Introduction
1. Clinical presentation
A 74- year old woman was at the ER due to a painful stomach. She only has a light form of asthma in her medical history. For the last 2 months, she often had pain in the left lower side of the abdomen and often felt feverish. Since this week the pain had become progressively worse. This morning she could not handle the pain and came to the ER, she cannot exactly locate the pain. Physical examination showed a painful woman with a temperature of 38.7 degrees. Her pulse is 105/min regular and blood pressure is normal. Blood tests showed a CRP of 111 and leukocytes of 34.
A sonography fast showed fluid in the peritoneal cavity. A CT scan was made afterwards, there were a few diverticles with a thickened wall, perforation of a diverticle in the sigmoid colon could be seen. The CT scan also showed a bit of free air and fluid in the peritoneal cavity. Diverticulitis Hinchey 3 was suspected.
The patient was treated by going under operation the same day. She got a sigmoid resection with a colostoma, Hartmann procedure.
Also, the golden standard in the treatment of acute diverticulitis Hinchey classification 3 is either Hartmann procedure or sigmoid resection with primary anastomosis.
I was wondering if there were other treatments for acute diverticulitis Hinchey classification 3 that were less invasive. When looking at the literature, it said that laparoscopic lavage was also a treatment option for Hinchey classification 3.
So, what I wanted to know was if laparoscopic lavage was a better treatment option for patients in this group than resection of the sigmoid colon. The morbidity and mortality for the current standard treatments is very high, 20-40% and 10-20%. (1) I was wondering if these 2 factors are lower when treated with laparoscopic lavage. Also, the difference and severity of complications is something I want to know.
2. Clinical question
PICO question: Is laparoscopic lavage a better treatment option for acute diverticulitis with peritoneal peritonitis than sigmoid resection with anastomosis or Hartmann procedure regarding mortality, morbidity and complications?
P: Patients with acute diverticulitis, Hinchey 3
I: Laparoscopic lavage
C: Sigmoid resection with primary anastomosis or Hartmann procedure
O: Mortality, complications, morbidity
3. Guidelines
According to the protocol of VUmc, acute diverticulitis with purulent peritonitis is treated with either sigmoid resection with primary anastomosis or with the Hartmann procedure. Laparoscopic lavage as treatment is not mentioned in the protocol. (2)
The national guidelines say that for Hinchey 3 and 4 the golden standard is: sigmoid resection with primary anastomosis and Hartmann procedure. It is said that sigmoid resection has a high morbidity and mortality. Another option that was given for the treatment in only the Hinchey 3 group is laparoscopic lavage with intravenous antibiotics. The guideline recommends that when treated with this option, patients should be included in a study since the current grade of evidence is not very high. There is low evidence of the effect of treatment in Hinchey grade 4. (3)
4. Methods
Search strategy
The aim was to identify systematic reviews that considered the difference between laparoscopic lavage and sigmoid resection with stoma or primary anastomosis in the treatment of acute diverticulitis Hinchey classification 3. To identify relevant publications, I searched in the database of Pubmed and Conchrane library. Only studies written in English and published in the past 10 years were included.
Furthermore, the Mesh terms that was used were: ‘laparoscopy’ AND (‘primary resection’ OR ‘Hartmann procedure’, OR ‘sigmoidectomy’), AND ‘Diverticulitis’, AND ‘Peritonitis’ AND ‘therapeutic irrigation’ or ‘lavage’.
Selection criteria
Studies that were included, if they were written in English, a systematic review design, published in the past 10 years and assessed the difference between laparoscopic lavage and resection of the sigmoid.
Studies that were excluded, if anything other than systematic reviews, non-English publications and publication of the article was more than 10 years ago.
After applying the selection criteria, 9 articles are included. After reading the title and abstracts of the remaining reviews only 1 article was relevant to answer my question.
The article which I chose was: ‘Laparoscopic lavage versus resection in perforated diverticulitis with purulent peritonitis: a meta-analysis of randomized controlled trials.’ (4) This article was published in 2016. Other reviews found were much older or did not answer the review question.