J. Vermeulen

Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis : a multicentre, parallel-group, randomised, open-label trial

BACKGROUND Case series suggest that laparoscopic peritoneal lavage might be a promising alternative to sigmoidectomy in patients with perforated diverticulitis. We aimed to assess the superiority of laparoscopic lavage compared with sigmoidectomy in patients with purulent perforated diverticulitis, with respect to overall long-term morbidity and mortality. METHODS We did a multicentre, parallel-group, randomised, open-label trial in 34 teaching hospitals and eight academic hospitals in Belgium, Italy, and the Netherlands (the Ladies trial). The Ladies trial is split into two groups: the LOLA group comparing laparoscopic lavage with sigmoidectomy and the DIVA group comparing Hartmanns procedure with sigmoidectomy plus primary anastomosis. The DIVA section of this trial is still underway but here we report the results of the LOLA section. Patients with purulent perforated diverticulitis were enrolled for LOLA, excluding patients with faecal peritonitis, aged older than 85 years, with high-dose steroid use (≥20 mg daily), and haemodynamic instability. Patients were randomly assigned (2:1:1; stratified by age [<60 years vs ≥60 years]) using secure online computer randomisation to laparoscopic lavage, Hartmanns procedure, or primary anastomosis in a parallel design after diagnostic laparoscopy. Patients were analysed according to a modified intention-to-treat principle and were followed up after the index operation at least once in the outpatient setting and after sigmoidoscopy and stoma reversal, according to local protocols. The primary endpoint was a composite endpoint of major morbidity and mortality within 12 months. This trial is registered with ClinicalTrials.gov, number NCT01317485. FINDINGS Between July 1, 2010, and Feb 22, 2013, 90 patients were randomly assigned in the LOLA section of the Ladies trial when the study was terminated by the data and safety monitoring board because of an increased event rate in the lavage group. Two patients were excluded for protocol violations. The primary endpoint occurred in 30 (67%) of 45 patients in the lavage group and 25 (60%) of 42 patients in the sigmoidectomy group (odds ratio 1·28, 95% CI 0·54-3·03, p=0·58). By 12 months, four patients had died after lavage and six patients had died after sigmoidectomy (p=0·43). INTERPRETATION Laparoscopic lavage is not superior to sigmoidectomy for the treatment of purulent perforated diverticulitis. FUNDING Netherlands Organisation for Health Research and Development.

Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann’s procedure be considered a one‐stage procedure?

Objective  Hartmann’s procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis.

The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitisA and Hartmann's procedure or resection with primary anastomosis for purulent or faecal peritonitisB in perforated diverticulitis (NTR2037)

BackgroundRecently, excellent results are reported on laparoscopic lavage in patients with purulent perforated diverticulitis as an alternative for sigmoidectomy and ostomy.The objective of this study is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis).Methods/DesignIn this multicentre randomised trial all patients with perforated diverticulitis are included. Upon laparoscopy, patients with purulent peritonitis are treated with laparoscopic lavage and drainage, Hartmanns procedure or sigmoidectomy with primary anastomosis in a ratio of 2:1:1 (LOLA-arm). Patients with faecal peritonitis will be randomised 1:1 between Hartmanns procedure and resection with primary anastomosis (DIVA-arm). The primary combined endpoint of the LOLA-arm is major morbidity and mortality. A sample size of 132:66:66 patients will be able to detect a difference in the primary endpoint from 25% in resectional groups compared to 10% in the laparoscopic lavage group (two sided alpha = 5%, power = 90%). Endpoint of the DIVA-arm is stoma free survival one year after initial surgery. In this arm 212 patients are needed to significantly demonstrate a difference of 30% (log rank test two sided alpha = 5% and power = 90%) in favour of the patients with resection with primary anastomosis. Secondary endpoints for both arms are the number of days alive and outside the hospital, health related quality of life, health care utilisation and associated costs.DiscussionThe Ladies trial is a nationwide multicentre randomised trial on perforated diverticulitis that will provide evidence on the merits of laparoscopic lavage and drainage for purulent generalised peritonitis and on the optimal resectional strategy for both purulent and faecal generalised peritonitis.Trial registrationNederlands Trial Register NTR2037

Outcome after Emergency Surgery for Acute Perforated Diverticulitis in 200 Cases

Background: Mortality and morbidity rates of acute perforated diverticulitis remain high. The ideal treatment is still controversial. The object of this study was to compare patients with perforated diverticulitis treated either by resection with primary anastomosis (PA) or Hartmann’s procedure (HP). Methods: A multicenter study was carried out on 200 consecutive patients with acute perforated diverticulitis who were presented in the surgical units of four affiliated teaching hospitals in Rotterdam, The Netherlands, between 1995 and 2005. Mortality and morbidity were compared in relation to type of surgery, ASA classification, age, gender, Mannheim Peritonitis Index (MPI), Hinchey score, surgeon’s experience, and the time of operation. Results: There was a tendency for more severely affected patients (Hinchey, MPI, ASA and age) to undergo HP. Multivariate logistic regression analysis showed no significant difference in mortality between HP and PA. After HP, more patients needed one or more reinterventions to treat postoperative complications compared to PA. Besides, HP resulted in a longer total hospital and intensive care unit stay. Specialist colorectal surgeons performed significantly more frequently a PA instead of a HP and had fewer postoperative complications than general surgeons. The time of operation did not influence the choice of surgical procedure. Conclusion: Selected patients with perforated diverticulitis can be managed well by PA, as it does not seem to be inferior to HP in terms of severe postoperative complications that need surgical or radiological reintervention and mortality. This decision should be made while taking into account the patient’s concomitant diseases, response on preoperative resuscitation and the availability of a surgeon experienced in colorectal surgery.

Treatment of perforated diverticulitis with generalized peritonitis: Past, present, and future

BackgroundThe supposed optimal treatment of perforated diverticulitis with generalized peritonitis has changed several times during the last century, but at present is still unclear.Methods/resultsThe first cases of complicated perforated diverticulitis of the colon were reported in the beginning of the twentieth century. At that time the first therapeutic guidelines were postulated in which an initial nonresectional procedure was provided to be the safest plan of management. After many years in which resection had become standard practice, today, one century later, again (laparoscopic) nonresectional surgery is presented as a safe and promising alternative in treatment of complicated perforated diverticulitis. The question rises what had happened to close the circle?ConclusionsThis paper includes a historic summary of changing patterns in surgical strategies in perforated diverticulitis complicated by generalized peritonitis.

Management of penetrating neck injuries.

Routine surgical exploration after penetrating neck injury (PNI) leads to a large number of negative neck explorations and potential iatrogenic injury. Selective non‐operative management (SNOM) of PNI is gaining favour. The present study assessed the feasibility of SNOM in PNI.

Primary Closure of the Skin after Stoma Closure

Background and Aims: Whether or not the skin can be closed primarily after stoma closure is still debated in the existing literature. Therefore, this present study was undertaken to compare the complications and consequences between primary or delayed closure of the skin after stoma closure. Patients and Methods: All consecutive stoma closures between January 2001 and August 2004 were included. In 25 patients (group I), the skin at the stoma site was closed primarily. In 37 patients (group II), the skin was left open. Patient characteristics, comorbidity, medication use, hospital stay and long-term complications were recorded and retrospectively compared between the two groups. Results: In group I, wound infection rate was 36% versus 5% in group II (p = 0.005). Infected wounds were mostly found after ileostomy closure with primary closure of the skin (p = 0.018). The occurrence of a wound infection was not related to the use of corticosteroids, diabetes mellitus, fistula formation, anastomotic leakage, or primary disease and did not lead to a prolonged hospital stay or an increased number of incisional hernias. Conclusion: In our opinion, it is safe to close the skin after stoma closure, but patients should be informed carefully about the advantages and disadvantages of this strategy, especially in case of ileostomy closure.

Anterolateral rectopexy for correction of rectoceles leads to good anatomical but poor functional results

BackgroundSeveral different surgical repair procedures for symptomatic rectocele have been described with variable results. In our clinic, a modified anterolateral rectopexy is used. In this article we evaluate our results, with emphasis on patient satisfaction.MethodsFrom 2001 until 2003, twenty patients with a symptomatic rectocele were treated by anterolateral rectopexy. The preoperative dynamic defecogram and anorectal complaints were analyzed and compared to postoperative outcome via a standardized questionnaire.ResultsAfter surgery, all rectoceles were restored as shown by postoperative defecogram. Anorectal symptoms (incomplete evacuation, continuous urge, prolapse, digital evacuation) were improved in 40%. As new-onset symptoms, dyspareunia (50%), digital support (55%) and incomplete evacuation (75%) were mentioned frequently. Most of the patients with larger rectoceles (>3.5 cm) had increased anorectal complaints after surgery.ConclusionsAnterolateral rectopexy for treatment of rectocele give limited improvement of anorectal complaints. Besides, many patients developed new complaints postoperatively and hence overall satisfaction was low.

Long-term survival after perforated diverticulitis

Aim  Short‐term survival after emergency surgery for perforated diverticulitis is poor. Less is known about long‐term survival. The aims of this study were to evaluate long‐term survival after discharge from hospital and to identify factors associated with prognosis.

Primary resection and side-to-end anastomosis next to an endcolostomy in the management of acute malignant obstruction of the left bowel: an alternative in selected patients

BackgroundPatients presenting with an acute obstructing carcinoma of the left bowel are a surgical challenge. Under more difficult circumstances with gross distension of the proximal colon many surgeons will decide to defer anastomosis. Hartmann’s procedure still represents a valid treatment option. We describe our experience with primary resection and side-to-end anastomosis next to an end-colostomy in the management of acute malignant obstruction of the left bowel.MethodsThe surgical procedure involves resection of the tumour and primary stapled side-to-end anastomosis next to a protecting end-colostomy. This type of enterostomy was first described by Santulli and Blanc in 1961. Colostomy closure is possible via a local procedure avoiding relaparotomy. Ten patients (five women) underwent surgery using this technique. Their mean age was 71 years (range 54–88 years). All patients had a massively distended colon. All obstructing lesions were biopsy-proven adenocarcinomas.ResultsThere was no postoperative mortality and no anastomotic leakage. The colostomy could be closed without a laparotomy in all patients. The only two complications were one superficial necrosis of the stoma and one wound infection after colostomy closure. In all other patients the postoperative course was uneventful. Wound infection after colostomy closure was seen in the very first patient in whom the wound was closed primarily. In subsequent patients the skin was left open.ConclusionsThe concept of an end-colostomy next to the anastomosis is an alternative approach combining the safety of proximal decompression and the advantages of primary anastomosis. This technique may be considered in patients presenting with a massively distended and faeces-loaded colon caused by an obstructing tumour in the descending or sigmoid colon, when the surgeon would otherwise elect to defer anastomosis.