This month we report on a paper published June 2017 in the British Journal of Surgery on the SCANDIV trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis.
https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.10567
What is known on the subject
In acute perforated diverticulitis, several case series on laparoscopic peritoneal lavage and drainage without resection of the diseased bowel segment have shown exceptional results with respect to mortality and morbidity. However, recent randomized trials have challenged this strategy and suggest a much more differentiated approach towards surgery for acute perforated diverticulitis. The Dutch LOLA trial showed a total re-intervention rate, at 30 days of 35% in the lavage group versus 7% in the resection group, but similar major morbidity and mortality within 12 months. These findings were confirmed by short-term results of the present SCANDIV trial with higher risks of both early reoperation and abscess drainage following laparoscopic lavage compared with primary resection.
What this study adds?
The SCANDIV trial was a multicentre RCT on acute perforated diverticulitis comparing laparoscopic lavage and sigmoid resection conducted between February 2010 and June 2014 at 21 hospitals in Norway and Sweden. Out of a total of 199 enrolled patients, 101 were allocated randomly to laparoscopic lavage and 98 to colonic resection.
The long-term outcome at 1 year after surgery confirmed the findings of the LOLA trial, that neither severe complications nor disease-related mortality differed significantly between the lavage and resection groups. Complications and re-interventions after laparoscopic lavage were mainly related to the retained diseased bowel segment bearing the risk of a persisting perforation, recurrence or undiagnosed perforated malignancy. In contrast, most complications after primary resection were related to the abdominal access and stoma formation rather than to the primary disease. Reoperations in this group consisted mainly of stoma reversals and some operations for surgical wound healing problems. More than one-third of patients in the resection group had a stoma 1 year after surgery.
An important additional finding of the study was that QoL measured by the Cleveland Global QoL score, showed no significant differences between groups for pain, social and sexual function at 1 year. In 11 of the 199 included patients (5.5%), a sigmoid carcinoma as the cause of perforation was found and this is in line with previous studies. Five of these were suspected intraoperatively and had an oncological resection. In the lavage group, four out of seven carcinomas were not detected at the index operation. Early assessment to exclude misdiagnosed sigmoid carcinoma was thus recommended.
Implications for colorectal surgical practice
The results of the SCANDIV study add to the already complicated picture of surgical treatment for acute perforated diverticulitis. Laparoscopic lavage is a feasible option with comparable but not superior results compared to colonic resection. Therefore, the colorectal surgeon is still left without a general recommendation regarding surgical strategy. The way forward must continue to be a stratified, tailored approach considering on a patient-by-patient basis the risks of sepsis, early re-interventions, perforated carcinoma and recurrence of diverticulitis balanced against the competing risks of resection, including a long-term stoma.
References
Schultz JK, Wallon C, Blecic L, Forsmo HM, Folkesson J, Buchwald P, et al. One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis. The British Journal of Surgery. 2017;104(10):1382-92.
Vennix S, Musters GD, Mulder IM, Swank HA, Consten EC, Belgers EH, et al. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet. 2015;386(10000):1269-77.