Laparoscopic Lavage for Hinchey III Diverticulitis—But to Whom?

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To the Editor:
We read with great interest the article by Angenete et al,1 where they compared laparoscopic lavage with the Hartmann procedure in patients with acute diverticulitis and purulent peritonitis. It is not self-evident that trials on emergency surgery will be completed,2 and we congratulate the authors for carrying out such a demanding multicenter, prospective, randomized study on a topical issue. Although earlier studies have shown the feasibility of laparoscopic lavage,3 detailed knowledge of patient selection is crucial in interpreting the results and we have some comments regarding this.
First, Hinchey grade III patients were included on the basis of intraoperative findings. This equals to purulent peritonitis, and patients with no free fluid or fecal contamination were excluded from the study. However, were all cases with inflamed colon segment together with free fluid in the abdomen considered as Hinchey grade III? In our experience, some patients with an acute diverticulitis who have undergone explorative laparoscopy due to suspected appendicitis show inflamed sigmoid colon with small amount of purulent exudate in the pelvis. However, these patients do not have inflamed peritoneum or fibrin deposits and we do not consider them to have a generalized peritonitis. In these cases, peritoneal cavity is lavaged and patients generally do well. To do the Hartmann procedure on these patients seems overkill. Furthermore, it is likely that some patients in the trial could have been handled by laparoscopic sigmoid resection with primary anastomosis. It would be interesting to know in more detail the status of the abdominal cavity in these patients who underwent randomization.
Second, 54% (21/39) of patients in the laparoscopic lavage group and 47% (17/36) of patients in the Hartmann procedure group did not have generalized peritonitis on abdominal examination. The decision to operate on these patients was solely based on radiological imaging studies, which showed intra-abdominal fluid or gas. We and others have shown that patients who have pneumoperitoneum, but no generalized peritonitis on abdominal examination can undergo nonoperative treatment with 62% to 100% success rate and 0% mortality.4–6 Patients with diverticulitis and free abdominal fluid in the absence of generalized peritonitis and pneumoperitoneum are usually treated nonoperatively in our institution. It is possible that some patients in the trial could have been handled similarly by intravenous antibiotics alone.
Third, organ dysfunction is a strong prognostic factor in peritonitis7 and it is not stated whether patients undergoing operation had preoperative organ dysfunction. It has been shown that patients with acute diverticulitis with associated peritonitis (purulent or fecal), but without an organ dysfunction, have only 4% mortality.8 On the contrary, patients with diverticulitis-associated peritonitis and an organ dysfunction have 32% mortality and half require intensive care.8
Fourth, the majority of patients were ASA class 1 or 2 (74% in the laparoscopic lavage group and 58% in the Hartmann procedure group). There were no ASA class 4 patients in the laparoscopic lavage group, and no ASA class 5 patients at all. In our material, 65% (40/62) of patients who underwent operation due to Hinchey grade III diverticulitis were ASA class 3–5 patients (39% ASA class 3, 21% ASA class 4, and 5% ASA class 5). Thus, it seems that the fittest were selected in the trial.
As we can see, Hinchey grade III patients are not equal, and it seems that some could be treated nonoperatively whereas others (the ones with organ dysfunction) have high mortality despite surgery. It is interesting to note that 30-day mortality of the laparoscopic lavage group was 8% compared with 0% in the Hartmann procedure group. However, the mortality balanced out in longer 90-day follow-up.

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