Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: The SCANDIV Randomized Clinical Trial

• Published in: JAMA : the journal of the American Medical Association 2015-10, Vol.314 (13), p.1364-1375
• Main Authors: Schultz, Johannes Kurt, Yaqub, Sheraz, Wallon, Conny, Blecic, Ljiljana, Forsmo, Håvard Mjørud, Folkesson, Joakim, Buchwald, Pamela, Körner, Hartwig, Dahl, Fredrik A, Øresland, Tom
• Format: Article
• Language: English
• Subjects: Acute Disease; Adult; Aged, 80 and over; Clinical outcomes; Colon; Digestive System Surgical Procedures; Diverticulitis, Colonic - complications; Diverticulitis, Colonic - surgery; Emergency Treatment; Female; Gastroenterology; Humans; Intestinal Perforation - etiology; Intestinal Perforation - surgery; Laparoscopy; Laparoscopy - methods; Length of Stay; Male; Middle Aged; Morbidity; Peritoneal Lavage - methods; Peritonitis - complications; Postoperative Complications; Quality of Life; Reoperation; Time Factors; Treatment Outcome
• ISSN: 0098-7484; 1538-3598; 1538-3598
• DOI: 10.1001/jama.2015.12076

IMPORTANCE: Perforated colonic diverticulitis usually requires surgical resection, which is associated with significant morbidity. Cohort studies have suggested that laparoscopic lavage may treat perforated diverticulitis with less morbidity than resection procedures. OBJECTIVE: To compare the outcomes from laparoscopic lavage with those for colon resection for perforated diverticulitis. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized clinical superiority trial recruiting participants from 21 centers in Sweden and Norway from February 2010 to June 2014. The last patient follow-up was in December 2014 and final review and verification of the medical records was assessed in March 2015. Patients with suspected perforated diverticulitis, a clinical indication for emergency surgery, and free air on an abdominal computed tomography scan were eligible. Of 509 patients screened, 415 were eligible and 199 were enrolled. INTERVENTIONS: Patients were assigned to undergo laparoscopic peritoneal lavage (n = 101) or colon resection (n = 98) based on a computer-generated, center-stratified block randomization. All patients with fecal peritonitis (15 patients in the laparoscopic peritoneal lavage group vs 13 in the colon resection group) underwent colon resection. Patients with a pathology requiring treatment beyond that necessary for perforated diverticulitis (12 in the laparoscopic lavage group vs 13 in the colon resection group) were also excluded from the protocol operations and treated as required for the pathology encountered. MAIN OUTCOMES AND MEASURES: The primary outcome was severe postoperative complications (Clavien-Dindo score >IIIa) within 90 days. Secondary outcomes included other postoperative complications, reoperations, length of operating time, length of postoperative hospital stay, and quality of life. RESULTS: The primary outcome was observed in 31 of 101 patients (30.7%) in the laparoscopic lavage group and 25 of 96 patients (26.0%) in the colon resection group (difference, 4.7% [95% CI, −7.9% to 17.0%]; P = .53). Mortality at 90 days did not significantly differ between the laparoscopic lavage group (14 patients [13.9%]) and the colon resection group (11 patients [11.5%]; difference, 2.4% [95% CI, −7.2% to 11.9%]; P = .67). The reoperation rate was significantly higher in the laparoscopic lavage group (15 of 74 patients [20.3%]) than in the colon resection group (4 of 70 patients [5.7%]; difference, 14.6% [95% CI, 3.5% to 25.6%]; P = .01)