Laparoscopic lavage versus primary resection in acute perforated diverticulitis

1. Laparoscopic lavage versus primary resection in acute perforated diverticulitis - a randomised multicenter study

2. Pseudo diverticula:

3. Prevalence Diverticulosis >60 years of age: 30-50% Diverticulitis 10-30% of those with diverticulosis: Conservative/medical treatment: 75-90% Surgical intervention: 10-30%

4. Hincheygrading

5. Complicated diverticulitis Obstruction Abscess formation Fistula formation Perforation - Peritonitis Mortality(historical): Purulent peritonitis 6%; Faecal peritonitis 35% (Nagorny et al 1985) • Incidence of acute perforated diverticulitis • 3-5 /100.000

6. Surgical options Three stage Transverse colostomy with lavage and suture of defect ’ Sigmoid reection and anastomosis Closure of stoma Hartmann Sigmoid resection with sigmoidostomy Closed rectum (or mucous fistula) Primary anastomosis with or with out covering stoma Lavage using the laparoscope

7. Hospital mortality after emergency surgery for perforated diverticulitis Netherlands: Five teaching hospitals 291pts 1995 – 2005 Overall in-hospital mortality 29% Ned Tijdschr Geeneskd. 2009;153:B195 Southeast England: One hosp 110pts 2002 – 2006 Mortality 10.9% World J Emerg Surg. 2008 Jan 24;3-5

8. Hospital mortality after emergency surgery for perforated diverticulitis England: ’Hospital Episode Statistics’ database between 1996 and 2006 Emergency surgery for sigmoid diverticular disease 30 -day death 1923/10198 pts = 15.9% Alim Pharm Therapeutics 2009;30: 1171-1182

9. Rationale • E. Myers et. al., BJS 2008 “Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis” Laparoscopy in 100 patients with perforated diverticulitis - laparoscopic lavage in 92 patients - 8 patients converted to Hartmann due to faecal peritonitis Mortality 3%, morbidity 4% • Similar results reported in other papers with fewer patients

10. No randomized studies

11. Primary endpoint severe complications within 90 days (Clavien-Dindo >IIIa ) power analysis 30 % v.s. 10 % complications = 130 pts Aim = 150 patients Secondary endpoints -duration of procedure -time spent in hospital -complications individually -enterostoma one year after initial surgery - “Cleveland Global Quality of Life” -costs

12. Inclusion criteria : - age >18 years - clinical signs of perforated diverticulitis and need for surgery - CT displays free gas and do not contradict the clinical diagnosis - the patient tolerates general anesthesia - the patient has given written informed consent Exclusion criteria: - pregnancy - bowel obstruction

13. www.scandiv.com Log in with hospital name and password The patient will be informed on used technique only postoperatively

14. Techniques In all cases, lavage with minimum 4 l saline, wound drain and Hinchey grading Laparoscopic lavage usual port placement: umbilicus, suprapubic, right lower quadrant faecal peritonitis (including visible hole) convert to Hartmann adhesions to the sigmoid should not be dealt with Sigmoid resection with or without stoma www.scandiv.com

15. Case report forms www.scandiv.com

16. Case report form, follow-up www.scandiv.com

17. Patient information and consent www.scandiv.com