta-analyze randomized controlled trials (RCTs) comparing outcomes and complications between different surgical approaches for acute diverticulitis and its complications. METHODS: Nine electronic databases including PubMed, Scopus, and Web of Science were searched for RCTs comparing different surgical procedures for different grades of diverticulitis. The risk of bias was assessed using the Cochrane Collaboration tool. The protocol was registered in PROSPERO (CRD42015032290). RESULTS: Outcome data were analyzed from five RCTs comparing laparoscopic sigmoid resection (LSR) (n = 247) versus open sigmoid resection (OSR) (n = 237) for treatment of acute complicated diverticulitis with minimal heterogeneity. There was no significant difference in short-term postoperative overall morbidity (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.61-1.31; P = 0.56) and long-term postoperative major morbidity (RR 0.78, 95% CI 0.46-1.31, P = 0.34). In other six RCTs compared laparoscopic lavage with resection for treatment of perforated diverticulitis with peritonitis, the postoperative mortality rate was non-significant in both short-term (RR 1.55, 95% CI 0.79-3.04; P = 0.21) and long-term (RR 0.67, 95% CI 0.29-1.58; P = 0.36) follow up. CONCLUSIONS: LSR is not superior over OSR regarding postoperative morbidity and mortality for acute symptomatic diverticulitis. Furthermore, laparoscopic lavage was proved to be as safe as resection for perforated diverticulitis with peritonitis. Further RCTs are still needed to make an accurate decision regarding these and other procedures.

Current Options for the Emergency Management of Diverticular Disease and Options to Reduce the Need for Colostomy.

This article reviews the current options and recommendations for the emergency management of acute diverticulitis, including the spectrum of antibiotics, percutaneous drainage, laparoscopic lavage, and surgical options for resection with the restoration of bowel continuity.

Laparoscopic lavage versus surgical resection for acute diverticulitis with generalised peritonitis: a systematic review and meta-analysis.

This systematic review and meta-analysis investigates current evidence on the therapeutic role of laparoscopic lavage in the management of diverticular peritonitis. A systematic review of the literature was performed on PubMed until June 2016, according to preferred reporting items for systematic reviews and meta-analyses guidelines. All randomised controlled trials comparing laparoscopic lavage with surgical resection, irrespective of anastomosis or stoma formation, were analysed. After assessment of titles and full text, 3 randomised trials fulfilled the inclusion criteria. Overall the quality of evidence was low because of serious concerns regarding the risk of bias and imprecision. In the laparoscopic lavage group, there was a statistically significant higher rate of postoperative intra-abdominal abscess (RR 2.54, 95% CI 1.34-4.83), a lower rate of postoperative wound infection (RR 0.10, 95% CI 0.02-0.51), and a shorter length of postoperative hospital stay during index admission (WMD = -2.03, 95% CI -2.59 to -1.47). There were no statistically significant differences in terms of postoperative mortality at index admission or within 30 days from intervention in all Hinchey stages and in Hinchey stage III, postoperative mortality at 12 months, surgical reintervention at index admission or within 30-90 days from index intervention, stoma rate at 12 months, or adverse events within 90 days of any Clavien-Dindo grade. The surgical reintervention rate at 12 months from index intervention was significantly lower in the laparoscopic lavage group (RR 0.57, 95% CI 0.38-0.86), but these data included emergency reintervention and planned intervention (stoma reversal). This systematic review and meta-analysis did not demonstrate any significant difference between laparoscopic peritoneal lavage and traditional surgical resection in patients with peritonitis from perforated diverticular disease, in terms of postoperative mortality and early reoperation rate. Laparoscopic lavage was associated with a lower rate of stoma formation. However, the finding of a significantly higher rate of postoperative intra-abdominal abscess in patients who underwent laparoscopic lavage compared to those who underwent surgical resection is of concern. Since the aim of surgery in patients with peritonitis is to treat the sepsis, if one technique is associated with more postoperative abscesses, then the technique is ineffective. Even so, laparoscopic lavage does not appear fundamentally inferior to traditional surgical resection and this technique may achieve reasonable outcomes with minimal invasiveness.

Long-Term Results After Laparoscopic Lavage for Perforated Diverticulitis Purulent Peritonitis in Sweden: A Population-Based Observational Study.

Objective: To compare long-term outcomes after laparoscopic lavage with resection surgery for perforated diverticulitis, Hinchey grade III as practiced in Sweden for 3 years. Background: Laparoscopic lavage has been studied in 3 randomized controlled trials. Long-term results indicate that additional surgery and a remaining stoma are less common after lavage compared with resection, but data from routine care and larger cohorts are needed to get a more complete picture. Methods: LapLav is a national cohort study with nearly complete coverage of all patients operated in Sweden between 2016 and 2018. The cohort was retrieved from the national patient register by a definition based on the Classification of Diseases and Related Health Problems-10 code plus the surgical procedural code. All medical records have been reviewed and data retrieved in addition to registry data. Propensity score with inverse probability weighting was used to balance the 2 groups, that is, laparoscopic lavage vs resection surgery. Results: Before the propensity score was applied, the cohort consisted of 499 patients. Additional surgery was more common in the resection group [odds ratio, 0.714; 95% confidence interval (CI) = 0.529-0.962; P = 0.0271]. Mortality did not differ between the groups (hazard ratio, 1.20; 95% CI = 0.69-2.07; P = 0.516). In the lavage group, 27% of patients went on to have resection surgery. Conclusions: In Swedish routine care, laparoscopic lavage was feasible and safe for the surgical treatment of perforated diverticulitis, Hinchey grade III. Our results indicate that laparoscopic lavage can be used as a first-choice treatment.

Contemporary management of diverticulitis.

The treatment of diverticulitis is experiencing a shift in management due to a number of large scale clinical trials. For instance, clinicians are beginning to recognize that avoidance of antibiotics in uncomplicated diverticulitis is not associated with worse outcomes. Additionally, while the decision to proceed with elective surgical resection for recurrent uncomplicated disease is less conclusive and favors a patient-centric approach, complicated disease with a large abscess denotes more aggressive disease and would likely benefit from elective surgical resection. Lastly, in patient with acutely perforated diverticulitis who require urgent surgical intervention, laparoscopic lavage is generally not recommended due to high re-intervention rates and the preferred surgical procedure is primary anastomosis with or without diversion due to high morbidity and low rates of Hartmann reversal.

A Meta-Analysis of Short-Term Outcomes After Laparoscopic Lavage Versus Colonic Resection in the Treatment of Perforated Diverticulitis.

The management of perforated non-faeculent diverticulitis has traditionally involved performing a colonic resection (CR). Laparoscopic lavage (LL) has emerged as a less invasive alternative in recent years. The aim of this meta-analysis was to assess the role of LL in the surgical treatment of perforated non-faeculent diverticulitis. To that end, we conducted a search on Embase, Medline, and Cochrane databases for comparative studies in the English language published till June 2021 [PROSPERO (CRD42021269410)]. The risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomised trials (RoB 2) and the methodological index for non-randomised studies (MINORS). Data were analysed using Cochrane RevMan. Pooled odds ratio (POR) and cumulative weighted ratios (CWR) were calculated. A total of 13 studies involving 1061 patients were found eligible, including seven studies based on three randomised control trials (RCTs). LL was associated with a reduced risk of wound infection, stoma formation, and need for further surgery by 77% [POR: 0.23, 95% confidence interval (CI): 0.07-0.74], 83% (POR: 0.17, 95% CI: 0.05-0.56), and 53% (POR: 0.47, 95% CI: 0.23-0.97) respectively. Duration of surgery and hospitalisation was reduced by 54% and 43% respectively. However, LL was associated with higher rates of unplanned reoperations (POR: 2.05, 95% CI: 1.22-3.42), recurrence (POR: 9.47, 95% CI: 3.24-27.67), and peritonitis (POR: 8.92, 95% CI: 2.71-29.33). No differences in mortality or readmission rates were observed. LL in Hinchey III diverticulitis lowers the incidence of stoma formation and overall reoperations without an increase in mortality but at the cost of higher recurrence rates and peritonitis. A limitation of this study was the inclusion of non-RCTs. An elective resection should be considered after LL. Guidelines for surgical techniques in LL need to be standardised.

Update on the management of sigmoid diverticulitis.

Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc.) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.

Laparoscopic Lavage in Complicated Diverticulitis with Colonic Perforation, Always Be Closing?

Laparoscopic lavage is seen as an acceptable alternative to colonic resection in selected patients with acute diverticulitis with purulent peritonitis. There is no consensus on what surgical technique should be used when performing this procedure. This case series describes the disease course of 3 patients with acute diverticulitis with purulent peritonitis treated with laparoscopic lavage and direct suturing of a colonic perforation. All patients (38- and 71-year-old males and a 44-year-old female) were seen in the emergency department due to acute lower abdominal pain. Clinical examination and laboratory and imaging studies were suggestive of perforated diverticular disease. Laparoscopic lavage with placement of drain(s) and direct suturing of a colonic perforation was performed. Postoperative treatment with intravenous antibiotics was continued for a variable term. Postoperative courses were uneventful. Patients were discharged on postoperative days 5, 5, and 7. At almost 1-year follow-up, all patients are in good clinical condition and have not had a recurrent episode of diverticulitis. Therefore, this case series shows promising results of laparoscopic lavage with direct suturing of colonic perforation in patients with diverticulitis with perforation and purulent peritonitis.

Is laparoscopic lavage safe in purulent diverticulitis versus colonic resection? A systematic review and meta-analysis.

BACKGROUND: Diverticulitis is one of the most common gastrointestinal diseases in western population. Colonic resection is recommended by international guidelines as a routinely used technique for purulent diverticulitis. Laparoscopic lavage was introduced as a non-resection alternative. The studies available so far have shown contradictory results. This meta-analysis aims to compare laparoscopic lavage versus colonic resection in patients with Hinchey Ⅲ-Ⅳ diverticulitis. METHODS: We did a systematic review of articles published before March 20, 2019, with no language restriction by searching PubMed, Cochrane library, EMBASE databases, clinicaltrials.gov, and Google Scholar databases. We included all RCTs and cohort studies comparing outcomes between patients with Hinchey Ⅲ-Ⅳ diverticulitis undergoing laparoscopic lavage versus colonic resection. Important outcomes were mortality, complications, length of stay, readmission and reoperation rates. We combined data to assess the outcomes using DerSimonian and Laird random-effects model. RESULTS: A total of 569 patients with diverticulitis of which more than 80% were Hinchey Ⅲ were enrolled from 3 RCTs and 5 cohort studies. Laparoscopic lavage was associated with shorter operative time (WMD -78.9, 95%CI -100.58 to -57.11, P < 0.0001) and total postoperative hospital stay (WMD -7.62, 95%CI -11.60 to -3.63, P = 0.0002) but a higher rate of intra-abdominal abscess (OR 2.69, 95%CI 1.39 to 5.21, P = 0.0032) and secondary peritonitis (OR 5.30, 95%CI 1.91 to 14.73, P = 0.0014). CONCLUSION: Laparoscopic lavage for patients with Hinchey Ⅲ to Ⅳ diverticulitis does provide similar mortality, shorter operative time and hospital stay. However, the evidence so far suggests that it might be inadequate for sepsis control and may result in more unplanned reoperations. Further studies are needed to standardize the formal indication for laparoscopic lavage.

Laparoscopic lavage and drainage for Hinchey III diverticulitis: review of technical aspects.

The surgical treatment for patients with generalized peritonitis complicating sigmoid diverticulitis is currently debated; particularly in case of diffuse purulent contamination (Hinchey 3). Laparoscopic lavage and drainage (LLD) has been proposed by some authors as a safe and effective alternative to single- or multi-stage resective surgery. However, among all the different studies on LLD, there is no uniformity in terms of surgical technique adopted and data show significant differences in postoperative outcomes. Aim of this review was to analyze the differences and similarities among the authors in terms of application, surgical technique and outcomes of LLD in Hinchey 3 patients. A bibliographical research was performed by referring to PubMed and Cochrane. "Purulent peritonitis", "Hinchey 3 diverticulitis", "acute diverticulitis", "colonic perforation" and "complicated diverticulitis" were used as key words. Twenty-eight papers were selected, excluding meta-analysis, reviews and case reports with a very small number of patients. The aim of this review was to establish how LLD should be done, suggesting important technical tricks. We found agreement in terms of indications, preoperative management, ports' positioning, antibiotics, enteral feeding and drain management. On the contrast, different statements regarding indications, adhesiolysis and management of colonic hole and failure of laparoscopic lavage are reported. A widespread diffusion of LLD and standardization of its technique are impossible because of data heterogeneity and selection bias in the limited RCTs. It is necessary to wait for long terms results from randomized clinical trials (RCTs) in progress to establish the efficacy and safety of this technique. More importantly, an increased number of highly skilled and dedicated colorectal laparoscopic surgeons are required to standardized the procedure.

The Multidisciplinary Management of Acute Complicated Diverticulitis.

BACKGROUND: Acute complicated diverticulitis (ACD) is an important and increasing issue in Western countries that leads to a significant impact and burden for patients, but also for the society due to its effects on hospital costs. In recent years, essential progression has been made regarding the research and implementation of novel or improved treatment strategies for the various disease entities of ACD. Much debated topics in the multidisciplinary approach of patients with ACD, such as the choice for nonoperative treatment options, the role of percutaneous drainage for diverticular abscesses, the role of laparoscopic lavage for perforated diverticulitis with purulent peritonitis, and the role of sigmoidectomy with primary anastomosis for patients with perforated diverticulitis, require clinicians to attentively follow and participate in these discussions. SUMMARY: The aim of this review article is to provide clinicians with a structured overview of the recent literature on the multidisciplinary management of complicated diverticulitis by a panel of experts on the topic. By performing an extensive literature search in the online medical databases MEDLINE (Ovid) and Embase, insights into nonoperative treatment, percutaneous drainage, minimally invasive and open surgical treatment of ACD are provided. Furthermore, a comprehensive algorithm for the treatment of ACD has been developed. KEY MESSAGES: Accurate patient evaluation and selection based on patient and disease characteristics is of paramount importance to determine the appropriate treatment strategy for patients with complicated diverticulitis. The presence of an experienced surgeon with advanced skills in laparoscopic emergency colorectal surgery is crucial for the treatment of patients with perforated diverticulitis in order to properly evaluate, select and treat patients suitable for nonoperative or operative treatment with an open or laparoscopic approach.

Laparoscopic Lavage in the Management of Perforated Diverticulitis: a Contemporary Meta-analysis.

IMPORTANCE: Perforated diverticulitis carries the risk of significant comorbidity and mortality. Although colon resection provides adequate source control, the procedure itself carries morbidity, as well as later stoma reversal procedures. The effectiveness of laparoscopic lavage to treat perforated diverticulitis remains unclear. OBJECTIVE: We aimed to conduct a meta-analysis to evaluate current studies comparing laparoscopic lavage with colon resection in cases of perforated diverticulitis for the effectiveness in source control, without the need for subsequent interventions, stoma formation, and death. DATA SOURCES: Electronic database searches were conducted using EMBASE, Pubmed, CINAHL, Cochrane databases, and clinicaltrials.gov following PRISMA guidelines. STUDY SELECTION: Randomized controlled trials (RCTs) were included that compared laparoscopic lavage against colon resection for perforated diverticulitis. DATA EXTRACTION AND SYNTHESIS: Risk of bias in RCT's was assessed the Cochrane Assessment of Bias risk tool and Jadad scale. A meta-analysis was performed using random-effects risk ratios (RR) and 95% confidence intervals (CI). MAIN OUTCOME: Outcome measures included the total rate of reoperation, rate of reoperation for infection, need for subsequent percutaneous drainage, stoma formation, and mortality rate within 90 days. RESULTS: Three eligible randomized controlled studies were identified, with a combined total of 372 patients. Laparoscopic lavage carried an increased rate of total reoperations (RR 2.07; CI 1.12-3.84; p = 0.021) and an increased rate of reoperation for infection (RR 5.56; CI 1.97-15.69; p = 0.001) compared with colon resection. In addition, laparoscopic lavage increased the rate of subsequent percutaneous drainage (RR 6.54; CI 1.77-24.16; p = 0.005) compared with colon resection, but a lesser risk of stoma formation within 90 days (RR 0.18; CI 0.12-0.27; p < 0.001). No difference in mortality rate was observed between treatments (RR 1.03; CI 0.45-2.34; p = 0.950). CONCLUSION: Despite decreased rates of stoma formation and equivalent mortality rates as compared with colon resection, laparoscopic lavage for Hinchey III diverticulitis fails to completely control the source of infection. Our data show that laparoscopic lavage is associated with increased rates of total reoperations, increased rates of reoperation for infections, and need for subsequent percutaneous drainage.

A historical review of surgery for peritonitis secondary to acute colonic diverticulitis: from Lockhart-Mummery to evidence-based medicine.

The management of patients with colonic diverticular perforation is still evolving. Initial lavage with or without simple suture and drainage was suggested in the late 19th century, replaced progressively by the three-stage Mayo Clinic or the two-stage Mickulicz procedures. Fears of inadequate source control prompted the implementation of the resection of the affected segment of colon with formation of a colostomy (Hartman procedure) in the 1970's. Ensuing development of the treatment strategies was driven by the recognition of the high morbidity and mortality and low reversal rates associated with the Hartman procedure. This led to the wider use of resection and primary anastomosis during the 1990's. The technique of lavage and drainage regained popularity during the 1990's. This procedure can also be performed laparoscopically with the advantage of faster recovery and shorter hospital stay. This strategy allows resectional surgery to be postponed or avoided altogether in many patients; and higher rates of primary resection and anastomosis can be achieved avoiding the need for a stoma. The three recent randomized controlled trials comparing laparoscopic peritoneal lavage alone to resectional surgery reported inconsistent outcomes. The aim of this review is to review the historical evolution and future reflections of surgical treatment modalities for diffuse purulent and feculent peritonitis. In this review we classified the various surgical strategies according to Krukowski et al. and Vermeulen et al. and reviewed the literature related to surgical treatment separately for each period.