P (patients)
I (intervention)
C (comparator)
O (outcomes)
Hinchey III diverticulitis
Sigmoidectomy (Hartmann’s or primary resection and anastomosis with or without diversion)
Laparoscopic peritoneal lavage (washout)
Resolution recurrence
A systematic literature search was performed of MEDLINE and PubMed to identify English language publications related to utilization of laparoscopic peritoneal lavage in perforated diverticulitis, published from January 1990 through December 2015. Combinations of key words were constructed and applied to these databases. The search strategy used in MEDLINE included both MeSH subject headings when possible and/or keyword mapping alias operator commands for the terms ‘diverticulitis’ or ‘diverticulum’, AND ‘laparoscopy’ or ‘laparoscopic’, AND ‘peritoneal lavage’, ‘lavage’, or ‘therapeutic irrigation’. Similar combinations were then applied to PubMed. The biographies of all the original articles were then explored for any additional germane publications. Studies that did not include more than one laparoscopic peritoneal lavage or therapeutic irrigation patient were excluded. Case reports, letters, systematic reviews, and duplicate articles were also excluded.
Results
Twenty-two English language studies were identified. Several studies represented extended series including previously reported patients [15–22]. One database analysis out of Ireland [23] may include the patients reported by Myers et al. [24].
Results of Low and Very-Low Quality Studies
Using the GRADE system approach to developing practice guidelines, 19 of 22 studies were rated either low or very low quality; reasons for this included small sample size, lack of institutional comparator, allocation concealment, surgeon bias, failure to adhere to the intention-to-treat principle, and lack of reporting on salient outcome metrics such as non-resolution or recurrence requiring resection. Most of the excluded studies had more than one of these limitations. These studies are summarized in Table 27.2.
Table 27.2
Low and very low quality evidence on laparoscopic peritoneal lavage
Study | Study period | Unique lavage patients | H3 | Lavage population | Morbidity (%) | Death (%) | Non-resolution requiring resection (%) | Recurrence requiring resection (%) | Elective resection without recurrence (%) | Symptom free, no resection (%) |
|---|---|---|---|---|---|---|---|---|---|---|
O’Sullivan et al. [16] | ‘91–‘94 | 8 | 8 | CD and GP intra-op; (H3 only) | 2 (25) | 0 | 0 | 0 | 0 | 6 (75) |
Faranda et al. [24] | ‘94-‘98 | 18 | 16 | CD and GP on presentation | 3 (17) | 0 | 0 | NR | 15 (83) ~4 m | NR |
Mutter et al. [29] | ’96–‘03 | 10 | 10 | CD, (−) PCD, intra-op with (−) GP, (−) visible perforation, (−) H4 | 0 | 0 | 1 (10) | 0 | 6 (60) ~2–3 m | NR |
Taylor et al. [20] | ’02–‘05 | 14 | 10 | CD with perforation | 0 (major) | 0 | 3 (21) | 0 2–15 m | 8 (57) ~6w later | 2 (14) 2–15 m |
Bretagnol et al. [18] | ’00–‘04 | 24 | 18 | CD and GP or FoMM or septic shock | 2 (8) | 0 | 0 | 0 ~4 m; 2–6 m | 24 (100 %) ~4 m; 2–6 m | 0 |
Franklin et al. [22] | ’91–‘06 | 40 | 32 | CD and GP | 8 (20) | 0 | 0 | 0 96 m; 1–168 m | 24a (60) | 16 (40) 96 m; 1–168 m |
Myers et al. [26] | ’00–‘07 | 92 | 67 | CD and GP; (+) free air, (−) H4 | (4) | 3 (3.2) | 1 (2) | 0 36 m; 12–84 m | 0 36 m; 12–84 m | 88 (96) 36 m; 12–84 m |
Favuzza et al. [30] | NR | 7 | NR | CD and peritonitis; Imaging (+) fluid (−) discrete abscess | NR | 0 | 1 (14) | 1 (14) 3 m | 5 (71) | 0 |
Karoui et al. [23] | ’94–‘06 | 35 | 35 | CD and GP on presentation (H3 only) | 9 (26) | 0 | 1 (3) | 0 | 25 (71) 4 m; 2–7 | 8 (23) 21 m; 7–48 m |
White et al. [19] | ’99–‘08 | 35 | 11 | CD and GP, or (+) free air or 2QP (+) >3 cm collection with FoMM | 19 (54) | 0 | 8 (23) | 8 (23) 6 m; 2–12 m | 8 (23) 2–3 m later | 11 (31) 20 m; 6–60 m |
Liang et al. [21] | ’91–‘10 | 47 | 36 | CD and GP with (+) free air and (+) contrast extravasation | 2 (4) | 0 | 3 (6.4) | 0 | 18a (38) | 26 (55) |
Rogers et al. [25] | ’95–‘08 | 427 | NR | NR | 60 (14) | 17 (4) | NR | NR | NR | NR |
Edieken et al. [31] | ’09–‘12 | 10 | 8 | CD with FoMM or (+) free air; (+) HDS | NR | 0 | 3 (30) | 3 (30) | 0 | NR |
Swank et al. [32] | ’08–‘10 | 38 | 33 | CD with perforation; (+) free air or H3 | 17 (45) | 4 (11) | 5 (13) | 3 (8) 6–12 m | 0 | 30 (79) 3 m |
Gentile et al. [33] | ’09–‘12 | 14 | 3 | CD with perforation (H2-3 only) | 3 (21) | 1 (7) | NR | NR | NR | NR |
Rade et al. [17] | ’00–‘13 | 71 | 47 | CD with GP; (−) shock (−) distention (−) previous surg (−) H4 | 20 (28) | 4 (6) | 11 (15) | NR | 55 (77) 3 m; 1–9 m | NR |
Rossi et al. [34] | ’06–‘13 | 46 | 46 | CD with GP; intra-op H3 only, (+) HDS | 11 (24) | 0 | 5 (11) | NR | NR | NR |
Horesh et al. [35] | ’07–‘12 | 10 | 7 | CD and peritonitis with (+) free air, or FoMM | 3 (30 %) | 0 | 1 (10 %) | 2 (20 %) ~9 m | NR | 6 (60 %) |
Sorrentino et al. [36] | ’01–‘13 | 63 | 54 | CD and intra-op; (−) fecal peritonitis >1 quadrant | 9 (14) | 1 (2) | 6 (10) | 4 (7) ~5y | 0 | 53 (84) ~5y |
There are a total of 946 patients represented by low or very low quality studies undergoing laparoscopic peritoneal lavage and at least 758 are presumed unique patients across a 22-year period (1991–2013). Of studies clearly reporting intraoperative Hinchey classification, 76 % of patients (311 of 416) had Hinchey III diverticulitis, defined as free purulent contamination of the peritoneal cavity. Some studies allowed patients who had failed an initial trial of medical management with or without percutaneous drainage of accessible abscess cavities; others only included patients determined to be urgent surgical candidates on presentation. Four studies included an intraoperative decision point to proceed with lavage, recognizing the inherent surgeon bias in this approach.
Lavage technique varied, including decision to disrupt inflammatory adhesions, use of pelvic drains, decision to patch, suture, or apply fibrin glue to visible perforations, volume of warm saline used, addition of agents to the irrigant (betadine or heparin) and duration of postoperative antibiotics. It is not known whether any one lavage technique positively or negatively influenced outcome.
Of unique studies reporting appropriate outcomes, the morbidity of lavage was ~19 %, with ~3 % mortality. Approximately 10 % of patients experienced non-resolution after lavage requiring return to the operating room and sigmoidectomy (~2/3 of studies reporting on this outcome); ~ 6 % of patients experienced a recurrence requiring sigmoid resection over a time frame ranging from 2 months to 14 years, ~28 % of patients underwent elective resection within 2–9 months after peritoneal lavage, and ~68 % of patients are symptom-free without any further intervention over an unknown time interval (~1/2 of studies reporting on the aforementioned three outcomes). The decision to proceed with elective resection was an institutional tenet defining lavage as a strategy to bridge patients through an emergency presentation so that they could undergo surgery in the elective setting. Other studies highlighted lavage as a potentially definitive procedure.
If we are to define success of peritoneal lavage as those patients who are either symptom-free with no recurrences or further intervention, or were able to undergo elective resection prior to any recurrent episode, then lavage was known to be successful in ~46 % of the total unique patient population represented by these studies, with approximately half of studies not reporting on these outcomes.
Several authors suggested criteria to identify those who are likely to fail lavage, including patients with elevated American Society of Anesthesia (ASA) classification, immune suppression, or advanced age [17], those with Hinchey IV diverticulitis (most series) or a visible perforation, and those with distention or obstruction limiting technical feasibility of lavage.
Results of Randomized-Controlled Trials
Of the 22 studies identified, 3 are recent randomized controlled multicenter trials, all rated high quality based on the GRADE system [37, 38, 39]. The results of these studies are summarized in Table 27.3. To allow for better comparison between trials, the author of this chapter utilized supplementary data from these trials to report on similar outcomes; that is 30–90 day morbidity beyond IIIb, and mortality, excluding Hinchey IV patients.
Table 27.3
Randomized controlled trials on laparoscopic peritoneal lavage
