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IMPROVING PATIENT CARE

Laparoscopic Lavage for Perforated Diverticulitis With Purulent Peritonitis: A Randomized TrialLaparoscopic Lavage for Perforated Diverticulitis With Purulent Peritonitis

Anders Thornell, MD; Eva Angenete, MD, PhD; Thue Bisgaard, MD, DMSc; David Bock, PhD; Jakob Burcharth, MD, PhD; Jane Heath, RN; Hans-Christian Pommergaard, MD, PhD; Jacob Rosenberg, MD, DMSc; Nikolaj Stilling, MD; Stefan Skullman, MD, PhD; and Eva Haglind, MD, PhD
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 19 January 2016.


From University of Gothenburg, Gothenburg, Sweden; University of Copenhagen, Copenhagen, Denmark; and Odense University Hospital, Odense, Denmark.

Acknowledgment: The authors thank all departments of surgery at Sahlgrenska University Hospital, Skaraborg Hospital Skövde, Norra Älvsborgs Hospital Trollhättan, Karlstad Central Hospital, Herlev Hospital at the University of Copenhagen, Køge Hospital, Odense University Hospital, Svendborg Hospital, and Holbæk Hospital.

Financial Support: From Sahlgrenska University Hospital, Swedish Research Council (2012-1770), the Health and Medical Care Committee of the Regional Executive Board and Region Västra Götaland, Adlerbertska Research Foundation, Alice Swenzons Foundation, Anna-Lisa and Bror Björnsson Foundation, Swedish Society of Medicine, Faith Regen Foundation, Göteborg Medical Society, Sahlgrenska University Hospital Health Technology Assessment Center, Johan & Jacob Söderberg Foundation, Bengt Ihre Foundation, Wilhelm & Martina Lundgren Foundation, Magnus Bergvall Foundation, Ruth and Richard Julin Foundation, Signe and Olof Wallenius Foundation, Adlerbertska Foundation and Mary von Sydow Foundation.

Disclosures: Dr. Thornell reports grants from Alice Swenzons Foundation, Anna-Lisa and Bror Björnsson Foundation, Göteborg Medical Society, Johan & Jacob Söderberg Foundation, Wilhelm & Martina Lundgren Foundation, Signe and Olof Wallenius Foundation, Adlerbertska Foundation, and Mary von Sydow Foundation during the conduct of the study. Dr. Haglind reports grants from the Swedish Research Council and Sahlgrenska University Hospital during the conduct of the study and grants from the Swedish Research Council and Mary von Sydow Foundation outside the submitted work. Dr. Burcharth reports a travel grant from Davol (Bard) outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1210.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol: Available for free access at ssorg.net. Statistical code: Available to interested readers by contacting Dr. Bock (e-mail, david.bock@gu.se). Data set: Not available.

Requests for Single Reprints: Eva Haglind, MD, PhD, Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, 416 85 Gothenburg, Sweden; e-mail, eva.haglind@vgregion.se.

Current Author Addresses: Drs. Thornell, Angenete, Bock, and Haglind; and Ms. Heath: Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, 416 85 Gothenburg, Sweden.

Dr. Bisgaard: Gastro Unit, Surgical Division, Hvidovre Hospital, University of Copenhagen, Kettegård Allé 30, DK-2650 Hvidovre, Denmark.

Drs. Burcharth, Pommergaard, and Rosenberg: Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730 Herlev, Denmark.

Dr. Stilling: Department of Surgery, Odense University Hospital, DK-5000 Odense C, Denmark.

Dr. Skullman: Department of Surgery, Skaraborg Hospital, S-54185 Skövde, Sweden.

Author Contributions: Conception and design: A. Thornell, E. Angenete, J. Burcharth, J. Heath, J. Rosenberg, S. Skullman, E. Haglind.

Analysis and interpretation of the data: A. Thornell, E. Angenete, T. Bisgaard, D. Bock, J. Burcharth, J. Heath, H. Pommergaard, J. Rosenberg, N. Stilling, S. Skullman, E. Haglind.

Drafting of the article: A. Thornell, E. Angenete, T. Bisgaard, D. Bock, J. Burcharth, J. Rosenberg, N. Stilling, S. Skullman, E. Haglind.

Critical revision of the article for important intellectual content: E. Angenete, T. Bisgaard, J. Burcharth, J. Heath, H. Pommergaard, J. Rosenberg, N. Stilling, E. Haglind.

Final approval of the article: A. Thornell, E. Angenete, T. Bisgaard, J. Burcharth, J. Heath, H. Pommergaard, J. Rosenberg, N. Stilling, S. Skullman, E. Haglind.

Provision of study materials or patients: E. Angenete, J. Heath, J. Rosenberg, S. Skullman, E. Haglind.

Statistical expertise: D. Bock.

Obtaining of funding: E. Angenete, E. Haglind, A. Thornell.

Administrative, technical, or logistic support: J. Heath, J. Rosenberg, N. Stilling.

Collection and assembly of data: A. Thornell, E. Angenete, T. Bisgaard, J. Heath, H. Pommergaard, J. Rosenberg, N. Stilling, S. Skullman, E. Haglind.


Ann Intern Med. 2016;164(3):137-145. doi:10.7326/M15-1210
Text Size: A A A

Background: Perforated diverticulitis with purulent peritonitis has traditionally been treated with open colon resection and stoma formation with risk for reoperations, morbidity, and mortality. Laparoscopic lavage alone has been suggested as definitive treatment.

Objective: To compare laparoscopic lavage with open colon resection and colostomy (Hartmann procedure) for perforated diverticulitis with purulent peritonitis.

Design: Randomized, controlled, multicenter, open-label trial. (ISRCTN registry number: ISRCTN82208287)

Setting: 9 hospitals in Sweden and Denmark.

Patients: Patients who have confirmed Hinchey grade III perforated diverticulitis with purulent peritonitis at diagnostic laparoscopy.

Intervention: Randomization between laparoscopic lavage and the Hartmann procedure.

Measurements: Primary outcome was the percentage of patients having 1 or more reoperations within 12 months. Key secondary outcomes were number of reoperations, hospital readmissions, total length of hospital stay during 12 months, and adverse events.

Results: A total of 43 and 40 patients were randomly assigned to laparoscopic lavage and the Hartmann procedure with a median (first, third quartiles) follow-up of 372 days (336, 394) and 378 days (226, 396), respectively. Fewer patients in the laparoscopic group (12 of 43; 27.9%) than in the Hartmann group (25 of 40; 62.5%) had at least 1 reoperation within 12 months (relative risk reduction, 59%; relative risk, 0.41 [95% CI, 0.23 to 0.72]; P = 0.004). Mortality and severe adverse events did not differ between groups. Total length of hospital stay (days) within 12 months was shorter for the laparoscopic group than the Hartmann group, with a reduction of 35% (relative risk, 0.65 [CI, 0.45 to 0.94]; P = 0.047). After 12 months, 3 patients in the laparoscopic group and 11 in the Hartmann group had a stoma.

Limitation: Not all patients presenting with suspected diverticulitis were enrolled.

Conclusion: Laparoscopic lavage reduced the need for reoperations, had a similar safety profile to the Hartmann procedure, and may be an appropriate treatment of choice for acute perforated diverticulitis with purulent peritonitis.

Primary Funding Source: ALF; Sahlgrenska University Hospital, Gothenburg.

Figures

Grahic Jump Location
Figure.

Study flow diagram.

* Technical failure was defined as inability to perform diagnostic laparoscopy because of surgical difficulties, such as adhesions, rendering the procedure unsafe without proper diagnosis.

† Excluded in per-protocol analysis due to the following reasons: cancer (n = 3), declined further active participation (n = 1), and small bowel perforation (n = 1).

‡ Excluded in per-protocol analysis due to the following reasons: cancer (n = 1), withdrew consent (n = 1), gynecologic infection (n = 1), sigmoid resection with primary anastomosis (n = 1), and small bowel obstruction with ischemia (n = 1).

Grahic Jump Location

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