Laparoscopic lavage and primary resection were found to yield similar mortality, functional outcomes, and quality of life outcomes at 5 years for patients with perforated purulent diverticulitis, according to the results of a study reported in JAMA Surgery.
The international randomized Scandinavian Diverticulitis (SCANDIV) trial (ClinicalTrials.gov Identifier: NCT01047462) was conducted in 21 hospitals in Sweden and Norway and enrolled patients with perforated purulent diverticulitis between February 2010 and June 2014. Investigators compared the outcomes of laparoscopic peritoneal lavage and primary resection as treatment for the patients during follow-up conducted from March 2018 to November 2019. Patients who were available for trial intervention (Hinchey stages <IV) were included in the follow-up. The primary outcome was severe complications within 5 years, and secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life.
Among a total of 199 patients, 101 were assigned to undergo laparoscopic peritoneal lavage and 98 were assigned to undergo colon resection. Perforated purulent diverticulitis was confirmed at the time of surgery in 74 patients who underwent lavage and 71 who underwent resection. Median follow-up was 59 months (interquartile range, 51-78; full range, 0-110). The final analysis included 73 patients who underwent laparoscopic lavage (mean [SD] age, 66.4  years; 39 men [53%]) and 69 who underwent resection (mean [SD] age, 63.5  years; 36 men [52%]).
The rate of severe complications was similar among both groups (36% for laparoscopic lavage and 35% for resection; P = .92). Overall mortality was 32% and 25% for the laparoscopic lavage group and the resection group, respectively (P =.36). Stoma prevalence was 8% in the laparoscopic lavage group compared with 33% (P =.002) in the resection group among patients who remained alive; secondary procedures, including stoma reversal, were conducted in 36% vs 35% (P = .92) of patients in the 2 groups, respectively.
Diverticulitis recurrence was higher after laparoscopic lavage compared with resection (21% vs 4%; P = .004). Among participants in the laparoscopic lavage group, 30% eventually underwent sigmoid resection.
The long-term results “demonstrate no significant difference in severe complications or overall mortality between the 2 treatment groups,” stated the study authors. “However, there were more unplanned reoperations, unplanned readmissions, and recurrence of diverticulitis in the laparoscopic lavage group,” they noted. “Nearly one-third of patients (30%) in the laparoscopic lavage group ended up with a sigmoid resection. Not surprisingly, the overall stoma prevalence was remarkably lower in the laparoscopic lavage group.”
The main limitation of the study, according to the investigators, is that approximately 50% of all eligible patients were not included, which can be attributed to the difficulties in conducting randomized clinical trials in an emergency clinical setting. Also, patients with the most severe illness and frailty might not have been included, and so the results are not generalizable to them.
“The question of which surgical approach should be the treatment of choice when facing a patient in the emergency department with perforated purulent diverticulitis remains,” the researchers commented. “Laparoscopic lavage is faster and cost-effective but leads to a higher reoperation rate and recurrence rate, often requiring secondary sigmoid resection. However, the stoma prevalence is lower in the laparoscopic lavage group, both in short-term and long-term follow-up. After 5 years, approximately 1 in 3 patients still had a stoma in the resection group. Therefore, laparoscopic lavage may be used as a bridge to overcome the emergency septic state and lead to an elective sigmoid resection.”
Azhar N, Johanssen A, Sundström T, et al; for the SCANDIV Study Group. Laparoscopic lavage vs primary resection for acute perforated diverticulitis: long-term outcomes from the Scandinavian Diverticulitis (SCANDIV) randomized clinical trial. JAMA Surg. Published online December 23, 2020. doi:10.1001/jamasurg.2020.5618