A Comprehensive Review of Laparoscopic Left Colectomy for Acute Diverticulitis: Techniques, Outcomes and Complications

Abstract

ABSTRACT

Background: Laparoscopic left colectomy has emerged as a potential alternative to open surgery for the treatment of acute diverticulitis. However, the evidence on the safety and efficacy of this approach is still subject to debate.

Aim: This review aims to provide a comprehensive overview of the techniques, outcomes and complications associated with laparoscopic left colectomy for acute diverticulitis.

Methods: A systematic review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that met the inclusion criteria were analyzed for patient demographics, surgical techniques, outcomes and complications.

Results: A total of 23 studies involving a total of 3,214 patients who underwent laparoscopic left colectomy for acute diverticulitis was conducted. The majority of studies reported favorable outcomes for laparoscopic left colectomy, with patients experiencing shorter hospital stays, less postoperative pain and a faster return to normal activities. Specifically, the studies reported an average hospital stay of 5-7 days for laparoscopic left colectomy patients compared to 7-10 days for open colectomy patients. Additionally, laparoscopic patients reported lower pain scores and required fewer pain medications, with a reduced need for opioid analgesics. However, there were also some complications reported in these studies, including anastomotic leakage, wound infections and intra-abdominal abscesses. The overall incidence of complications was relatively low, ranging from 4-18% depending on the study. The risk of complications was generally higher in patients with severe acute diverticulitis or those undergoing emergency surgery.

Conclusion: Laparoscopic left colectomy is a safe and effective approach for the treatment of acute diverticulitis, offering several potential benefits compared to open surgery. However, there is a need for further research to clarify the optimal patient selection criteria, surgical techniques and management of complications.

Keywords: laparoscopic left colectomy, acute diverticulitis, complications, outcomes, hospital stay, pain.

INTRODUCTION

Acute diverticulitis is a common inflammatory condition affecting the colon, which can lead to significant complications such as abscess formation, perforation, and peritonitis. The management of acute diverticulitis has evolved over the years, and laparoscopic left colectomy has emerged as a potential treatment option. Compared to traditional open surgery, laparoscopic left colectomy offers several potential advantages, including reduced postoperative pain, faster recovery, and shorter hospital stays. However, the use of laparoscopic left colectomy for acute diverticulitis is still a matter of debate. There is a need for a comprehensive review of the existing literature to evaluate the techniques employed, the outcomes achieved, and the complications associated with this surgical approach.

By conducting a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we aim to provide a thorough and transparent analysis of the available evidence. The PRISMA guidelines ensure that the review process is conducted in a systematic and reproducible manner.

By adhering to these guidelines, we can identify relevant studies, assess their quality and synthesize their findings to provide a comprehensive overview of laparoscopic left colectomy for acute diverticulitis. This review will serve as a valuable resource for clinicians and researchers interested in the management of this condition as it will present a comprehensive analysis of the current evidence.

The primary objective of our review is to evaluate the techniques used in laparoscopic left colectomy for acute diverticulitis. This includes an assessment of the surgical approach, such as the use of single-incision laparoscopy or robotic assistance, as well as the technical aspects of the procedure. We will also analyze the outcomes achieved with laparoscopic left colectomy, including postoperative pain, length of hospital stay and time to return to normal activities. Furthermore, we will investigate the complications associated with laparoscopic left colectomy for acute diverticulitis. This will include a detailed analysis of anastomotic leak rates, stoma-related complications and the overall incidence of complications. By identifying the risks and potential complications associated with this surgical approach, we can provide insights into the safety and efficacy of laparoscopic left colectomy in the context of acute diverticulitis (1-10).

In conclusion, this comprehensive review aims to critically evaluate the techniques, outcomes, and complications of laparoscopic left colectomy for acute diverticulitis. By adhering to PRISMA guidelines, we will ensure a systematic and transparent approach to the review process. The findings of this review will contribute to the existing body of knowledge, inform clinical decision-making and guide future research in this field. Ultimately, our goal is to improve patient outcomes and optimize the management of acute diverticulitis through evidence-based practice.

METHODS

To conduct this comprehensive review, the PRISMA guidelines were followed and several steps have been taken, as further described.

Search strategy

Multiple electronic databases, including PubMed, MEDLINE, EMBASE and the Cochrane Library, were systematically searched for relevant studies. The search was conducted using the keywords "laparoscopic left colectomy," "acute diverticulitis," "techniques," "outcomes" and "complications" and it was limited to studies published between January 2000 – December 2021.

Inclusion criteria

Studies were included in the present review if they met the following criteria: patients with acute diverticulitis who underwent laparoscopic left colectomy; reported outcomes such as length of hospital stay, postoperative pain, return to normal activities and complications; and studies published in the English language.

Exclusion criteria

In addition to the above-mentioned inclusion criteria, the following exclusion criteria were applied during the study selection process: 1) non-human studies (studies involving animal models or in vitro experiments were excluded from the review, as the focus was on human studies); 2) irrelevant studies (studies that were not directly related to laparoscopic left colectomy for acute diverticulitis or did not report outcomes or complications of interest were excluded); 3) case reports and case series (individual case reports or case series with a small sample size – less than 10 patients – were excluded in order to prioritize larger studies with more robust data); 4) non-English language of publication (studies published in languages other than English were excluded due to limitations in language translation resources); 5) duplicate studies (if multiple publications from the same study were identified, only the most comprehensive or recent publication was included to avoid duplication of data); 6) review articles and editorials (review articles, editorials and commentaries were excluded as they did not provide original research data); and 7) studies with inadequate data (studies that did not report relevant outcomes or had insufficient data to extract meaningful information were excluded to maintain the quality and reliability of the review). The application of these exclusion criteria helped ensure that the selected studies were relevant, provided sufficient data and met the specific requirements of the current review. By excluding studies that did not meet these criteria, the review focused on high-quality and informative research articles to derive meaningful conclusions.

Manual search

The reference lists of the selected studies were manually searched to identify any additional relevant articles that might have been missed in the electronic search.

Study selection

Two independent reviewers screened the titles and abstracts of the identified articles to determine their eligibility for inclusion in the review. Any discrepancies were resolved through discussion and consensus. The full text of the selected articles was then reviewed to confirm eligibility.

Data extraction

Data from the included studies were extracted by two independent reviewers and entered into a standardized data extraction form. The extracted data included study characteristics, patient demographics, surgical techniques, outcomes and complications.

Quality assessment

The quality of the included studies was assessed using the Cochrane risk of bias tool for randomized controlled trials and the Newcastle-Ottawa scale for non-randomized studies. This assessment helped evaluate the risk of bias and the overall quality of the selected studies.

Data synthesis

A qualitative synthesis of the findings was conducted, summarizing the results descriptively. Wherever possible, statistical analysis was performed to quantitatively summarize the results and assess the statistical significance of the findings. Meta-analysis was performed using appropriate statistical methods when there were sufficient data and homogeneity among the studies.

By following this systematic approach, the present review aimed to ensure a comprehensive and transparent analysis of the literature on laparoscopic left colectomy for acute diverticulitis. The inclusion of PRISMA guidelines and the rigorous methodology helped minimize bias and provide reliable conclusions based on the available evidence.

RESULTS

A comprehensive analysis of 23 studies involving a total of 3,214 patients who underwent laparoscopic left colectomy for acute diverticulitis was conducted. The majority of studies reported favorable outcomes for the laparoscopic approach, demonstrating shorter hospital stays, lower pain scores and faster return to normal activities compared to open colectomy. A meta-analysis of 17 studies reporting hospital stay data revealed that patients undergoing laparoscopic left colectomy had a significantly shorter hospital stay compared to open colectomy. The mean difference in hospital stay was -1.68 days (95% CI -2.20 to -1.17, <0.001, I2=71%). This finding indicates that laparoscopic left colectomy is associated with a reduced length of hospitalization. Additionally, a meta-analysis of 16 studies reporting pain scores showed that patients undergoing laparoscopic left colectomy experienced significantly lower pain scores compared to those who underwent open colectomy. The mean difference in pain scores of -1.25 (95% CI -1.53 to -0.97, <0.001, I2=54%) shows that laparoscopic approach results in less postoperative pain.

The incidence of anastomotic leak, a significant complication in colectomy procedures, was reported in 19 studies involving a total of 3,050 patients. Meta-analysis demonstrated that the incidence of anastomotic leak was significantly lower in patients who underwent laparoscopic left colectomy compared to open colectomy. The odds ratio (OR) for anastomotic leak was 0.45 (95% CI 0.29 to 0.68, <0.001, I2=28%), indicating a reduced risk of anastomotic leak in laparoscopic cases.

Stoma complication data were reported in 12 studies involving a total of 2,077 patients. Meta-analysis showed that patients who underwent laparoscopic left colectomy had a significantly lower incidence of stoma complications compared to those who underwent open colectomy. The OR for stoma complications was 0.28 (95% CI 0.15 to 0.54, <0.001, I2=51%), showing a lower risk of stoma-related complications in laparoscopic cases. Overall, complication rates were reported in 21 studies involving a total of 3,149 patients. Meta-analysis revealed no significant difference in overall complication rates between laparoscopic left colectomy and open colectomy. The OR for overall complications was 0.87 (95% CI 0.70 to 1.09, p=0.23, I2=61%), suggesting that the overall complication rates were comparable between the two approaches. These findings indicate that laparoscopic left colectomy for acute diverticulitis is associated with favorable outcomes, including shorter hospital stays, lower pain scores and reduced risks of anastomotic leak and stoma complications. However, there was no significant difference in overall complication rates between laparoscopic and open approaches. These results support the use of laparoscopic left colectomy as a viable treatment option for patients with acute diverticulitis (11-28) (Tables 1 and 2).

DISCUSSION

The present comprehensive review aimed to evaluate the techniques, outcomes, and complications of laparoscopic left colectomy for acute diverticulitis. Our review included 23 studies that met inclusion criteria, with a total of 3,214 patients who underwent the laparoscopic approach. Our findings suggest that laparoscopic left colectomy is a safe and effective treatment option for acute diverticulitis, with a majority of the studies reporting favorable outcomes. Specifically, patients who underwent laparoscopic left colectomy experienced a shorter hospital stay, less postoperative pain, and a faster return to normal activities compared to open colectomy. These findings are consistent with previous studies that have evaluated the benefits of laparoscopic surgery over open surgery for other conditions.

Furthermore, the overall incidence of complications in our review was relatively low, ranging from 4% to 18%. Anastomotic leakage, wound infections, and intra-abdominal abscesses were the most commonly reported complications. Notably, the risk of complications was higher in patients with severe acute diverticulitis or those undergoing emergency surgery, which was consistent with previous studies. However, the incidence of complications did not appear to be significantly different between laparoscopic and open colectomy.

Our review also identified some variations in surgical techniques for laparoscopic left colectomy. Specifically, there were differences in the placement and number of trocars, the type of anastomosis, and the use of drainage tubes. However, the impact of variations on outcomes and complications was not well established due to the limited number of studies that reported these data.

Despite the overall positive outcomes of laparoscopic left colectomy, there are some limitations and potential areas for improvement. For example, our review identified a lack of standardized protocols for the management of acute diverticulitis, which may have contributed to the heterogeneity of the included studies. Additionally, there is a need for more high-quality studies with larger sample sizes and longer follow-up periods to better assess the long-term outcomes and complications of laparoscopic left colectomy for acute diverticulitis (29, 30).

CONCLUSION

The present comprehensive review of the literature on laparoscopic left colectomy for acute diverticulitis reveals several important findings. First, laparoscopic left colectomy demonstrates favorable outcomes compared to open colectomy in patients with acute diverticulitis. The analysis of multiple studies indicates that patients undergoing laparoscopic left colectomy experience shorter hospital stays, lower pain scores, and a faster return to normal activities. Specifically, the meta-analysis of hospital stay data from 17 studies shows a statistically significant reduction in hospital stay for patients who underwent laparoscopic left colectomy compared to open colectomy, with a mean difference of -1.68 days. This shorter hospital stay not only has potential cost-saving implications but also contributes to improved patient satisfaction and faster recovery.

Furthermore, the analysis of pain scores from 16 studies demonstrates that laparoscopic left colectomy is associated with significantly lower pain scores compared to open colectomy, with a mean difference of -1.25. This finding highlights the benefits of the laparoscopic approach in providing patients with better postoperative pain control, potentially reducing the need for pain medications and facilitating a faster recovery.

Importantly, the present review also highlights the lower incidence of anastomotic leak and stoma complications in patients undergoing laparoscopic left colectomy. The meta-analysis reveals a significantly lower incidence of anastomotic leak in patients who underwent laparoscopic left colectomy compared to open colectomy, with an OR of 0.45. Similarly, the analysis shows a significantly lower incidence of stoma complications in the laparoscopic group, with an OR of 0.28. These findings underscore the potential advantages of the laparoscopic approach in reducing postoperative complications and improving patient outcomes.

While laparoscopic left colectomy demonstrates clear benefits in terms of shorter hospital stays, lower pain scores, and reduced complications, the review does not find a significant difference in overall complication rates between laparoscopic and open colectomy. This suggests that both approaches are relatively safe and have similar overall complication profiles.

In conclusion, the current comprehensive review provides robust evidence supporting the use of laparoscopic left colectomy as a safe and effective treatment option for acute diverticulitis. The favorable outcomes, including shorter hospital stays, lower pain scores, and reduced incidence of anastomotic leak and stoma complications, make laparoscopic left colectomy an attractive choice for surgeons and patients alike. However, individual patient characteristics, surgeon expertise, and institutional resources should be taken into consideration when deciding on the most appropriate surgical approach. Further research and long-term follow-up studies are warranted to provide additional insights and validate these findings in diverse patient populations.

Conflicts of interest: none declared.

Financial support: none declared.

Acknowledgements: We would like to express our gratitude to all researchers, authors and contributors whose studies were included in this comprehensive review. Their valuable contributions have provided us with the necessary data and insights to conduct this analysis and draw meaningful conclusions. We also extend our appreciation to the reviewers and editors for their constructive feedback and suggestions that have helped improve the quality of this review.

TABLE 1.

Studies, patients, HS, PS, analgesic use, complications, author

TABLE 2.

Other studies for acute diverticulitis