Original article
Determinants of outcome following laparoscopic peritoneal lavage for perforated diverticulitis F. Radé1 , F. Bretagnol2 , M. Auguste1 , C. Di Guisto1 , N. Huten1 and L. de Calan1 1 Department of Digestive and Endocrine Surgery, Trousseau Hospital, Tours, and 2 Department of Digestive Surgery, Foch Hospital, Suresnes, France Correspondence to: Professor F. Bretagnol, Department of Digestive Surgery, Foch Hospital, 40 Rue Worth, 92151 Suresnes, France (e-mail: [email protected])
Background: Laparoscopic peritoneal lavage has been proposed for generalized peritonitis from perfo-
rated diverticulitis to avoid a stoma. Reports of its feasibility and safety are promising. This study aimed to establish determinants of failure to enable improved selection of patients for this approach. Methods: The study included all patients with perforated sigmoid diverticulitis who underwent emergency laparoscopic peritoneal lavage from January 2000 to December 2013. Factors predicting failure of laparoscopic treatment were analysed from data collected retrospectively. Results: For patients undergoing emergency sigmoid resection (72 of 361), mortality and morbidity rates were 13 and 35 per cent respectively. In all, 71 patients had laparoscopic lavage, with mortality and morbidity rates of 6 and 28 per cent respectively. Reintervention was necessary in 11 patients (15 per cent) for unresolved sepsis. Age 80 years or more, American Society of Anesthesiologists grade III or above, and immunosuppression were associated with reintervention. Conclusion: Elderly patients and those with immunosuppression or severe systemic co-morbidity are at risk of reintervention after laparoscopic lavage. Presented to the 114th French Congress of Surgery, Paris, France, October 2013 Paper accepted 27 June 2014 Published online 9 September 2014 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9621
Introduction
The optimal surgical management for diverticular peritonitis is currently under debate1 . A non-restorative operation was once considered the standard, and may be appropriate for very ill patients with faecal peritonitis, but resection with anastomosis may be the best choice for stable patients with purulent peritonitis. The downsides of this approach are a temporary stoma necessitating further surgery and reintervention for anastomotic problems. It is possible to perform the resection laparoscopically and without a stoma (in some circumstances), and French guidelines2 provide room for interpretation. First described by the late Gerry O’Sullivan3 , the Irish have championed a new approach for generalized purulent peritonitis: laparoscopic lavage without resection4 . This has been adopted by French5 – 8 , Dutch9 , Italian10 , Belgian11 and American12,13 surgeons, amongst others. The approach is effective with low morbidity and mortality rates, and avoidance of a stoma with a relatively short hospital stay. The largest data set, of 427 patients, came © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
from a population-based study14 where the mortality rate was 4 per cent (compared with 10 per cent for resection) and the mean length of hospital stay was only 10 days. The present authors’ unit began offering this strategy in 20007 . The aim of this study was to define at-risk groups for postoperative problems, in order to improve understanding of the contraindications to laparoscopic lavage.
Methods
Between January 2000 and December 2013, all consecutive patients in the authors’ department with generalized peritonitis due to perforated sigmoid diverticulitis undergoing laparoscopic peritoneal lavage were included in a prospective database. Diagnosis was based on clinical examination, blood tests and radiological evaluation. Emergency operation was indicated for diffuse peritonitis or failure to improve after 48 h of conservative medical management. The severity of disease was staged during the operation. BJS 2014; 101: 1602–1606
Laparoscopic peritoneal lavage for perforated diverticulitis
1603
Patient characteristics, including the Hinchey classification, operative details amd postoperative outcomes were recorded in the database1 . Emergency laparoscopic surgery was indicated in patients with Hinchey stage III (generalized purulent peritonitis) or Hinchey II (pelvic abscess) disease, when percutaneous radiological drainage was not feasible or had failed. Any visible hole was sutured, a drain was placed and antibiotics were given for 21 days (for 5 days intravenously). The laparoscopic approach was contraindicated in patients with intestinal distension, a history of complex abdominal surgery or septic shock. It was also contraindicated for faecal contamination (Hinchey IV), for which a resection with an end colostomy was always performed. A colonoscopy was proposed systematically 2–3 months later to rule out other lesions such as polyps or carcinoma. In accordance with French guidelines, a prophylactic colectomy was offered electively thereafter.
Surgery failure analysis To assess the risk of laparoscopic lavage failure, 13 variables were analysed: personal and medical patient variables including sex, age 80 years or more, body mass index (BMI) above 25 kg/m2 , American Society of Anesthesiologists (ASA) grade, immunosuppression, previous abdominal surgery and previous diverticulitis; procedure-related variables including fever (temperature above 38⋅5∘ C), white blood cell count (WBC), CRP (C-reactive protein)
concentration, pneumoperitoneum seen on CT, Hinchey stage and any observation of colonic perforation.
Statistical analysis Quantitative data are shown as median (range). The correlation between the risk of laparoscopic lavage failure and the aforementioned variables was studied by univariable analysis (Pearson’s χ2 and Student’s t test as appropriate). All tests were two-sided, and P < 0⋅050 was considered to be significant. All variables with P < 0⋅050 were included in a multivariable analysis. Statistical analysis was performed using the software SPSS® for Windows® version 17.0 (IBM, Armonk, New York, USA). Results
During the study period, 361 patients were admitted with complicated sigmoid diverticulitis, of whom 209 (57⋅9 per cent) were treated with antibiotics alone. Six patients underwent percutaneous drainage and 146 (40⋅4 per cent) had surgical treatment. The surgical procedures included resection with end colostomy in 53 patients, resection with anastomosis and temporary stoma in ten patients, surgical drainage (transvaginal and transrectal) in two, and a diverting colostomy in one patient. In the resection group of 72 patients (sigmoid resection with end colostomy, 53; anastomosis and stoma, 10; conversion to open surgery, 9) (Fig. 1), overall morbidity and mortality
Complicated sigmoid diverticulitis n = 361
Antibiotics n = 209 Radiological drainage n = 6
Laparoscopic exploration n = 80
Faecal peritonitis; conversion to open surgery n=9
Sigmoid resection with end colostomy n = 53
Surgery n = 146
Surgical drainage n = 2 Diverting colostomy n=1
Resection with anastomosis and temporary stoma n = 10
Laparoscopic lavage n = 71
Flow diagram showing the selection of patients for laparoscopic peritoneal lavage from those presenting with complicated sigmoid diverticulitis
Fig. 1
© 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
www.bjs.co.uk
BJS 2014; 101: 1602–1606
1604
F Radé, F. Bretagnol, M. Auguste, C. Di Guisto, N. Huten and L. de Calan
rates were 35 per cent (25 patients) and 13 per cent (9) respectively. In total, 80 patients had emergency laparoscopic exploration (Fig. 1), which showed that all had acute sigmoid diverticulitis. Nine of these patients had faecal contamination and the procedure was converted to open resection with end colostomy. The remaining 71 patients were managed laparoscopically with peritoneal lavage and drainage: 39 women and 32 men of median age 58 (26–88) years. Their characteristics are summarized in Table 1. Half of the patients (36 of 71) had a high fever. Their median WBC was 13 700 (4300–41 200) cells/μl, and median CRP concentration was 160 (1–410) mg/l. Diagnosis was based on CT in 62 patients (87 per cent). Pneumoperitoneum was seen on CT in 41 patients (58 per cent), and an abdominal abscess with a median diameter of 60 (range 30–100) mm was present in 35 (49 per cent). Twenty-four patients had a pericolic abscess or localized peritonitis (Hinchey I/II) and 47 had diffuse purulent peritonitis (stage III). The median duration of surgery was 61 (20–110) min. Colonic perforation was observed in ten patients, and sutured in all. No conversion to open surgery was required and no stoma was created. Surgery was successful in 60 patients (85 per cent), and 11 (15 per cent) required reintervention. Recurrent abscess was diagnosed in nine patients, necessitating a Hartmann procedure in seven, and resection with anastomosis and a temporary stoma in two. Two patients had signs of recurrent generalized peritonitis, for which one had a Hartmann procedure and the other a resection with anastomosis and temporary stoma. Of these 11 patients with treatment failure, three died and five had further complications. Characteristics of patients with perforated sigmoid diverticulitis undergoing laparoscopic peritoneal lavage
The perioperative mortality rate was four (6 per cent) of 71 patients, of whom three had required reoperation with Hartmann’s procedure including one patient aged 86 years (stroke) and one 53-year-old who developed severe hepatic insufficiency after reoperation for pelvic haematoma. The overall morbidity rate was 28 per cent (20 of 71), with surgical complications in 23 per cent (16) (Table 2). The median time to oral feeding was 4 (1–15) days, and median hospital stay was 12 (5–55) days. Table 3 details the results of the univariable analysis of risk factors for failure of laparoscopic lavage. Three variables were significantly associated with laparoscopic lavage Postoperative complications in 71 patients undergoing laparoscopic peritoneal lavage for complicated sigmoid diverticulitis
Table 2
No. of complications Surgical complications Recurrent abscess Colocutaneous fistula Recurrent peritonitis Pelvic haematoma Medical complications Myocardial infarction Pulmonary embolus Peptic ulcer Ischaemic stroke
16 9 4 2 1 4 1 1 1 1
Total
20
Univariable analysis of risk factors for failure of laparoscopic lavage
Table 3
Table 1
No. of patients* (n = 71) Age (years)† Sex ratio (M : F) Body mass index (kg/m2 )† ASA grade I II III IV V History of abdominal surgery History of diverticulitis Immunosuppression Diabetes mellitus Steroid treatment Other immunosuppressive drugs
58 (26–88) 32 : 39 26 (17–42) 24 37 10 0 0 38 10 17 10 4 3
*Unless indicated otherwise; †values are median (range). ASA, American Society of Anesthesiologists.
© 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
Age ≥ 80 years Sex ratio (M : F) Body mass index > 25 kg/m2 Missing data ASA grade > II History of abdominal surgery History of diverticulitis Immunosuppression Fever ≥ 38⋅5∘ C Median WBC (×103 cells/μl) Median CRP concentration (mg/l) Hinchey stage I–II III Colonic perforation
Favourable outcome (n = 60)
Treatment failure (n = 11)
3 28 : 32 31 5 4 30 7 10 33 15⋅1 143⋅6
3 4:7 5 2 5 6 3 5 3 12⋅3 158⋅9
0⋅001 0⋅403 0⋅079 0⋅028 0⋅643 0⋅173† 0⋅575†
17 43 9
7 4 1
0⋅051 0⋅079 0⋅268
P* 0⋅033 0⋅162 0⋅377
ASA, American Society of Anesthesiologists; WBC, white blood cell count; CRP, C-reactive protein. *Pearson’s χ2 test, except †Student’s t test.
www.bjs.co.uk
BJS 2014; 101: 1602–1606
Laparoscopic peritoneal lavage for perforated diverticulitis
failure: age 80 years or more, ASA grade III or above, and immunosuppression. Multivariable analysis showed that ASA grade III or higher (severe systemic disease) was associated with treatment failure (odds ratio 48⋅56, 95 per cent confidence interval 5⋅97 to 395⋅19; P < 0⋅010). A colonoscopy was performed in 42 patients a median of 57 (28–115) days after the emergency surgical procedure. No malignancy was diagnosed, but simultaneous resection of polyps was carried out in nine of these patients. Prophylactic sigmoid resection was performed in 55 patients, laparoscopically in 45. Elective surgery was planned for a median of 3⋅3 (1⋅1–8⋅8) months after the emergency procedure. Median duration of surgery was 200 (112–410) min, with six conversions. The overall elective morbidity rate was 7 per cent (4 of 55 patients: anastomotic leakage, 2; pelvic haematoma, 1; urinary tract infection, 1). No patient died, or required reoperation or a stoma. Median hospital stay was 6 (3–19) days. Discussion
This study confirms the good results for laparoscopic peritoneal lavage for perforated diverticulitis reported previously7 . Treatment was successful in the majority of patients, with acceptable mortality and morbidity rates – better than those associated with major emergency resection. Successful treatment included no stoma in most patients. Although some patients needed reintervention, this was in a semielective setting with better sepsis parameters. The alternative of resection would have necessitated a stoma and a further operation. A previous randomized study15 compared two-stage procedures for acute diverticular perforation with peritonitis. Resection with anastomosis and diverting ileostomy was superior to resection with end colostomy in terms of stoma reversal (90 versus 57 per cent), operating time and in-hospital costs. Historically, the mortality rate for patients with generalized peritonitis has been 10–28 per cent, with morbidity in up to 44 per cent3 . Laparoscopic colonic resection for acute diverticulitis has been described, with acceptable results16,17 . However, many patients do not have a macroscopic colonic perforation and therefore do not require colonic resection, as shown in the present single-centre series. This study aimed to evaluate the authors’ overall experience, from 2000 to the end of 2013 (thus including the 24 patients reported previously7 ). It has confirmed the efficacy of the procedure, with a success rate of 85 per cent and no conversion to open surgery. This high rate is probably explained by the preoperative selection of patients. Nonetheless, selection of suitable patients for laparoscopic © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
1605
lavage can be difficult. Although percutaneous drainage remains an effective therapeutic approach for patients with an abscess (Hinchey II), suspected Hinchey III peritonitis often requires laparoscopy for diagnosis. The authors believe, as do others18 , that faecal peritonitis with faecal contamination is a contraindication to laparoscopic lavage. Although the present results appear positive, with an overall morbidity rate of 28 per cent (mostly surgical complications) and a mortality rate of 6 per cent, they are worse than those in the authors’ preliminary experience7 . A group from the Netherlands9 observed a morbidity rate of 32 per cent in patients with controlled sepsis. Although this Dutch study suffered from the limitations of retrospective and multicentre research, the authors did underline the benefits of patient selection. The present data indicate that laparoscopic peritoneal lavage for generalized peritonitis remains challenging, even for experienced surgeons. Similar to the Irish multicentre experience14 , patients of advanced age and those with significant co-morbidity or immunosuppression were more likely to die from a perforated diverticular episode, irrespective of the surgical approach. The results of randomized clinical trials are awaited to define the place of laparoscopic lavage versus resection for perforated diverticulitis.
Disclosure
The authors declare no conflict of interest.
References 1 McDermott FD, Collins D, Heeney A, Winter DC. Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis. Br J Surg 2014; 101: e90–e99. 2 Mabrut JY, Buc E, Zins M, Pilleul F, Bourreille A, Panis Y. [Question 3. Therapeutic management of complicated forms of sigmoid diverticulitis (abscess, fistulas, peritonitis).] Gastroenterol Clin Biol 2007; 31: 3S27–3S33. 3 O’Sullivan GC, Murphy D, O’Brien MG, Ireland A. Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg 1996; 171: 432–434. 4 Myers E, Hurley M, O’Sullivan GC, Kavanagh D, Wilson I, Winter DC. Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 2008; 95: 97–101. 5 Rizk N, Barrat C, Faranda C, Catheline JM, Champault G. [Laparoscopic treatment of generalized peritonitis with diverticular perforation of the sigmoid colon. Report of 10 cases.] Chirurgie 1998; 123: 358–362.
www.bjs.co.uk
BJS 2014; 101: 1602–1606
1606
6 Faranda C, Barrat C, Catheline JM, Champault GG. Two-stage laparoscopic management of generalized peritonitis due to perforated sigmoid diverticula: eighteen cases. Surg Laparosc Endosc Percutan Tech 2000; 10: 135–138. 7 Bretagnol F, Pautrat K, Mor C, Benchellal Z, Huten N, de Calan L. Emergency laparoscopic management of perforated sigmoid diverticulitis: a promising alternative to more radical procedures. J Am Coll Surg 2008; 206: 654–657. 8 Karoui M, Champault A, Pautrat K, Valleur P, Cherqui D, Champault G. Laparoscopic peritoneal lavage or primary anastomosis with defunctioning stoma for Hinchey 3 complicated diverticulitis: results of a comparative study. Dis Colon Rectum 2009; 52: 609–615. 9 Swank HA, Mulder IM, Hoofwijk AGM, Nienhuijs SW, Lange JF, Bemelmen WA; Dutch Diverticular Disease Collaborative Study Group. Early experience with laparoscopic lavage for perforated diverticulitis. Br J Surg 2013; 100: 704–710. 10 Da Rold AR, Guerriero S, Fiamingo P, Pariset S, Veroux M, Pilon F et al. Laparoscopic colorrhaphy, irrigation and drainage in the treatment of complicated acute diverticulitis: initial experience. Chir Ital 2004; 56: 95–98. 11 Lam HD, Tinton N, Cambier E, Navez B. Laparoscopic treatment in acute complicated diverticulitis: a review of 11 cases. Acta Chir Belg 2009; 109: 56–60. 12 Liang S, Russek K, Franklin ME Jr. Damage control strategy for the management of perforated diverticulitis with
F Radé, F. Bretagnol, M. Auguste, C. Di Guisto, N. Huten and L. de Calan
13
14
15
16
17
18
generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann’s procedure. Surg Endosc 2012; 26: 2835–2842. Edeiken SM, Maxwell RA, Dart BW IV, Mejia VA. Preliminary experience with laparoscopic peritoneal lavage for complicated diverticulitis: a new algorithm for treatment? Am Surg 2013; 79: 819–825. Rogers AC, Collins D, O’Sullivan GC, Winter DC. Laparoscopic lavage for perforated diverticulitis: a population analysis. Dis Colon Rectum 2012; 55: 932–938. Oberkofler CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger P, Buchli C et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 2012; 256: 819–826. Letarte F, Hallet J, Drolet S, Charles Grégoire R, Bouchard A, Gagné JP et al. Laparoscopic emergency surgery for diverticular disease that failed medical treatment: a valuable option? Results of a retrospective comparative cohort study. Dis Colon Rectum 2013; 56: 1395–1402. Turley RS, Barbas AS, Lidsky ME, Mantyh CR, Migaly J, Scarborough JE. Laparoscopic versus open Hartmann procedure for the emergency treatment of diverticulitis: a propensity-matched analysis. Dis Colon Rectum 2013; 56: 72–82. Collins D. Laparoscopy in diverticular disease: controversies. Best Pract Rev Clin Gastroenterol 2014; 28: 175–182.
Editor’s comments
Redefinition of diverticulitis management in the past decade was long overdue1 . Antibiotics are not required for mild episodes and suffice alone for sepsis from local peritonitis. Interventional radiological drainage is unnecessary for all but recalcitrant abscesses. Elective resection is indicated only for significantly recurrent or complicated disease. Emergency surgery for perforated diverticulitis should no longer commit the patient to an end colostomy (unless shocked or requiring inotropes). Where resection is deemed necessary (faecal peritonitis or apparent colonic wall breach), anastomosis with defunctioning stoma is ideal. More importantly, laparoscopy for generalized peritonitis with peritoneal lavage is maturing into an established and accepted approach for non-faeculent (ruptured abscess) perforations. Bretagnol and colleagues have added to the mounting evidence that mortality is half that of those requiring resection with acceptable morbidity. Their finding that reintervention is more likely in the elderly and infirm patient echoes that of previous studies published in the BJS. D. Winter Editor, BJS 1 McDermott FD, Collins D, Heeney A, Winter DC. Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis. Br J Surg 2014; 101: e90-e99.
© 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
www.bjs.co.uk
BJS 2014; 101: 1602–1606
Determinants of outcome following laparoscopic peritoneal lavage for perforated diverticulitis F. Radé1 , F. Bretagnol2 , M. Auguste1 , C. Di Guisto1 , N. Huten1 and L. de Calan1 1 Department of Digestive and Endocrine Surgery, Trousseau Hospital, Tours, and 2 Department of Digestive Surgery, Foch Hospital, Suresnes, France Correspondence to: Professor F. Bretagnol, Department of Digestive Surgery, Foch Hospital, 40 Rue Worth, 92151 Suresnes, France (e-mail: [email protected])
Background: Laparoscopic peritoneal lavage has been proposed for generalized peritonitis from perfo-
rated diverticulitis to avoid a stoma. Reports of its feasibility and safety are promising. This study aimed to establish determinants of failure to enable improved selection of patients for this approach. Methods: The study included all patients with perforated sigmoid diverticulitis who underwent emergency laparoscopic peritoneal lavage from January 2000 to December 2013. Factors predicting failure of laparoscopic treatment were analysed from data collected retrospectively. Results: For patients undergoing emergency sigmoid resection (72 of 361), mortality and morbidity rates were 13 and 35 per cent respectively. In all, 71 patients had laparoscopic lavage, with mortality and morbidity rates of 6 and 28 per cent respectively. Reintervention was necessary in 11 patients (15 per cent) for unresolved sepsis. Age 80 years or more, American Society of Anesthesiologists grade III or above, and immunosuppression were associated with reintervention. Conclusion: Elderly patients and those with immunosuppression or severe systemic co-morbidity are at risk of reintervention after laparoscopic lavage. Presented to the 114th French Congress of Surgery, Paris, France, October 2013 Paper accepted 27 June 2014 Published online 9 September 2014 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9621
Introduction
The optimal surgical management for diverticular peritonitis is currently under debate1 . A non-restorative operation was once considered the standard, and may be appropriate for very ill patients with faecal peritonitis, but resection with anastomosis may be the best choice for stable patients with purulent peritonitis. The downsides of this approach are a temporary stoma necessitating further surgery and reintervention for anastomotic problems. It is possible to perform the resection laparoscopically and without a stoma (in some circumstances), and French guidelines2 provide room for interpretation. First described by the late Gerry O’Sullivan3 , the Irish have championed a new approach for generalized purulent peritonitis: laparoscopic lavage without resection4 . This has been adopted by French5 – 8 , Dutch9 , Italian10 , Belgian11 and American12,13 surgeons, amongst others. The approach is effective with low morbidity and mortality rates, and avoidance of a stoma with a relatively short hospital stay. The largest data set, of 427 patients, came © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
from a population-based study14 where the mortality rate was 4 per cent (compared with 10 per cent for resection) and the mean length of hospital stay was only 10 days. The present authors’ unit began offering this strategy in 20007 . The aim of this study was to define at-risk groups for postoperative problems, in order to improve understanding of the contraindications to laparoscopic lavage.
Methods
Between January 2000 and December 2013, all consecutive patients in the authors’ department with generalized peritonitis due to perforated sigmoid diverticulitis undergoing laparoscopic peritoneal lavage were included in a prospective database. Diagnosis was based on clinical examination, blood tests and radiological evaluation. Emergency operation was indicated for diffuse peritonitis or failure to improve after 48 h of conservative medical management. The severity of disease was staged during the operation. BJS 2014; 101: 1602–1606
Laparoscopic peritoneal lavage for perforated diverticulitis
1603
Patient characteristics, including the Hinchey classification, operative details amd postoperative outcomes were recorded in the database1 . Emergency laparoscopic surgery was indicated in patients with Hinchey stage III (generalized purulent peritonitis) or Hinchey II (pelvic abscess) disease, when percutaneous radiological drainage was not feasible or had failed. Any visible hole was sutured, a drain was placed and antibiotics were given for 21 days (for 5 days intravenously). The laparoscopic approach was contraindicated in patients with intestinal distension, a history of complex abdominal surgery or septic shock. It was also contraindicated for faecal contamination (Hinchey IV), for which a resection with an end colostomy was always performed. A colonoscopy was proposed systematically 2–3 months later to rule out other lesions such as polyps or carcinoma. In accordance with French guidelines, a prophylactic colectomy was offered electively thereafter.
Surgery failure analysis To assess the risk of laparoscopic lavage failure, 13 variables were analysed: personal and medical patient variables including sex, age 80 years or more, body mass index (BMI) above 25 kg/m2 , American Society of Anesthesiologists (ASA) grade, immunosuppression, previous abdominal surgery and previous diverticulitis; procedure-related variables including fever (temperature above 38⋅5∘ C), white blood cell count (WBC), CRP (C-reactive protein)
concentration, pneumoperitoneum seen on CT, Hinchey stage and any observation of colonic perforation.
Statistical analysis Quantitative data are shown as median (range). The correlation between the risk of laparoscopic lavage failure and the aforementioned variables was studied by univariable analysis (Pearson’s χ2 and Student’s t test as appropriate). All tests were two-sided, and P < 0⋅050 was considered to be significant. All variables with P < 0⋅050 were included in a multivariable analysis. Statistical analysis was performed using the software SPSS® for Windows® version 17.0 (IBM, Armonk, New York, USA). Results
During the study period, 361 patients were admitted with complicated sigmoid diverticulitis, of whom 209 (57⋅9 per cent) were treated with antibiotics alone. Six patients underwent percutaneous drainage and 146 (40⋅4 per cent) had surgical treatment. The surgical procedures included resection with end colostomy in 53 patients, resection with anastomosis and temporary stoma in ten patients, surgical drainage (transvaginal and transrectal) in two, and a diverting colostomy in one patient. In the resection group of 72 patients (sigmoid resection with end colostomy, 53; anastomosis and stoma, 10; conversion to open surgery, 9) (Fig. 1), overall morbidity and mortality
Complicated sigmoid diverticulitis n = 361
Antibiotics n = 209 Radiological drainage n = 6
Laparoscopic exploration n = 80
Faecal peritonitis; conversion to open surgery n=9
Sigmoid resection with end colostomy n = 53
Surgery n = 146
Surgical drainage n = 2 Diverting colostomy n=1
Resection with anastomosis and temporary stoma n = 10
Laparoscopic lavage n = 71
Flow diagram showing the selection of patients for laparoscopic peritoneal lavage from those presenting with complicated sigmoid diverticulitis
Fig. 1
© 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
www.bjs.co.uk
BJS 2014; 101: 1602–1606
1604
F Radé, F. Bretagnol, M. Auguste, C. Di Guisto, N. Huten and L. de Calan
rates were 35 per cent (25 patients) and 13 per cent (9) respectively. In total, 80 patients had emergency laparoscopic exploration (Fig. 1), which showed that all had acute sigmoid diverticulitis. Nine of these patients had faecal contamination and the procedure was converted to open resection with end colostomy. The remaining 71 patients were managed laparoscopically with peritoneal lavage and drainage: 39 women and 32 men of median age 58 (26–88) years. Their characteristics are summarized in Table 1. Half of the patients (36 of 71) had a high fever. Their median WBC was 13 700 (4300–41 200) cells/μl, and median CRP concentration was 160 (1–410) mg/l. Diagnosis was based on CT in 62 patients (87 per cent). Pneumoperitoneum was seen on CT in 41 patients (58 per cent), and an abdominal abscess with a median diameter of 60 (range 30–100) mm was present in 35 (49 per cent). Twenty-four patients had a pericolic abscess or localized peritonitis (Hinchey I/II) and 47 had diffuse purulent peritonitis (stage III). The median duration of surgery was 61 (20–110) min. Colonic perforation was observed in ten patients, and sutured in all. No conversion to open surgery was required and no stoma was created. Surgery was successful in 60 patients (85 per cent), and 11 (15 per cent) required reintervention. Recurrent abscess was diagnosed in nine patients, necessitating a Hartmann procedure in seven, and resection with anastomosis and a temporary stoma in two. Two patients had signs of recurrent generalized peritonitis, for which one had a Hartmann procedure and the other a resection with anastomosis and temporary stoma. Of these 11 patients with treatment failure, three died and five had further complications. Characteristics of patients with perforated sigmoid diverticulitis undergoing laparoscopic peritoneal lavage
The perioperative mortality rate was four (6 per cent) of 71 patients, of whom three had required reoperation with Hartmann’s procedure including one patient aged 86 years (stroke) and one 53-year-old who developed severe hepatic insufficiency after reoperation for pelvic haematoma. The overall morbidity rate was 28 per cent (20 of 71), with surgical complications in 23 per cent (16) (Table 2). The median time to oral feeding was 4 (1–15) days, and median hospital stay was 12 (5–55) days. Table 3 details the results of the univariable analysis of risk factors for failure of laparoscopic lavage. Three variables were significantly associated with laparoscopic lavage Postoperative complications in 71 patients undergoing laparoscopic peritoneal lavage for complicated sigmoid diverticulitis
Table 2
No. of complications Surgical complications Recurrent abscess Colocutaneous fistula Recurrent peritonitis Pelvic haematoma Medical complications Myocardial infarction Pulmonary embolus Peptic ulcer Ischaemic stroke
16 9 4 2 1 4 1 1 1 1
Total
20
Univariable analysis of risk factors for failure of laparoscopic lavage
Table 3
Table 1
No. of patients* (n = 71) Age (years)† Sex ratio (M : F) Body mass index (kg/m2 )† ASA grade I II III IV V History of abdominal surgery History of diverticulitis Immunosuppression Diabetes mellitus Steroid treatment Other immunosuppressive drugs
58 (26–88) 32 : 39 26 (17–42) 24 37 10 0 0 38 10 17 10 4 3
*Unless indicated otherwise; †values are median (range). ASA, American Society of Anesthesiologists.
© 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
Age ≥ 80 years Sex ratio (M : F) Body mass index > 25 kg/m2 Missing data ASA grade > II History of abdominal surgery History of diverticulitis Immunosuppression Fever ≥ 38⋅5∘ C Median WBC (×103 cells/μl) Median CRP concentration (mg/l) Hinchey stage I–II III Colonic perforation
Favourable outcome (n = 60)
Treatment failure (n = 11)
3 28 : 32 31 5 4 30 7 10 33 15⋅1 143⋅6
3 4:7 5 2 5 6 3 5 3 12⋅3 158⋅9
0⋅001 0⋅403 0⋅079 0⋅028 0⋅643 0⋅173† 0⋅575†
17 43 9
7 4 1
0⋅051 0⋅079 0⋅268
P* 0⋅033 0⋅162 0⋅377
ASA, American Society of Anesthesiologists; WBC, white blood cell count; CRP, C-reactive protein. *Pearson’s χ2 test, except †Student’s t test.
www.bjs.co.uk
BJS 2014; 101: 1602–1606
Laparoscopic peritoneal lavage for perforated diverticulitis
failure: age 80 years or more, ASA grade III or above, and immunosuppression. Multivariable analysis showed that ASA grade III or higher (severe systemic disease) was associated with treatment failure (odds ratio 48⋅56, 95 per cent confidence interval 5⋅97 to 395⋅19; P < 0⋅010). A colonoscopy was performed in 42 patients a median of 57 (28–115) days after the emergency surgical procedure. No malignancy was diagnosed, but simultaneous resection of polyps was carried out in nine of these patients. Prophylactic sigmoid resection was performed in 55 patients, laparoscopically in 45. Elective surgery was planned for a median of 3⋅3 (1⋅1–8⋅8) months after the emergency procedure. Median duration of surgery was 200 (112–410) min, with six conversions. The overall elective morbidity rate was 7 per cent (4 of 55 patients: anastomotic leakage, 2; pelvic haematoma, 1; urinary tract infection, 1). No patient died, or required reoperation or a stoma. Median hospital stay was 6 (3–19) days. Discussion
This study confirms the good results for laparoscopic peritoneal lavage for perforated diverticulitis reported previously7 . Treatment was successful in the majority of patients, with acceptable mortality and morbidity rates – better than those associated with major emergency resection. Successful treatment included no stoma in most patients. Although some patients needed reintervention, this was in a semielective setting with better sepsis parameters. The alternative of resection would have necessitated a stoma and a further operation. A previous randomized study15 compared two-stage procedures for acute diverticular perforation with peritonitis. Resection with anastomosis and diverting ileostomy was superior to resection with end colostomy in terms of stoma reversal (90 versus 57 per cent), operating time and in-hospital costs. Historically, the mortality rate for patients with generalized peritonitis has been 10–28 per cent, with morbidity in up to 44 per cent3 . Laparoscopic colonic resection for acute diverticulitis has been described, with acceptable results16,17 . However, many patients do not have a macroscopic colonic perforation and therefore do not require colonic resection, as shown in the present single-centre series. This study aimed to evaluate the authors’ overall experience, from 2000 to the end of 2013 (thus including the 24 patients reported previously7 ). It has confirmed the efficacy of the procedure, with a success rate of 85 per cent and no conversion to open surgery. This high rate is probably explained by the preoperative selection of patients. Nonetheless, selection of suitable patients for laparoscopic © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
1605
lavage can be difficult. Although percutaneous drainage remains an effective therapeutic approach for patients with an abscess (Hinchey II), suspected Hinchey III peritonitis often requires laparoscopy for diagnosis. The authors believe, as do others18 , that faecal peritonitis with faecal contamination is a contraindication to laparoscopic lavage. Although the present results appear positive, with an overall morbidity rate of 28 per cent (mostly surgical complications) and a mortality rate of 6 per cent, they are worse than those in the authors’ preliminary experience7 . A group from the Netherlands9 observed a morbidity rate of 32 per cent in patients with controlled sepsis. Although this Dutch study suffered from the limitations of retrospective and multicentre research, the authors did underline the benefits of patient selection. The present data indicate that laparoscopic peritoneal lavage for generalized peritonitis remains challenging, even for experienced surgeons. Similar to the Irish multicentre experience14 , patients of advanced age and those with significant co-morbidity or immunosuppression were more likely to die from a perforated diverticular episode, irrespective of the surgical approach. The results of randomized clinical trials are awaited to define the place of laparoscopic lavage versus resection for perforated diverticulitis.
Disclosure
The authors declare no conflict of interest.
References 1 McDermott FD, Collins D, Heeney A, Winter DC. Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis. Br J Surg 2014; 101: e90–e99. 2 Mabrut JY, Buc E, Zins M, Pilleul F, Bourreille A, Panis Y. [Question 3. Therapeutic management of complicated forms of sigmoid diverticulitis (abscess, fistulas, peritonitis).] Gastroenterol Clin Biol 2007; 31: 3S27–3S33. 3 O’Sullivan GC, Murphy D, O’Brien MG, Ireland A. Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg 1996; 171: 432–434. 4 Myers E, Hurley M, O’Sullivan GC, Kavanagh D, Wilson I, Winter DC. Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 2008; 95: 97–101. 5 Rizk N, Barrat C, Faranda C, Catheline JM, Champault G. [Laparoscopic treatment of generalized peritonitis with diverticular perforation of the sigmoid colon. Report of 10 cases.] Chirurgie 1998; 123: 358–362.
www.bjs.co.uk
BJS 2014; 101: 1602–1606
1606
6 Faranda C, Barrat C, Catheline JM, Champault GG. Two-stage laparoscopic management of generalized peritonitis due to perforated sigmoid diverticula: eighteen cases. Surg Laparosc Endosc Percutan Tech 2000; 10: 135–138. 7 Bretagnol F, Pautrat K, Mor C, Benchellal Z, Huten N, de Calan L. Emergency laparoscopic management of perforated sigmoid diverticulitis: a promising alternative to more radical procedures. J Am Coll Surg 2008; 206: 654–657. 8 Karoui M, Champault A, Pautrat K, Valleur P, Cherqui D, Champault G. Laparoscopic peritoneal lavage or primary anastomosis with defunctioning stoma for Hinchey 3 complicated diverticulitis: results of a comparative study. Dis Colon Rectum 2009; 52: 609–615. 9 Swank HA, Mulder IM, Hoofwijk AGM, Nienhuijs SW, Lange JF, Bemelmen WA; Dutch Diverticular Disease Collaborative Study Group. Early experience with laparoscopic lavage for perforated diverticulitis. Br J Surg 2013; 100: 704–710. 10 Da Rold AR, Guerriero S, Fiamingo P, Pariset S, Veroux M, Pilon F et al. Laparoscopic colorrhaphy, irrigation and drainage in the treatment of complicated acute diverticulitis: initial experience. Chir Ital 2004; 56: 95–98. 11 Lam HD, Tinton N, Cambier E, Navez B. Laparoscopic treatment in acute complicated diverticulitis: a review of 11 cases. Acta Chir Belg 2009; 109: 56–60. 12 Liang S, Russek K, Franklin ME Jr. Damage control strategy for the management of perforated diverticulitis with
F Radé, F. Bretagnol, M. Auguste, C. Di Guisto, N. Huten and L. de Calan
13
14
15
16
17
18
generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann’s procedure. Surg Endosc 2012; 26: 2835–2842. Edeiken SM, Maxwell RA, Dart BW IV, Mejia VA. Preliminary experience with laparoscopic peritoneal lavage for complicated diverticulitis: a new algorithm for treatment? Am Surg 2013; 79: 819–825. Rogers AC, Collins D, O’Sullivan GC, Winter DC. Laparoscopic lavage for perforated diverticulitis: a population analysis. Dis Colon Rectum 2012; 55: 932–938. Oberkofler CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger P, Buchli C et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 2012; 256: 819–826. Letarte F, Hallet J, Drolet S, Charles Grégoire R, Bouchard A, Gagné JP et al. Laparoscopic emergency surgery for diverticular disease that failed medical treatment: a valuable option? Results of a retrospective comparative cohort study. Dis Colon Rectum 2013; 56: 1395–1402. Turley RS, Barbas AS, Lidsky ME, Mantyh CR, Migaly J, Scarborough JE. Laparoscopic versus open Hartmann procedure for the emergency treatment of diverticulitis: a propensity-matched analysis. Dis Colon Rectum 2013; 56: 72–82. Collins D. Laparoscopy in diverticular disease: controversies. Best Pract Rev Clin Gastroenterol 2014; 28: 175–182.
Editor’s comments
Redefinition of diverticulitis management in the past decade was long overdue1 . Antibiotics are not required for mild episodes and suffice alone for sepsis from local peritonitis. Interventional radiological drainage is unnecessary for all but recalcitrant abscesses. Elective resection is indicated only for significantly recurrent or complicated disease. Emergency surgery for perforated diverticulitis should no longer commit the patient to an end colostomy (unless shocked or requiring inotropes). Where resection is deemed necessary (faecal peritonitis or apparent colonic wall breach), anastomosis with defunctioning stoma is ideal. More importantly, laparoscopy for generalized peritonitis with peritoneal lavage is maturing into an established and accepted approach for non-faeculent (ruptured abscess) perforations. Bretagnol and colleagues have added to the mounting evidence that mortality is half that of those requiring resection with acceptable morbidity. Their finding that reintervention is more likely in the elderly and infirm patient echoes that of previous studies published in the BJS. D. Winter Editor, BJS 1 McDermott FD, Collins D, Heeney A, Winter DC. Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis. Br J Surg 2014; 101: e90-e99.
© 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
www.bjs.co.uk
BJS 2014; 101: 1602–1606
