Twelve-month results of laparoscopic lavage in perforated acute diverticulitis—Update of meta-analysis results. New evidences, which perspectives?
The management and treatment of acute diverticulitis is one of the hottest topic of the moment and is a good example of the interaction between the principles of emergency surgery and the innovative aspects of the minimally invasive surgery derived from elective surgery.
The debate about laparoscopic lavage in acute perforated diverticulitis is really very intense as described well by the excellent analysis of Biffl and colleagues:1 in 1 year were published three randomized trials, and their results were summarized in six different meta-analysis, all with similar findings.
Actually, laparoscopic lavage in Hichey III acute diverticulitis seems to be a safe procedure with similar mortality and morbidity compared with resection but is associated with a higher reoperation rate at the index admission due to failure of the treatment and intra-abdominal abscess formation.
The 1 year results of the SCANDIV trial, the biggest trial comparing laparoscopic lavage versus emergency resection in Hinchey III acute diverticulitis, have been recently published.2 Due to the high interest on the topic and the strong need of solid evidences, these new data allow us to update the results of our previously published meta-analysis, with the same methodology described elsewhere.3
The updated results shows that, as already demonstrated, laparoscopic lavage has a similar 12 months mortality with colonic resection (relative risk [RR], 0.89; 95% confidence interval [CI], 0.49–1.59; p = 0.69) (Forest plot A in Supplemental Digital Content 1, http://links.lww.com/TA/B35).
However, the insertion of the new data changed the results of about 12 months reoperations and stoma rate, laparoscopic lavage is now associated with a lower but not significant reoperation rate (RR, 0.67; 95% CI, 0.45–1.02; p = 0.06) and a reduced stoma rate (RR, 0.41; 95% CI, 0.21–0.78; p = 0.007) (Forest plot B and C in Supplemental Digital Content 1, http://links.lww.com/TA/B35).
At the light of these updated results, we would like to express some considerations about what we already know and what we still have to learn about this topic.
On one hand, sigmoid resection is considered the definitive solution for diverticular disease and is still the recommended choice for perforation.4 In many cases, intervention results in the need of a stoma as highlighted by the results of previous meta-analysis. At 12 months, this difference remains significative with a higher proportion of patients with stoma, in many cases definitive, in the resection group despite the numerous reinterventions due to stoma closure that make similar the reoperation rate.
On the other hand, laparoscopic lavage is associated with a considerable immediate failure rate that exposes patients to intra-abdominal abscess formation and to a second septic hit, limiting this approach only to elected patients. Moreover, it should be noted that the treatment could postpone the diagnosis of colorectal cancer. Despite these great limitations, laparoscopic lavage appears, only for selected patients, as an attempting option with similar mortality results, similar long-term reoperation rate, and lower stoma rate.
Laparoscopic lavage has been proposed as a bridge to elective sigmoid resection, but in all trials, was considered as a definitive treatment for the majority of patients with only a small percentage of patients operated electively. Nowadays, after an episode of uncomplicated acute diverticulitis, the indication to sigmoidectomy should be tailored on the single patient;4 considering laparoscopic lavage for Hinchey III diverticulitis a valid option, a new question is raised. Is elective surgery indicated after peritoneal lavage? At the moment, evidences are limited to 1 year follow-up, and further studies are needed to assess the burden of further acute episodes. However, the role of laparoscopic lavage should be carefully evaluated.