Transcript Powerpoint Presentation (Eng)

Laparoscopic lavage versus primary resection in
acute perforated diverticulitis
- a randomised multicenter study
Pseudo diverticula:
Prevalence
• Diverticulosis
– >60 years of age: 30-50%
• Diverticulitis
– 10-30% of those with diverticulosis:
• Conservative/medical treatment: 75-90%
• Surgical intervention: 10-30%
Hinchey grading
Complicated diverticulitis
• Obstruction
• Abscess formation
• Fistula formation
Perforation - Peritonitis
– Mortality (historical):
Purulent peritonitis 6%;
Faecal peritonitis 35%
(Nagorny et al 1985)
Incidence of acute perforated diverticulitis
3-5 /100.000
Surgical options
Three stage
Transverse colostomy with lavage and suture of defect
Sigmoid reection and anastomosis
Closure of stoma
Hartmann
Sigmoid resection with sigmoidostomy
Closed rectum (or mucous fistula)
Primary anastomosis
with or with out covering stoma
Lavage
using the laparoscope
Hospital mortality after emergency surgery for perforated
diverticulitis
Netherlands:
Five teaching hospitals 291pts 1995 – 2005
Overall in-hospital mortality 29%
Ned Tijdschr Geeneskd. 2009;153:B195
Southeast England:
One hosp 110pts 2002 – 2006
Mortality 10.9%
World J Emerg Surg. 2008 Jan 24;3-5
Hospital mortality after emergency surgery for perforated
diverticulitis
England: ’Hospital Episode Statistics’ database between 1996
and 2006
Emergency surgery for sigmoid diverticular disease
30 -day death
1923/10198 pts = 15.9%
Alim Pharm Therapeutics 2009;30: 1171-1182
Rationale
• E. Myers et. al., BJS 2008
“Laparoscopic peritoneal lavage for generalized
peritonitis due to perforated diverticulitis”
Laparoscopy in 100 patients with perforated diverticulitis
- laparoscopic lavage in 92 patients
- 8 patients converted to Hartmann due to faecal peritonitis
Mortality 3%, morbidity 4%
• Similar results reported in other papers with fewer patients
No randomized studies
Primary endpoint
severe complications within 90 days (Clavien-Dindo >IIIa )
power analysis 30 % v.s. 10 % complications = 130 pts
Secondary endpoints
-duration of procedure
-time spent in hospital
-complications individually
-enterostoma one year after initial surgery
- “Cleveland Global Quality of Life”
-costs
Aim = 150 patients
Inclusion criteria :
- age >18 years
- clinical signs of perforated diverticulitis and need for surgery
- CT displays free gas and do not contradict the clinical diagnosis
- the patient tolerates general anesthesia
- the patient has given written informed consent
Exclusion criteria:
- pregnancy
- bowel obstruction
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The patient will be informed on used technique only postoperatively
Techniques
In all cases, lavage with minimum 4 l saline, wound drain
and Hinchey grading
Laparoscopic lavage
usual port placement: umbilicus, suprapubic, right lower quadrant
faecal peritonitis (including visible hole) convert to Hartmann
adhesions to the sigmoid should not be dealt with
Sigmoid resection with or without stoma
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Case report forms
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Case report form, follow-up
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Patient information and consent
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