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Original Investigation
December 23, 2020

Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial

Author Affiliations
  • 1Department of Surgery, Skåne University Hospital, Malmö, Sweden
  • 2Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
  • 3Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
  • 4Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
  • 5Department of Surgery, Linköping University, Linköping, Sweden
  • 6Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
  • 7Department of Clinical Medicine, University of Bergen, Bergen, Norway
  • 8Department of Gastrointestinal Surgery, Østfold Hospital, Fredrikstad, Norway
  • 9Department of Gastrointestinal and Emergency Surgery, Haukeland University Hospital, Bergen, Norway
  • 10Faculty of Medicine, University of Oslo, Oslo, Norway
  • 11Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
  • 12Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
JAMA Surg. Published online December 23, 2020. doi:10.1001/jamasurg.2020.5618
Key Points

Question  What are the long-term outcomes of laparoscopic peritoneal lavage compared with primary resection as treatment of perforated purulent diverticulitis?

Findings  This multicenter randomized clinical trial of 145 patients at a Hinchey stage less than IV (73 with laparoscopic lavage and 69 with resection; 3 lost to follow-up) showed no difference in severe complications, mortality, functional outcomes, or quality of life between treatment groups over a median of 59 months of follow-up. There were more stomas in the resection group.

Meaning  In this trial, laparoscopic lavage and primary resection had similar long-term results in the treatment of perforated purulent diverticulitis.

Abstract

Importance  Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available.

Objective  To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis.

Design, Setting, and Participants  This international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-up was conducted between March 2018 and November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need and computed tomography–verified free air, were eligible. Those available for trial intervention (Hinchey stages <IV) were included in the long-term follow-up.

Interventions  Patients were assigned to undergo laparoscopic peritoneal lavage or colon resection based on computer-generated, center-stratified block randomization.

Main Outcomes and Measures  The primary outcome was severe complications within 5 years. Secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life.

Results  Of 199 randomized patients, 101 were assigned to undergo laparoscopic peritoneal lavage and 98 were assigned to colon resection. At the time of surgery, perforated purulent diverticulitis was confirmed in 145 patients randomized to lavage (n = 74) and resection (n = 71). The median follow-up was 59 (interquartile range, 51-78; full range, 0-110) months, and 3 patients were lost to follow-up, leaving a final analysis of 73 patients who had had laparoscopic lavage (mean [SD] age, 66.4 [13] years; 39 men [53%]) and 69 who had received a resection (mean [SD] age, 63.5 [14] years; 36 men [52%]). Severe complications occurred in 36% (n = 26) in the laparoscopic lavage group and 35% (n = 24) in the resection group (P = .92). Overall mortality was 32% (n = 23) in the laparoscopic lavage group and 25% (n = 17) in the resection group (P = .36). The stoma prevalence was 8% (n = 4) in the laparoscopic lavage group vs 33% (n = 17; P = .002) in the resection group among patients who remained alive, and secondary operations, including stoma reversal, were performed in 36% (n = 26) vs 35% (n = 24; P = .92), respectively. Recurrence of diverticulitis was higher following laparoscopic lavage (21% [n = 15] vs 4% [n = 3]; P = .004). In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection. There were no significant differences in the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores between the groups.

Conclusions and Relevance  Long-term follow-up showed no differences in severe complications. Recurrence of diverticulitis after laparoscopic lavage was more common, often leading to sigmoid resection. This must be weighed against the lower stoma prevalence in this group. Shared decision-making considering both short-term and long-term consequences is encouraged.

Trial Registration  ClinicalTrials.gov Identifier: NCT01047462

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