- a randomised multicenter study Laparoscopic lavage versus primary resection in acute perforated diverticulitis - a randomised multicenter study

Pseudo diverticula: Colonic diverticula are of the propulsion type, called false diverticula, - They are mucousal pouches traversing the gut wall musculature through a tunnel created by the vasa recta, small arteries that supply blood to the mucosa alongside any of the three taeniae. 95% of people with diverticulosis have the sigmoid colon involved. - Diverticula do not develop in the rectum, possibly because of the coalescence of taeniae into a longitudinal muscle layer there. 2

Prevalence Diverticulosis Diverticulitis >60 years of age: 30-50% 10-30% of those with diverticulosis: Conservative/medical treatment: 75-90% Surgical intervention: 10-30% 10 – 30 % of all patients with diverticulosis will experience one or more episodes of diverticulitis through their lifetime. 50% divertikulos 20% divertikulit = 10% Kirurgi 20 % = 2/100 3

Hinchey grading

Complicated diverticulitis Obstruction Abscess formation Fistula formation Perforation - Peritonitis Mortality (historical): Purulent peritonitis 6%; Faecal peritonitis 35% (Nagorny et al 1985) If the condition deteriorates with such complications, - traditionally that has mandated resuscitation, broad-spectrum antibiotics, and emergency open surgical exploration, ..... Even though   Incidence of acute perforated diverticulitis 3-5 /100.000 5

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

Netherlands: Five teaching hospitals 291pts 1995 – 2005 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 Secondary endpoints severe complications within 90 days (Clavien-Dindo >IIIa ) power analysis 30 % v.s. 10 % complications = 130 pts Aim = 150 patients Secondary endpoints -duration of procedure -time spent in hospital -complications individually -enterostoma one year after initial surgery - “Cleveland Global Quality of Life” -costs

Inclusion criteria : Exclusion 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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Sigmoid resection with or without stoma 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 www.scandiv.com

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