Reply to Letter: “Laparoscopic Lavage for Patients With Hinchey III”

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Reply:
We welcome the interest in the short-term results from the DILALA trial.1 The criteria for randomizing between the Hartmann procedure and laparoscopic lavage were perioperative findings corresponding with Hinchey grade III, which is defined as perforated diverticulitis with purulent peritonitis. The amount of pus or the extent of colonic inflammation is not described in the original article by Hinchey et al.2 The patients included in the DILALA trial had Hinchey grade III, and we have no further intraoperative details as those reported.
Studying the possibility of performing laparoscopic primary resection with anastomosis or a laparoscopic Hartmann procedure would indeed be interesting but was not the objective of this trial because it was not the gold standard in Sweden or Denmark at the time of the study. Oberkofler et al3 have attempted to study this previously, but unfortunately their study was disrupted. The ongoing Dutch Ladies trial on perforated diverticulitis randomizes between the Hartmann procedure and resection and primary anastomosis and may shed light on this interesting issue.4
The decision to operate was not based solely on radiologic imaging but rather on the surgeon's clinical evaluation of “sickness” and other factors such as laboratory findings, abdominal examination, and body temperature over time and radiology. Assessment of all clinical factors and the patient showing signs of failing conservative treatment were the basis for the decision to convert to surgery. We agree that patients with a nongeneralized peritonitis with no signs of sepsis can be treated conservatively in many cases.
We agree that more details regarding the perioperative state of the patient might be beneficial. Organ dysfunction is an important prognostic factor in all surgery, and this should have been included as variable and the lack of this might be considered as a weakness.
We have found no indications in our screening logs that this trial was a selection of the “fittest.” It is difficult to say whether there was an individual selection among the little over 60 different surgeons who included and randomized the 83 patients, but that seems unlikely. There was no significant difference in ASA classification between the 2 groups and thus the data are valid for comparison. Nevertheless, it is true that the trial cannot conclude which type of surgery should be preferred for patients with ASA classification IV and V. The trial was simply not designed for that.
The main cause of death in the lavage group was complications that can be related to the septic state of the patient (multiorgan failure, cardiac arrest, and congestive heart failure). In the Hartmann group, the causes of death were more dispersed. One patient died of complications due to previously metastasizing breast cancer, whereas the cause of death for the remaining 3 patients was related to the severity of the septic condition caused by perforated diverticulitis.
It is quite encouraging that there are high expectations of new knowledge regarding the best treatment of perforated diverticulitis. As there are results still to be presented from several studies, including the primary endpoint of the DILALA trial, we hope that it will further clarify the place for laparoscopic lavage in the treatment of perforated diverticulitis Hinchey grade III. It should be kept in mind that every trial can at best answer the question it was designed to answer.

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