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

2. 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

3. 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

4. Hinchey grading

5. 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 / 5

6. 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

7. Netherlands: Five teaching hospitals 291pts 1995 – 2005
Hospital mortality after emergency surgery for perforated diverticulitis
Netherlands: Five teaching hospitals 291pts – 2005
Overall in-hospital mortality 29%
Ned Tijdschr Geeneskd. 2009;153:B195
Southeast England: One hosp 110pts – 2006
Mortality 10.9%
World J Emerg Surg Jan 24;3-5

8. 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:

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%
• Similar results reported in other papers with fewer patients

10. No randomized studies

11. 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

12. 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

13. www.scandiv.com Log in with hospital name and password
The patient will be informed on used technique only postoperatively

14. 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

15. Case report forms

16. Case report form, follow-up

17. Patient information and consent