Laparoscopic Lavage in the Management of Perforated Diverticulitis: a Contemporary Meta-analysis

Abstract

ImportancePerforated diverticulitis carries the risk of significant comorbidity and mortality. Although colon resection provides adequate source control, the procedure itself carries morbidity, as well as later stoma reversal procedures. The effectiveness of laparoscopic lavage to treat perforated diverticulitis remains unclear. ObjectiveWe aimed to conduct a meta-analysis to evaluate current studies comparing laparoscopic lavage with colon resection in cases of perforated diverticulitis for the effectiveness in source control, without the need for subsequent interventions, stoma formation, and death. Data SourcesElectronic database searches were conducted using EMBASE, Pubmed, CINAHL, Cochrane databases, and clinicaltrials.gov following PRISMA guidelines. Study SelectionRandomized controlled trials (RCTs) were included that compared laparoscopic lavage against colon resection for perforated diverticulitis. Data Extraction and SynthesisRisk of bias in RCT’s was assessed the Cochrane Assessment of Bias risk tool and Jadad scale. A meta-analysis was performed using random-effects risk ratios (RR) and 95% confidence intervals (CI). Main OutcomeOutcome measures included the total rate of reoperation, rate of reoperation for infection, need for subsequent percutaneous drainage, stoma formation, and mortality rate within 90 days. ResultsThree eligible randomized controlled studies were identified, with a combined total of 372 patients. Laparoscopic lavage carried an increased rate of total reoperations (RR 2.07; CI 1.12–3.84; p = 0.021) and an increased rate of reoperation for infection (RR 5.56; CI 1.97–15.69; p = 0.001) compared with colon resection. In addition, laparoscopic lavage increased the rate of subsequent percutaneous drainage (RR 6.54; CI 1.77–24.16; p = 0.005) compared with colon resection, but a lesser risk of stoma formation within 90 days (RR 0.18; CI 0.12–0.27; p < 0.001). No difference in mortality rate was observed between treatments (RR 1.03; CI 0.45–2.34; p = 0.950). ConclusionDespite decreased rates of stoma formation and equivalent mortality rates as compared with colon resection, laparoscopic lavage for Hinchey III diverticulitis fails to completely control the source of infection. Our data show that laparoscopic lavage is associated with increased rates of total reoperations, increased rates of reoperation for infections, and need for subsequent percutaneous drainage.