0. Welcome to Gardermoen

1. Program 11.00 – 11.30 Introduction and status of SCANDIV
11.30 – Report from the Dutch diverticulitis trail (Hilco Swank)
12.45 – Discussion
13.00 – Lunch
13.45 – Discussion

2. Background
Hinchey grading
Prevalence
Incidence
Existing research

3. Perforated diverticulitis
Hinchey grading
(Hinchey et al. 1978)

4. Prevalence Diverticulosis Diverticulitis Raising with age
> 60 years of age: 30-50%
Diverticulitis
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 4 4

5. Population Demography

6. Incidence Diverticulitis: Ca 20-40/100.000/year
Acute perforated diverticulitis:
Ca 3-5/ /year

7. Surgical options
Three stages 1. Drainage and transversostomy Sigmoid resection
3. Closure of stoma
Hartmann Sigmoid resection with sigmoidostomy
2. Closure of stoma with colorectal anastomosis
Resection with primary anastomosis (with or without diverting stoma)
Laparoscopic lavage

8. Mortality
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 mortality / pts = 15.9%
Alim Pharm Therapeutics 2009;30:

9. 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% in the lavage group
• Similar results in other papers with fewer patients

10. But
No randomized studies

11. Randomized prospective multicenter trial
Laparoscopic lavage vs. primary resection as treatment for perforated diverticulitis
Start of inclusion February 2010
28 hospitals participate
42 patients included

12. Endpoints Secondary Primary
- severe complications within 90 days (Clavien-Dindo >IIIa )
power analysis 30 % v.s. 10 % complications = 130 pts Aim = 150 patients
Secondary
- duration of procedure
- time spent in hospital
- complications individually
- stoma one year after initial surgery
- “Cleveland Global Quality of Life”
- costs

13. Inclusion Inclusion criteria Exclusion criteria - age >18 years
- clinical signs of perforated diverticulitis and need for surgery
- CT displays free gas and possible diverticulitis
- the patient tolerates general anaesthesia
- the patient has given written informed consent
Exclusion criteria
- pregnancy
- bowel obstruction

14. 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, open or laparoscopic

15. Randomization

17. Participating hospitals

18. SCANDIV approximate catchment population (educated guess)
Borås Lasarett
Danderyd sjukhus, Stockholm
Diakonhjemmet sykehus
Haugesund sykehus
Haukeland Sykehus
Helsingborgs lasarett
Hudiksvalls sjukhus  
Innlandet sykehus, Hamar
Innlandet sykehus, Lillehammer
Karolinska sjukhuset, Stockholm
Huddinge
Solna
Kristiansund Sykehus  
Linköpings universitetssjukhus
Levanger Sykehus
Malmø Akademiska sjukhus
(Skånes universitetssjukhus)
Norrköping, Vrinnevisjukhuset
Molde sykehus
Oslo universitetssykehus, Aker
Oslo universitetssykehus, Ullevål ‎
Stavanger Universitetssykehus
Sørlandet sykehus, Kristiansand
Sykehus Østfold Fredrikstad
UNN, Tromsø
Uppsala Akademiska sjukhus
Umeå universitetssjukhus
Västerås Centrallasarettet
Vestre Viken HF Sykehuset Buskerud
Akershus Universitetssykehus
Ålesund sykehus
Total population ≈ ?
150 patients/year
with perforated diverticulitis?

19. Included patients

20. Patients per hospital

21. Case report forms

22. Case report form, follow-up

23. Patient information and consent

24. Web - CRF Web based Case Report Form Testing next week
Hope to start after Easter
Changes in patient information?