Laparoscopic Lavage - A Paradigm Shift for the Treatment of Perforated Diverticulitis with Purulent Peritonitis?

Sammanfattning: Introduction: Perforated diverticulitis of the colon is a condition that sometimes requires surgical treatment. Traditionally Hartmann’s procedure is the recommended treatment. Laparoscopic lavage has lately evoked interest as a definite treatment for perforated diverticulitis with purulent peritonitis. Aim: To evaluate the surgical treatment for perforated diverticulitis and to assess laparoscopic lavage as a definite treatment for perforated diverticulitis with purulent peritonitis. Patients and Methods: Paper I explores the morbidity and mortality of patients operated due to perforated diverticulitis at Sahlgrenska University Hospital 2003 to 2008. Papers II-IV describe the conception, structure and the results of the randomised controlled trial DILALA, which compares laparoscopic lavage to Hartmann’s procedure as a treatment for perforated diverticulitis with purulent peritonitis. Results: Paper I found that 44% of the patients were re-operated after surgical treatment for perforated diverticulitis. The mortality rate during first admission was 6%. The stoma, a result from Hartmann’s procedure, became permanent in 40% of the patients. The DILALA-trial showed that for laparoscopic lavage 28% were re-operated compared to 63% for the Hartmann’s procedure, a relative risk reduction of 59% for re-operation (RR 0.41, 95% CI 0.23-0.72) (p=0.004) There was also significantly shorter operating time and shorter length of hospital stay. No differences were found in mortality, morbidity or quality of life. Conclusion: The scientific evidence for laparoscopic lavage is still limited but our results indicate that laparoscopic lavage is superior to Hartmann’s procedure when treating perforated diverticulitis with purulent peritonitis.