Laparoscopic lavage versus primary resection in acute perforated diverticulitis
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Laparoscopic lavage versus primary resection in acute perforated diverticulitis - a randomised multicenter study. Pseudo diverticula:. Prevalence. Diverticulosis >60 years of age: 30-50% Diverticulitis 10-30% of those with diverticulosis: Conservative/medical treatment: 75-90%

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Laparoscopic lavage versus primary resection in acute perforated diverticulitis

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Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Laparoscopic lavage versus primary resection in acute perforated diverticulitis

- a randomised multicenter study


Pseudo diverticula

Pseudo diverticula:


Prevalence

Prevalence

Diverticulosis

>60 years of age: 30-50%

Diverticulitis

10-30% of those with diverticulosis:

Conservative/medical treatment: 75-90%

Surgical intervention: 10-30%


Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Hincheygrading


Complicated diverticulitis

Complicated diverticulitis

Obstruction

Abscess formation

Fistula formation

Perforation - Peritonitis

Mortality(historical): Purulent peritonitis 6%;

Faecal peritonitis 35%

(Nagorny et al 1985)

  • Incidence of acute perforated diverticulitis

  • 3-5 /100.000


Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Surgical options

Three stage

Transverse colostomy with lavage and suture of defect’

Sigmoid reection and anastomosis

Closure of stoma

Hartmann

Sigmoid resection with sigmoidostomy

Closed rectum (or mucous fistula)

Primary anastomosis

with or with out covering stoma

Lavage using the laparoscope


Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Hospital mortality after emergency surgery for perforated diverticulitis

Netherlands: Five teaching hospitals 291pts 1995 – 2005

Overall in-hospital mortality 29%

Ned Tijdschr Geeneskd. 2009;153:B195

Southeast England: One hosp 110pts 2002 – 2006

Mortality 10.9%

World J Emerg Surg. 2008 Jan 24;3-5


Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Hospital mortality after emergency surgery for perforated diverticulitis

England: ’Hospital Episode Statistics’ database between 1996 and 2006

Emergency surgery for sigmoid diverticular disease

30 -day death 1923/10198 pts = 15.9%

Alim Pharm Therapeutics 2009;30: 1171-1182


Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Rationale

• E. Myers et. al., BJS 2008

“Laparoscopic peritoneal lavage for generalized

peritonitis due to perforated diverticulitis”

Laparoscopy in 100 patients with perforated diverticulitis

- laparoscopic lavage in 92 patients

- 8 patients converted to Hartmann due to faecal peritonitis

Mortality 3%, morbidity 4%

• Similar results reported in other papers with fewer patients


Laparoscopic lavage versus primary resection in acute perforated diverticulitis

No randomized studies


Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Primary endpoint

severe complications within 90 days (Clavien-Dindo >IIIa )

power analysis 30 % v.s. 10 % complications = 130 pts Aim = 150 patients

Secondary endpoints

-duration of procedure

-time spent in hospital

-complications individually

-enterostoma one year after initial surgery

- “Cleveland Global Quality of Life”

-costs


Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Inclusion criteria :

- age >18 years

- clinical signs of perforated diverticulitis and need for surgery

- CT displays free gas and do not contradict the clinical diagnosis

- the patient tolerates general anesthesia

- the patient has given written informed consent

Exclusion criteria:

- pregnancy

- bowel obstruction


Laparoscopic lavage versus primary resection in acute perforated diverticulitis

www.scandiv.com

Log in with hospital name and password

The patient will be informed on used technique only postoperatively


Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Techniques

In all cases, lavage with minimum 4 l saline, wound drain and Hinchey grading

Laparoscopic lavage

usual port placement: umbilicus, suprapubic, right lower quadrant

faecal peritonitis (including visible hole) convert to Hartmann

adhesions to the sigmoid should not be dealt with

Sigmoid resection with or without stoma

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Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Case report forms

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Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Case report form, follow-up

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Laparoscopic lavage versus primary resection in acute perforated diverticulitis

Patient information and consent

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