Laparoscopic lavage versus resection in perforated diverticulitis with purulent peritonitis: a meta-analysis of randomized controlled trials
Ceresoli et al. World Journal of Emergency Surgery
Laparoscopic lavage versus resection in perforated diverticulitis with purulent peritonitis: a meta-analysis of randomized controlled trials
Marco Ceresoli 0
Federico Coccolini 0
Giulia Montori 0
Fausto Catena 2
Massimo Sartelli 1
Luca Ansaloni 0
0 Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital , Piazza OMS 1, 24127 Bergamo , Italy
1 Unit of General and Emergency Surgery, Macerata Hospital , Macerata , Italy
2 Unit of General and Emergency Surgery, Parma University Hospital , Parma , Italy
Objective: Purulent peritonitis from acute left colon diverticulitis is a relatively common presentation of diverticular disease; historically the treatment was the Hartmann procedure. Laparoscopic peritoneal lavage has been proposed as a lesser invasive treatment option with great interest and debate among surgeons and with contrasting results. The aim of this meta-analysis was to compare the results of sigmoid resection with laparoscopic lavage. Methods: A systematic review was performed to select randomized controlled trials comparing laparoscopic lavage versus resection in Hinchey III diverticulitis. Studies' selection, data extraction and risk of bias assessment were done by two independent authors; results were shown as OR with 95 % C.I. Results: Three RCT were selected for the meta-analysis including 315 patents. Laparoscopic lavage was associated with significantly more reoperations (OR 3.75, p = 0.006) and more intra-abdominal abscesses (OR 3.50, p = 0.0003) with no differences in mortality (OR 0.93, p = 0.92). At 12 months follow up laparoscopic lavage was associated with lesser reoperations (OR 0.32, p = 0.0004); there were no differences in term of stoma presence (OR 0.44 p = 0.27) and mortality (OR 0.74 p = 0.51). Conclusions: The present meta-analysis shows that in acute perforated diverticulitis with purulent peritonitis laparoscopic lavage is comparable to sigmoid resection in term of mortality but it is associated with a significantly higher rate of reoperations and a higher rate of intra-abdominal abscess. No differences in term of mortality were demonstrated at follow-up. Further studies are needed to better define the safety and appropriateness of this treatment.
Acute diverticulitis; Purulent peritonitis; Acute perforated diverticulitis; Laparoscopic lavage; Meta-analysis
Left colon diverticulosis is a common disease in western
countries with an increasing prevalence due probably to
the lifestyle [
]. Its prevalence is estimated at 5 % at 40
y.o. and increases with the ages till the 80 % in the
]. The commonest complication is acute
diverticulitis and recent evidences reported a lifetime risk to
develop diverticulitis in 4 % of patients . Acute
diverticulitis’ treatment depends on the severity of the
inflammation, graded with several proposed scoring
systems, all based on the CT scan findings [
] and it
varies from medical therapy with or without antibiotics in
mild inflammation, percutaneous drainage or sigmoid
resection in diffuse peritonitis. Up to 25 % of patients
with acute diverticulitis requires emergency surgery due
to the disease severity [
] and traditionally the
treatment was the Hartmann procedure, with high morbidity
(30–50 %) and mortality (10–20 %) associated [
Due to the high morbidity and mortality of the
procedure and in order to avoid a stoma, laparoscopic lavage
has been proposed for perforated diverticulitis with
purulent peritonitis as a lesser invasive treatment .
The first report of this technique in a prospective cohort
of patients demonstrated that laparoscopic lavage was
safe and feasible with very low mortality and morbidity
rate (3 and 4 % respectively). Since its publication there
was a great debate among the scientific community
about this new treatment and randomized controlled
trials have been launched to better investigate the issue.
The aim of the present meta-analysis is to investigate
the safety and the feasibility of laparoscopic lavage
compared to sigmoid reection in perforated acute
diverticulitis with purulent peritonitis.
Material and methods
Literature search strategy and studies selection
A systematic research was performed independently by
two different investigators (MC and FCo) in Medline,
Embase, PubMed, Cochrane Central Register of
Controlled Trials (CCTR) and Cochrane Database of
Systematic Reviews (CDSR) until March 2016. The search
terms were: “laparoscopic lavage”, “diverticulitis”,
“perforated diverticulitis” combined with AND/OR. No search
restrictions were imposed. The references of selected
articles were also reviewed. Duplicate published trials were
considered only in the last or at least in the more
complete version. All the retrieved articles were selected
if they met the inclusion criteria.
For this metaanalysis were selected prospective clinical
trials including patients with suspected perforated
purulent diverticulitis that underwent surgical intervention
and were randomized to receive bowel resection or
laparoscopic lavage. Case reports, letters, reviews and
metaanalysis, retrospective studies and non English
language publications were excluded.
Data extraction, outcome measures
Data were extracted for the intention to treat analysis or
the modified intention to treat according to the
inclusion criteria of the present meta-analysis. For each
selected study were reported the following data: year of
publication, study's characteristics, inclusion and
exclusion criteria, patients’ characteristics, sample size, type of
intervention, length of stay, length of surgery,
reoperation at index admission, mortality, specific morbidity at
index admission (intra abdominal abscess, UTIs,
pneumonia, wound infections, heart and lung complications),
severe morbidity and mortality at 90 days, mortality,
reoperations and presence of stoma at 12 months.
Assessment of risk of bias
There is a potential risk of overestimating the beneficial
treatment effects of RCT with a resultant risk of bias.
The risk of bias was assessed comprehensively according
to guidelines of The Cochrane Collaboration [
six items have been considered relevant (Table 1): 1)
whether the method of allocation was truly random; 2)
whether there was proper allocation concealment; 3)
whether the groups were similar at baseline; 4) whether
the eligibility criteria were documented; 5) whether loss
to follow-up in each treatment arm was specified; 6)
whether intention-to-treat analysis was conducted.
Therefore the evaluation of the quality level of the study
was conducted as follows: Positive answer to at least six
questions was required for a trial to be rated as high
quality. With a positive answer to five or four questions
the study was considered of fair quality. With a positive
answer to three or fewer questions the study was
registered as low quality.
Data were analyzed with Review Manager (RevMan)
(Version 5.3 Copenhagen: The Nordic Cochrane Centre,
The Cochrane Collaboration, 2011). Outcomes were
expressed as weighted Odds Ratio (OR) and 95 %
confidence interval (95 % C.I.) and were calculated with the
fixed-effects and random-effects models [
statistical heterogeneity was quantified using the I2
inconsistency test and if significant (p <0,1) were reported only
the results of the random-effects model.
One thousand two hundred sixty-four abstracts were
found and after a first review four were selected and
identified as potentially eligible for our study [
among them, after a full review of the manuscripts, one
study was excluded because was the publication of
preliminary results of an included study . For the
LADIES trial [
] were included patients of the LOLA arm.
PRISMA flow diagram is shown in Fig. 1.
Quality of trials and studies characteristics
There was good agreement between the reviewers
(MC and FC) about the eligibility and quality of the
studies. Table 1 demonstrates the quality of the three
Table 2 summarizes studies’ characteristics.
all the selected studies included patients >18 y.o. with
evidence of perforated sigmoid diverticulitis at the CT
scan and the indication of urgent surgery. In the
] and the DILALA [
] trials patients were
randomized after the demonstration of Hinchey III
purulent diverticulitis at the diagnostic laparoscopy; in
the SCANDIV [
] trial patients were randomized after
the CT scan: therefore were also randomized patients
with evidence of Hinchey I-II diverticulitis at
laparoscopy. In all the studies patients with Hinchey IV-fecaloid
peritonitis were drop out from the study and received
In all studies patients received empiric antibiotic therapy
before surgery. Laparoscopic lavage was performed with
at least 3–4 L of warm saline water. After the
laparoscopic lavage patients received a colonoscopy after a
time variable between 4 and 12 weeks but routine
sigmoidectomy was not recommended. In the SCANDIV
] colonic resection was performed in laparoscopy
or with open surgery according to the centre/surgeon’s
preference, with or without primary anastomosis; in the
LADIES trial [
] patients in resection group were
further randomized to receive Hartmann procedure or
primary anastomosis. In the DILALA trial [
randomized to resection all underwent Hartmann
procedure. All the included patients had an abdominal drain
Records identified through
(n = 1493 )
Records after duplicates removed
(n = 1264)
Full-text articles assessed
(n =4 )
(n = 3)
Fig. 1 PRISMA flow diagram
Records excluded after
review of title and
excluded (n = 1)
duplicate study [
after operation and were treated according to the local
Reoperation and mortality at index admission
Data about reoperation at mortality at index admission
were available for two studies [
] and included 232
patients: laparoscopic lavage failed, and needed a
reoperation, in 17.5 % of the patients (OR 3.75; 95 % C.I.
1.45–9.69; p = 0.006) but with no significant differences
in mortality (OR 0.93; 95 % C.I. 0.23–3.82; p = 0.92)
(Figs. 2 and 3).
All the three studies [
] reported data about
specific complications during the index admission,
including 315 patients. Laparoscopic lavage was associated
with a significantly higher incidence of intra-abdominal
abscess (OR 3.50; 95 % C.I. 1.79–6.86; p = 0.0003) (Fig.
4), a significantly reduced incidence of wound infections
(OR 0.14; 95 % C.I. 0.04–0.45; p = 0.0009) and no
significant differences in pneumonia (OR 1.13; 95 % C.I. 0.47–
2.69; p = 0.79), heart and lung complications (OR 0.60;
95 % C.I. 0.31–1.19; p = 0.15) and urinary tract infections
(OR 1.20; 95 % C.I. 0.29–4.97; p = 0.80).
Length of stay, length of surgery
No data in amenable format for meta-analysis were
available in the three included clinical trials.
90 days morbidity and mortality
All the three studies reported 90 days morbidity [
the analysis included 315 patients. Laparoscopic lavage
results in an increased morbidity with a subliminal statistical
significance (OR 1.70; 95 % C.I. 1.00–2.87; p = 0.05). Data
about 90 days mortality were reported in only two studies
] with 232 patients included: there were no
significant differences in 90 days mortality (OR 0.83; 95 % C.I.
0.32–2.11; p = 0.69).
12 months reoperations, mortality and stoma
Two studies [
] reported data about 12 months
reoperation rate, mortality and presence of stoma, including
191 patients. Laparoscopic lavage was associated with
significantly lesser reoperations (OR 0.32; 95 % C.I. 0.17–
a subgroup analysis of patients with Hinchey grade I-II-III diverticulitis
dementia, previous severe
abdominal irradiation, complications
high dose steroidal and mortality
therapy, shock, age >85 at 12 months
reoperation at 64
and death at
Sample Elegible Analysis
Laparoscopic Bowel Study Limits
drainage resection quality
Study or Subgroup
0.60; p = 0.0004) (Fig. 5); there were no significant
differences in mortality (OR 0.74; 95 % C.I. 0.30–1.82; p = 0.51)
and in presence of stoma (OR 0.44; 95 % C.I. 0.10–1.93; p
The present meta-analysis shows that laparoscopic lavage
in perforate acute diverticulitis with purulent peritonitis is
associated with more morbidity such intra-abdominal
abscess at index admission without differences in term of
mortality. Long term results show that laparoscopic lavage
is associated with lesser reoperations.
The treatment of peritonitis from acute diverticulitis is
an issue of great debate and great interest. Historically
the management of peritonitis involved the Hartmann
procedure with sigmoid resection and a terminal
colonostomy. This procedure is associated with high
mortality and morbidity, due above all to the patients’
characteristics; furthermore the presence of a stoma,
with its impact on the quality of life, requires a further
hospitalization and surgical intervention to restore
intestinal continuity later in the time. Successively,
laparoscopy and primary anastomosis were proposed also in
acute setting and seems to be associated with better
]. Laparoscopic lavage was proposed in 1996
 and since the first appearance lot of case series and
review were published reporting contrasting results [
0.05 0.2 1
Laparoscopic lavage resection
Despite promising results there are great debate and
skepticism about this new approach to peritonitis due to
the non definitive treatment of the underlying pathology
Results of the present meta-analysis do not show
significant differences in term of mortality during the
index admission and during the follow up in patients
with purulent peritonitis from acute diverticulitis.
However, despite the subliminal significance,
laparoscopic lavage is associated with an increased severe
morbidity within 90 days from the event. This data is
also confirmed by the elevated need of reoperations
during the index admission, due to the failure of the
treatment, as highlighted by the significative higher
incidence of intra-abdominal abscess as a
consequence of the poor source control. The presence of
abscess and further reoperations do not resulted in
augmented mortality; however it inevitably required
prolonged antibiotic therapies, since the source of the
infection was not removed, in discordance with the
principles of adequate source control in treatment of
sepsis and increasing the risk for antibiotic resistant
pathogens selections. Laparoscopic lavage results in a
reduced rate of wound infections and no differences
in term of medical complications (pneumonia, UTI,
heart and lung complications). In all the three trials
there were no significative differences in term of
length of stay but no data amenable to be
metaStudy or Subgroup
analyzed are available. On the other hand
laparoscopic lavage, when successful, resulted in a complete
resolution of the peritonitis without stoma: despite
after 1 year there are no differences in presence of
stoma, patients randomized to resection undergo
reoperations significantly more frequently compared to
those randomized to laparoscopic lavage due to
restoring intestinal continuity, with no differences in
term of mortality.
The results of the present meta-analysis should be
interpreted at the light of some considerations and
limitations. The number of included studies and
patients is quite small. Furthermore the LADIES trial
] was ended before reaching the sample size
requested due to a safety issues and therefore it was
largely underpowered. Moreover the included studies
were not homogeneous in inclusion and exclusion
criteria: the SCANDIV trial [
] randomized patients
before the diagnostic laparoscopy with the inclusion
in the study of Hinchey I-II patients and results could
be consequently overestimated. Above all, the three
included studies had different primary end points
barely combinable, reducing the number of the
patients and the strong of the evidence.
Even in the randomized studies, among eligible
patients, only a small part of them was effectively
randomized (Table 2): for sure to conduct a randomized
0.05 0.2 1
laparoscopic lavage resection
trial in an emergency setting is really difficult but this
could be a potential origin of selection bias, with only
patients in better conditions selected for randomization
Another randomized controlled trial is now
ongoing-the LapLand trial [
]-with similar study’s
design but with the operative and in-hospital
mortality as primary endpoint. Enrollment was expected to
be completed in December 2015 and there is a great
expectation for the results. The results of the present
meta-analysis are not definitive and they should be
interpreted also at the light of the poor data available,
awaiting for this new trial's results.
In conclusion the present meta-analysis shows that
in acute perforated diverticulitis with purulent
peritonitis laparoscopic lavage is comparable to sigmoid
resection in term of mortality but it is associated
with a significantly higher rate of reoperations and a
higher rate of intra-abdominal abscess. No
differences in term of mortality were demonstrated at
90 days and 12 months. After 1 year from the event
there were no differences in presence of stoma and
patients randomized to resection underwent
significantly more reoperations. Further studies are needed
Study or Subgroup
laparoscopic lavage resection Odds Ratio
Events Total Events Total Weight M-H, Fixed, 95% CI
12 43 25 40 53.9% 0.23 [0.09, 0.59]
20 46 27 42 46.1% 0.43 [0.18, 1.01]
to better define the safety and appropriateness of
No funding for this research.
Availability of data and material
The datasets analyzed during the current study is available from the
corresponding author on reasonable request.
MC, FCo, LA design the study; MC, FCo retrieved the literature and MC, FCo,
GM, FC and MS analyzed and interpreted the data. MC, FCo write the
manuscript and all the author contributes with critical revisions. All the
author read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
All the included studies reported the ethical approval from the respective
ethical committees. No ethical approval or consent to participate was
needed for this meta-analysis.
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