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

Schmidt, Susann; Ismail, Tarek M; Puhan, Milo A.; Soll, Christopher; Breitenstein, Stefan

doi:10.1007/s00423-018-1686-x

Cited by 21 publications

(14 citation statements)

References 44 publications

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“…In the three studies, a total of 358 Hinchey III patients were included of whom 185 underwent laparoscopic lavage [122][123][124]. Several meta-analyses have been performed with somewhat different results [125][126][127][128][129][130][131][132][133]. There are several noncomparative cohorts showing that laparoscopic lavage is feasible in selected patients [134].…”

Section: Which Surgical Approach Is Appropriate In Patients With Purumentioning

confidence: 99%

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

Schultz

Azhar

Binda³

et al. 2020

Colorectal Disease

188

177

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Aim The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons. Methods The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements. Results This guideline contains 38 evidence based consensus statements on the management of diverticular disease. Conclusion This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

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Section: Which Surgical Approach Is Appropriate In Patients With Purumentioning

confidence: 99%

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

Schultz

Azhar

Binda³

et al. 2020

Colorectal Disease

188

177

View full text Add to dashboard Cite

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“…The results of RCTs showed a similar morbidity and mortality in short term follow-up and reduced length of stay in HP patients; the long term followup showed more definitive stomas, a worse quality of life and higher morbidity after stoma reversal. The meta-analysis of RCTs [48] showed no statistical differences in mortality or major morbidity between PRA and HP. Stoma reversal rate was higher in PRA compared to HP, and morbidity was lower in PRA patients.…”

Section: Reconstruction After Sigmoid Colectomymentioning

confidence: 85%

Hot Topics in Surgical Management of Acute Diverticulitiss

Binda

Papa

Persiani

et al. 2020

JGLD

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In this session different issues for the surgical management of diverticular disease DD) were considered. The first session debated about the antibiotic treatment for acute uncomplicated diverticulitis (AUD), and supports their use selectively rather than routinely in patients with AUD. The second session discussed the best surgical treatment for those patients. Open approach is a valid choice especially in acute setting, while the laparoscopic approach should be individualised according to the level of skills of the surgeon and the risk factors of the patient (such as obesity and state of health at the time of the operation). The third session debated about the peritoneal lavage and drainage, which is still a safe surgical procedure. However, it requires longer follow-up and results of other trials to draw an adequate conclusion. The last session covers the current surgical certainties in managing complicated DD: 1. urgent colectomy has higher mortality in immune-compromised patients, while in elective surgery is comparable with other populations; 2. laparoscopic peritoneal lavage (LPL) should be the choice in young/fit patients; 3. elective resection is safer in an inflammation free interval; 4. laparoscopic resection shows advantages in several outcomes (such as post-operative morbidity and lower stoma and re-operation rate); 5. in Hinchey III/fecal peritonitis, primary sigmoid resection and anastomosis (open or laparoscopic) could be proposed in young/ fit patient; 6. in case of emergency surgery, Hartmann procedure (open or laparoscopic) must be considered in critically ill/unstable patient.

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“…LPL was proposed in 1996 [45] with initial favorable results [46][47][48] encouraging its unselective use in perforated diverticulitis with peritonitis [49]. Three subsequent randomised controlled trials (RCTs) comparing LPL to sigmoidectomy obtained different results [50][51][52] Recent meta-analyses also reached different conclusions on the 30-day and 90-day reoperation risk, possibly due to methodological flaws [53][54][55][56][57][58][59][60]. Some findings are conclusive: resolution of sepsis and early morbidity and mortality rates after LPL are similar to those after sigmoidectomy, rates of abscesses and unplanned reoperations at index admission are higher after LPL, and total reoperation rate (including planned stoma closure), permanent stoma rate and costs [61][62][63] are lower after LPL than after resective surgery.…”

Section: Considerationsmentioning

confidence: 99%

“…RCTs comparing PRA with HP found no significant difference in mortality and overall morbidity after the index procedure, but all studies were prematurely terminated due to slow patient recruitment or for safety reasons [66][67][68]. Likewise, meta-analyses of experimental/observational studies and RCTs reported similar rates of major complications and postoperative mortality both for Hinchey III and IV disease [58,[69][70][71]. More recently, the LADIES trial found no significant differences in short-term outcome both in Hinchey III and IV patients, although this study also ended prematurely confirming the trial's vulnerability to discontinuation in the emergency setting, a feature that potentially leads to an overestimation of treatment benefits [72].…”

Section: Considerationsmentioning

confidence: 99%

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

et al. 2020

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Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

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

Cited by 21 publications

References 44 publications

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

Hot Topics in Surgical Management of Acute Diverticulitiss

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

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