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Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis : Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial

Azhar, Najia LU orcid ; Johanssen, Anette ; Sundström, Tove ; Folkesson, Joakim ; Wallon, Conny ; Kørner, Hartvig ; Blecic, Ljiljana ; Forsmo, Håvard Mjørud ; Øresland, Tom and Yaqub, Sheraz , et al. (2021) In JAMA Surgery 156(2). p.121-121
Abstract
Importance Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available.

Objective To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis.

Design, Setting, and Participants This international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-up was conducted between March 2018 and... (More)
Importance Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available.

Objective To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis.

Design, Setting, and Participants This international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-up was conducted between March 2018 and November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need and computed tomography–verified free air, were eligible. Those available for trial intervention (Hinchey stages <IV) were included in the long-term follow-up.

Interventions Patients were assigned to undergo laparoscopic peritoneal lavage or colon resection based on computer-generated, center-stratified block randomization.

Main Outcomes and Measures The primary outcome was severe complications within 5 years. Secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life.

Results Of 199 randomized patients, 101 were assigned to undergo laparoscopic peritoneal lavage and 98 were assigned to colon resection. At the time of surgery, perforated purulent diverticulitis was confirmed in 145 patients randomized to lavage (n = 74) and resection (n = 71). The median follow-up was 59 (interquartile range, 51-78; full range, 0-110) months, and 3 patients were lost to follow-up, leaving a final analysis of 73 patients who had had laparoscopic lavage (mean [SD] age, 66.4 [13] years; 39 men [53%]) and 69 who had received a resection (mean [SD] age, 63.5 [14] years; 36 men [52%]). Severe complications occurred in 36% (n = 26) in the laparoscopic lavage group and 35% (n = 24) in the resection group (P = .92). Overall mortality was 32% (n = 23) in the laparoscopic lavage group and 25% (n = 17) in the resection group (P = .36). The stoma prevalence was 8% (n = 4) in the laparoscopic lavage group vs 33% (n = 17; P = .002) in the resection group among patients who remained alive, and secondary operations, including stoma reversal, were performed in 36% (n = 26) vs 35% (n = 24; P = .92), respectively. Recurrence of diverticulitis was higher following laparoscopic lavage (21% [n = 15] vs 4% [n = 3]; P = .004). In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection. There were no significant differences in the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores between the groups.

Conclusions and Relevance Long-term follow-up showed no differences in severe complications. Recurrence of diverticulitis after laparoscopic lavage was more common, often leading to sigmoid resection. This must be weighed against the lower stoma prevalence in this group. Shared decision-making considering both short-term and long-term consequences is encouraged. (Less)
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author collaboration
organization
publishing date
type
Contribution to journal
publication status
published
subject
in
JAMA Surgery
volume
156
issue
2
pages
121 - 121
publisher
American Medical Association
external identifiers
  • pmid:33355658
  • scopus:85098322235
  • pmid:33355658
ISSN
2168-6254
DOI
10.1001/jamasurg.2020.5618
project
Clinical management of acute complicated and uncomplicated diverticulitis
language
English
LU publication?
yes
id
a659060e-2a41-4bdd-a62d-97bb04c65fd0
date added to LUP
2020-12-24 15:25:21
date last changed
2022-04-26 22:47:31
@article{a659060e-2a41-4bdd-a62d-97bb04c65fd0,
  abstract     = {{Importance  Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available.<br>
<br>
Objective  To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis.<br>
<br>
Design, Setting, and Participants  This international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-up was conducted between March 2018 and November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need and computed tomography–verified free air, were eligible. Those available for trial intervention (Hinchey stages &lt;IV) were included in the long-term follow-up.<br>
<br>
Interventions  Patients were assigned to undergo laparoscopic peritoneal lavage or colon resection based on computer-generated, center-stratified block randomization.<br>
<br>
Main Outcomes and Measures  The primary outcome was severe complications within 5 years. Secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life.<br>
<br>
Results  Of 199 randomized patients, 101 were assigned to undergo laparoscopic peritoneal lavage and 98 were assigned to colon resection. At the time of surgery, perforated purulent diverticulitis was confirmed in 145 patients randomized to lavage (n = 74) and resection (n = 71). The median follow-up was 59 (interquartile range, 51-78; full range, 0-110) months, and 3 patients were lost to follow-up, leaving a final analysis of 73 patients who had had laparoscopic lavage (mean [SD] age, 66.4 [13] years; 39 men [53%]) and 69 who had received a resection (mean [SD] age, 63.5 [14] years; 36 men [52%]). Severe complications occurred in 36% (n = 26) in the laparoscopic lavage group and 35% (n = 24) in the resection group (P = .92). Overall mortality was 32% (n = 23) in the laparoscopic lavage group and 25% (n = 17) in the resection group (P = .36). The stoma prevalence was 8% (n = 4) in the laparoscopic lavage group vs 33% (n = 17; P = .002) in the resection group among patients who remained alive, and secondary operations, including stoma reversal, were performed in 36% (n = 26) vs 35% (n = 24; P = .92), respectively. Recurrence of diverticulitis was higher following laparoscopic lavage (21% [n = 15] vs 4% [n = 3]; P = .004). In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection. There were no significant differences in the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores between the groups.<br>
<br>
Conclusions and Relevance  Long-term follow-up showed no differences in severe complications. Recurrence of diverticulitis after laparoscopic lavage was more common, often leading to sigmoid resection. This must be weighed against the lower stoma prevalence in this group. Shared decision-making considering both short-term and long-term consequences is encouraged.}},
  author       = {{Azhar, Najia and Johanssen, Anette and Sundström, Tove and Folkesson, Joakim and Wallon, Conny and Kørner, Hartvig and Blecic, Ljiljana and Forsmo, Håvard Mjørud and Øresland, Tom and Yaqub, Sheraz and Buchwald, Pamela and Schultz, Johannes Kurt}},
  issn         = {{2168-6254}},
  language     = {{eng}},
  number       = {{2}},
  pages        = {{121--121}},
  publisher    = {{American Medical Association}},
  series       = {{JAMA Surgery}},
  title        = {{Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis : Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial}},
  url          = {{http://dx.doi.org/10.1001/jamasurg.2020.5618}},
  doi          = {{10.1001/jamasurg.2020.5618}},
  volume       = {{156}},
  year         = {{2021}},
}