Evidence for laparoscopic peritoneal lavage for purulent diverticulitis

Perforated diverticulitis is graded by the Hinchey classification: Grade I is walled‐off pericolic abscess, Grade II is walled‐off pelvic abscess, Grade III is free purulent peritonitis, and Grade IV is free fecal peritonitis. Although patients with Grade I/II diverticulitis are managed conservatively, those with Grade III/IV diverticulitis are treated surgically by colonic resection and proximal colostomy (Hartmann's procedure) or colonic resection and primary anastomosis, with a high morbidity rate (30‐50%) and mortality rate (10‐20%).

In 1996, O'Sullivan proposed laparoscopic peritoneal lavage (LPL) in patients with peritonitis as a result of perforated diverticulitis1, and a recent systematic review of 19 studies including 871 patients showed that LPL should be considered an effective and safe option for the treatment of Grade III diverticulitis.2 To clarify the superiority of LPL to open colonic resection, several randomized controlled trials have been done in Western countries, and the results at present are somewhat conflicting.

The DILALA trial3 was done at nine surgical departments in Sweden and Denmark from February 2010 to February 2014 and compared LPL and Hartmann's procedure for Grade III diverticulitis. In that study, reoperation was not different between the LPL group (5/38, 13%) and the Hartmann group (6/35, 17%) and 90‐day mortality was not different between the two groups (8% vs 11%). The authors concluded that LPL for Grade III diverticulitis is feasible and safe for the treatment of Grade III diverticulitis.

The Ladies trial4 was carried out at 42 teaching hospitals in Belgium, Italy, and the Netherlands from July 2010 to February 2013 and compared LPL and sigmoid colectomy in Grade III diverticulitis. The results showed that major morbidity and mortality occurred in 30 of 45 LPL patients (67%) and in 25 of 42 sigmoid colectomy patients (60%), with an odds ratio of 1.28 (95% CI 0.54‐3.03, P=.6). The authors concluded that LPL is not superior to sigmoid colectomy for purulent diverticulitis.

The SCANDIV trial5 was conducted at 21 surgical units in Sweden and Norway from February 2010 to June 2014 and compared LPL and colon resection in Grade III/IV diverticulitis. Although postoperative severe complications and 90‐day mortality did not differ between 101 patients with LPL and 96 with resection (31% vs 26% and 14% vs 12%), intra‐abdominal abscess and reoperation differed between the two groups (22% vs 10%, P=.07 and 20% vs 6%, P<.05). Therefore, the authors do not support LPL for the treatment of acute perforated diverticulitis.

Based on the review of these randomized controlled trials in Europe, LPL is comparable to colon resection in terms of mortality but is associated with a higher rate of abscess formation and reoperation. The fourth trial (LapLAND) enrolling 300 patients in Ireland will provide further information about the efficacy of LPL compared with open colectomy and may give us a final decision for the treatment of perforated purulent diverticulitis.