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

Abstract

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. Graphical abstract

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

“…The definition of additional surgery, including bowel resections, stoma reversal, and hernia repair was in accordance with what has been used earlier. 7 – 9 Our national cohort reflects the clinical situation not uncommon in Europe, where Hartmann’s procedure remains the dominating surgery performed for perforated diverticulitis together with laparoscopic lavage.…”

“…Recurrent diverticulitis has been reported at a risk of up to 20 after laparoscopic lavage, 8 and during follow-up, resection rates vary between 20% and 45%. 7 – 9 Laparoscopic lavage has even been suggested as a “bridge to elective resection” surgery. 26 In our study, 27% of patients in the lavage group underwent resection within 2 years in routine care.…”

“…The proportion of patients requiring additional surgery after the emergency operation was similar across the 3 RCTs, while fewer patients had stoma in the lavage group compared with the resection group. 7 – 9 The prevalence of mortality and complications did not differ. Meta-analyses have reached somewhat diverse results due to differing definitions of outcomes.…”

“…Meta-analyses have reached somewhat diverse results due to differing definitions of outcomes. 10 – 14 Long-term results across the 3 RCTs 7 – 9 showed recurrent diverticulitis in around 20% of the lavage cases together with sigmoid resections in 20–45%. Moreover, cohort studies have found a higher complication burden, as measured by the Comprehensive Complication Index, after resection 15 and similar quality of life results.…”

Tobacco Smoking Is a Strong Predictor of Failure of Conservative Treatment in Hinchey IIa and IIb Acute Diverticulitis—A Retrospective Single-Center Cohort Study

“…There has been a wealth of research in observational and randomized controlled studies focusing on treating Hinchey I, III, or IV disease [ 10 , 11 , 12 , 13 , 14 ]. Conversely, little focus has been placed on the cohort of patients presenting with acute diverticulitis complicated by pericolic or pelvic Hinchey IIa-IIb abscesses.…”