Laparoscopic Peritoneal Lavage Research Articles

Evaluation of laparoscopic peritoneal lavage for perforated diverticulitis: a national registry-based study.

Laparoscopic lavage (LPL) has been suggested for treatment of non-feculent perforated diverticulitis. In this observational study, the surgical treatment of diverticular disease in Sweden outside prospective trials was investigated. This population-based study used the National Patient Register to identify all patients in Sweden with emergency admissions for diverticular disease, as defined by ICD codes from July 2014 to December 2020. Demographics, surgical procedures and outcomes were assessed. In addition, register data since 1997 were retrieved to assess co-morbidities, previous abdominal surgeries, and previous admissions for diverticular disease. Among 47 294 patients with emergency hospital admission, 2035 underwent LPL (427 patients) or sigmoid resection (SR, 1608 patients) for diverticular disease. The mean follow-up was 30.8 months. Patients selected for LPL were younger, healthier and with less previous abdominal surgery for diverticular disease than those in the SR group (P < 0.01). LPL was associated with shorter postoperative hospital stay (mean 9.4 versus 14.9 days, P < 0.001) and lower 30-day mortality (3.5% versus 8.7%, P < 0.001). Diverticular disease-associated subsequent surgery was more common in the SR group than the LPL group except during the first year (P < 0.001). LPL had a lower mortality rate during the study period (stratified HR 0.70, 95% c.i. 0.53-0.92, P = 0.023). Laparoscopic lavage constitutes a safe alternative to sigmoid resection for selected patients judged clinically to require surgery.

Usefulness of Intraductal Placement of a Dumbbell-Shaped Fully Covered Self-Expandable Metal Stent for Post-Cholecystectomy Bile Leaks.

Background and aims: In the treatment of post-cholecystectomy bile leaks, endoscopic naso-biliary drainage (ENBD) or biliary stenting using plastic stents is the standard of care. Fully covered self-expandable metal stent (FCSEMS) placement across the sphincter of Oddi is considered a salvage therapy for refractory cases, but pancreatitis and migration are the major concerns. Intraductal placement of a dumbbell-shaped FCSEMS (D-SEMS) could avoid these drawbacks of FCMSESs. In this retrospective study, we investigated the usefulness of intraductal placement of the D-SEMS for post-cholecystectomy bile leaks. Methods: Six patients who underwent intraductal placement of the D-SEMS for post-cholecystectomy bile leaks were enrolled. This method was performed as initial treatment in three patients and as salvage treatment in three ENBD refractory cases. Results: Technical and clinical successes were obtained in 6 (100%) patients and 5 (83%) patients, respectively. One clinically unsuccessful patient required laparoscopic peritoneal lavage. The early adverse event was one case of mild pancreatitis (17%). The median duration of the D-SEMS indwelling was 61 days (42-606 days) with no migration cases, all of which were successfully removed. The median follow-up after index ERCP was 761 (range: 161-1392) days with no cases of recurrent bile leaks. Conclusions: Intraductal placement of the D-SEMS for post-cholecystectomy bile leaks might be safe and effective even in refractory cases.

Laparoscopic lavage for Hinchey III perforated diverticulitis: factors for treatment failure in two randomized clinical trials.

The Scandinavian Diverticulitis (SCANDIV) trial and the LOLA arm of the LADIES trial randomized patients with Hinchey III perforated diverticulitis to laparoscopic peritoneal lavage or sigmoid resection. The aim of this analysis was to identify risk factors for treatment failure in patients with Hinchey III perforated diverticulitis. This was a post hoc analysis of the SCANDIV trial and LOLA arm. Treatment failure was defined as morbidity requiring general anaesthesia (Clavien-Dindo grade IIIb or higher) within 90 days. Age, sex, BMI, ASA fitness grade, smoking status, previous episodes of diverticulitis, previous abdominal surgery, time to surgery, and surgical competence were all tested in univariable and multivariable logistic regression analyses using an interaction variable. The pooled analysis included 222 patients randomized to laparoscopic lavage and primary resection (116 and 106 patients respectively). Univariable analysis found ASA grade to be associated with advanced morbidity in both groups, and the following factors in the laparoscopic lavage group: smoking, corticosteroid use, and BMI. Significant factors for laparoscopic lavage morbidity in multivariable analysis were smoking (OR 7.05, 95 per cent c.i. 2.07 to 23.98; P = 0.002) and corticosteroid use (OR 6.02, 1.54 to 23.51; P = 0.010). Active smoking status and corticosteroid use were risk factors for laparoscopic lavage treatment failure (advanced morbidity) in patients with perforated diverticulitis.

Long-term outcomes and risk factors for diverticulitis recurrence after a successful laparoscopic peritoneal lavage in Hinchey III peritonitis.

Recently, treatment of Hinchey III diverticulitis by laparoscopic peritoneal lavage has been questioned. Moreover, long-term outcomes have been scarcely reported. Primary outcome was to determine the recurrence rate of diverticulitis after a successful laparoscopic peritoneal lavage in Hinchey III diverticulitis. Secondary outcomes were identification of associated risk factors for recurrence and elective sigmoidectomy rate. A retrospective cohort study in a tertiary referral center was performed. Patients with Hinchey III diverticulitis who underwent a successful laparoscopic peritoneal lavage between June 2006 and December 2019 were eligible. Diverticulitis recurrence was analyzed according to the Kaplan-Meier and log-rank test, censoring for death, loss of follow-up, or elective sigmoid resection in the absence of recurrence. Risk factors for recurrence were identified using Cox regression analysis. Sixty-nine patients had a successful laparoscopic peritoneal lavage (mean age: 63years; 53.6% women). Four patients had an elective sigmoid resection without recurrences. Recurrence rate was 42% (n = 29) after a median follow-up of 63months. The cumulative global recurrence at 1, 3, and 5years was 30% (95% CI, 20-43%), 37.5% (95% CI, 27-51%), and 48.9% (95% CI, 36-64%), respectively. Smoking (HR, 2.87; 95% CI, 1.22-6.5; p = 0.016) and episodes of diverticulitis prior to laparoscopic peritoneal lavage (HR, 5.2; 95% CI, 2.11-12.81; p < 0.001) were independently associated with an increased risk of recurrence. Diverticulitis recurrence after a successful laparoscopic peritoneal lavage is high, decreasing after the first year of follow-up. Smoking and previous episodes of acute diverticulitis independently increase the risk of new episodes of diverticulitis.

Laparoscopic peritoneal lavage versus sigmoidectomy for perforated diverticulitis with purulent peritonitis: three-year follow-up of the randomised LOLA trial

BackgroundThis study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.MethodsWithin the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.ResultsLong-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.ConclusionLong-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.Graphical abstract

State-of-the-art surgery for sigmoid diverticulitis

SummaryBackgroundIn the last two decades, there has been a Copernican revolution in the decision-making for the treatment of Diverticular Disease.PurposeThis article provides a report on the state-of-the-art of surgery for sigmoid diverticulitis.ConclusionAcute diverticulitis is the most common reason for colonic resection after cancer; in the last decade, the indication for surgical resection has become more and more infrequent also in emergency. Currently, emergency surgery is seldom indicated, mostly for severe abdominal infective complications. Nowadays, uncomplicated diverticulitis is the most frequent presentation of diverticular disease and it is usually approached with a conservative medical treatment. Non-Operative Management may be considered also for complicated diverticulitis with abdominal abscess. At present, there is consensus among experts that the hemodynamic response to the initial fluid resuscitation should guide the emergency surgical approach to patients with severe sepsis or septic shock. In hemodynamically stable patients, a laparoscopic approach is the first choice, and surgeons with advanced laparoscopic skills report advantages in terms of lower postoperative complication rates. At the moment, the so-called Hartmann’s procedure is only indicated in severe generalized peritonitis with metabolic derangement or in severely ill patients. Some authors suggested laparoscopic peritoneal lavage as a bridge to surgery or also as a definitive treatment without colonic resection in selected patients. In case of hemodynamic instability not responding to fluid resuscitation, an initial damage control surgery seems to be more attractive than a Hartmann’s procedure, and it is associated with a high rate of primary anastomosis.

Management of postoperative complications after laparoscopic left hemicolectomy: an approach in modern times after incorporation of indocyanine green and full mobilization of the splenic flexure.

The aim of this study was to report our experience in the management of complications after laparoscopic left hemicolectomy (LLH) after the incorporation in our clinical practice of intraoperative indocyanine green (ICG) fluorescence angiography (FA). In our last period after incorporation of ICG-FA, 277 unselected consecutive patients underwent laparoscopic colorectal surgery with this technology. Ninety-seven (35%) right hemicolectomy, 19 segmental resection of the splenic flexure (6.9%), 54 anterior resection of the rectum (19.5%) and 107 LLH (38.6%) were performed. Complications were graded according to Clavien-Dindo classification, and anastomotic leakages (AL) were graded according to Clavien-Dindo classification and to International Study Group of Rectal Cancer (ISGRC) classification. Eight surgical and one medical complications (8.4%) were observed. Two AL occurred (1.9%). One drained spontaneously by drainage placed intraoperatively (Clavien-Dindo I, ISGRC A) and one treated by laparoscopic peritoneal lavage, leakage suture and ileostomy (Clavien-Dindo III-b, ISGRC C). Other complications were: wound infection (Clavien-Dindo II) (2); postoperative anemia caused by rectorrhagia (Clavien-Dindo II) (2); pelvic abscess between bladder and uterus (Clavien-Dindo III-a) (1); hemoperitoneum secondary to inferior mesenteric artery bleeding treated with peritoneal lavage and hemostasis (Clavien-Dindo III-b) (1); atrial fibrillation (Clavien-Dindo II) (1). All complications have been resolved. The complication rate after LLH after the incorporation of ICG-FA is low, since the number of AL have dramatically decreased in comparison to our previous experience. The management of these patients proved to be safe and effective due to in all cases the complication has been resolved. Further studies are required to standardize the management of these patients.

Laparoscopic Lavage in the Management of Hinchey III/IV Diverticulitis.

Diverticulitis manifestations may cover a spectrum of mild local inflammation to diffuse feculent peritonitis. Up to 35% of patients presenting with diverticulitis will have purulent (Hinchey grade III) or feculent (Hinchey grade IV) contamination of the abdomen, with a high-associated morbidity and mortality. Surgical management may involve segmental resection with or without restoration of bowel continuity. However, emergency resection for diverticulitis can be associated with high mortality rates, as well as low stoma reversal rates at 1 year. Therefore, laparoscopic peritoneal lavage has been proposed for use in selected patients with purulent peritonitis. The topic of laparoscopic peritoneal lavage for the treatment of perforated diverticulitis in the literature has been controversial. Our review of the recent data show that laparoscopic lavage may be safe and feasible in select patients with similar rates of mortality and major morbidity. There is, however, a concern regarding an associated higher rate of postoperative abscess and early reintervention risk.

Peritoneal Lavage Cytology Following Neoadjuvant Chemotherapy for Gastric Adenocarcinoma: Low Yield in Detecting Peritoneal Metastases.

Peritoneal lavage cytology (PLC) can detect advanced disease in gastric adenocarcinoma (GC); however, routine practice remains controversial. Furthermore, the effect of neoadjuvant chemotherapy (NAC) on cytological detection of carcinomatosis is unknown. Using a 2012-2020 prospective database, we retrospectively reviewed patients with GC who underwent NAC followed by a staging laparoscopic peritoneal lavage with or without biopsy of suspicious peritoneal nodules. PLC results were considered discordant if they did not align with the peritoneal biopsy results. Patients with benign peritoneal cytology (Cyt-) or biopsy results who had postoperative time to carcinomatosis of <6months were considered to have diagnostic failure of peritoneal lavage. Fifty-five patients with GC who underwent NAC followed by staging diagnostic laparoscopy with peritoneal lavage were identified. The majority of the patients in the cohort had Cyt- lavage (89.1%). Of the patients who underwent resection, 76.1% had T3 or greater disease on final pathology and 66% had nodal metastases. In 23 patients (41.8%) who had both peritoneal lavage and biopsy, four cases (17.4%) had discordant results. Diagnostic failure rate was 20% at 6months and 42.2% at 12months. The median time to carcinomatosis in patients who were Cyt- or biopsy negative was 7.9months. PLC after NAC has a high diagnostic failure rate and inaccurately predicts carcinomatosis in 20% of patients with GC. Novel methods for identifying cytology positive GC after NAC should also be developed and evaluated, since the risk of peritoneal dissemination is high.

Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis

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. To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis. 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. Patients were assigned to undergo laparoscopic peritoneal lavage or colon resection based on computer-generated, center-stratified block randomization. The primary outcome was severe complications within 5 years. Secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life. 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. 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. ClinicalTrials.gov Identifier: NCT01047462.

Using Video to Improve Understanding of Anatomy for Clinical Medical Students

Study Objective Surgical videos allow students to observe cases prior to entering the operating room, thereby improving the intra-operative learning experience for both the student and the educator. Minimally invasive surgery is especially suited to this modality of teaching. We created an interactive video series that allows students to better understand the elements of common gynecologic procedures, including laparoscopic salpingectomy-oophorectomy. Design This video on laparoscopic salpingectomy-oophorectomy was created as part of a 4-part series demonstrating common gynecologic procedures. The video reviews the indications for the procedure, basic tools used, port-site placement, and surgical footage of the laparoscopic entry, surveillance, peritoneal lavage, and removal of the ovary and fallopian tube to help students become more familiar with the different elements of the case. Setting The video was produced by the UCSF Educational Department to be used by third-year medical students during their OB-GYN rotation at an academic teaching hospital. Patients or Participants Videos were created for clinical medical students and narrated by senior medical students. Interventions The videos were shared on the OB-GYN rotation website. Following completion of the video, students were asked to complete a short anonymous survey about the effectiveness of the videos. Measurements and Main Results Of the 29 students who participated in the survey, 27 (93.1%) felt that they were significantly or somewhat more prepared to participate in the operating room after watching these videos compared to prior. Students found that the videos were either extremely or very useful for learning gynecologic anatomy (n=23, 79.3%) or learning the steps of surgical procedures (n=24, 82.8%), and 23 students (79.3%) were extremely or very willing to recommend these videos to their classmates. Conclusion Surgical film for medical students can improve the understanding and comfort in the operating during clinical rotations and enhance the clinical clerkship experience.

Abstract 4355: Different strategies for peritoneal lavage cytology testing in the staging of gastric cancer: A cost-effectiveness analysis

Abstract Background &amp; Aims: The positive peritoneal cytology (PCY) indicates metastasis disease in patients with gastric cancer (GC); thus, the cytology testing is directly related to subsequent treatments, patients' prognoses, and medical costs. However, the cost-effectiveness of PCY testing remains unclear. We aim to evaluate the cost-effectiveness of PCY testing by comparing two active testing strategies of a guideline-recommended intraoperative laparoscopic peritoneal lavage (ILPL) and a newly proposed preoperative percutaneous peritoneal lavage (PPPL), and a third strategy of exploratory laparotomy with no cytology testing (ELNC) among GC patients. Methods: We developed a decision-analytic Markov model to compare the cost-effectiveness of the above three strategies for a hypothetical cohort of GC patients with curative intent after initial imaging, from the perspective of Chinese society. Quality-adjusted life-years (QALYs), transition probabilities and costs were modeled using data mainly from published literature. We performed base case analysis and measured incremental cost-effectiveness ratios (ICERs) for various strategies, which were compared to a willingness-to-pay (WTP) threshold that was set to a three-fold of Chinese gross domestic product (GDP) per capita, $29,313/QALY gained. Furthermore, we conducted both one-way and probabilistic sensitivity analyses to investigate the model's robustness. Results: In the base case analysis, we found that ELNC was dominated (i.e., more expensive and less effective) by PPPL and ILPL. ILPL was the most cost-effective method, with an ICER of US $16,673/QALY compared to PPPL. One-way sensitivity analyses demonstrated that the exploratory laparotomy mortality following ILPL and the peritoneal cytology prevalence were the only two influential parameters within their plausible range when assessing the cost-effectiveness of PPPL and ILPL. In the probabilistic sensitivity analyses, the probability of ILPL being cost-effective was 71.3% at the WTP threshold of $29,313/QALY; however, PPPL was more likely to be cost-effective when the willing-to-pay (WTP) threshold was below $17,020/QALY gained. Conclusion: Cytology testing for GC staging through either ILPL or PPPL dominated ELNC in patients with curative intent. Moreover, ILPL was the most cost-effective modality at the current WTP threshold, while PPPL could potentially be cost-effective in lower-income areas. Citation Format: Qifei He, Jinyi Zhu, Anqiang Wang, Xia Li, Zhaode Bu, Jiafu Ji. Different strategies for peritoneal lavage cytology testing in the staging of gastric cancer: A cost-effectiveness analysis [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4355.

Is Ghost Ileostomy an Effective Method in Various Indications for Colorectal Surgery?

Diverting stoma has many complications and requires another operation. Ghost ileostomy is an option for occasional cases. We aimed to present the clinical data and early postoperative outcomes of our patients who had undergone ghost ileostomy. Ghost ileostomy was performed in 58 patients, depending on the level of the anastomosis, together with the experience and intraoperative decision of the surgeon. The patients were evaluated in terms of comorbidities, type of colorectal disease, and postoperative complications. Thirty-eight patients were male, the mean age was 59 ± 9 years, and the mean body mass index was 27 ± 5 kg/m2. Forty-six patients in whom a ghost ileostomy procedure was performed had sigmoid colon or proximal/middle rectal cancer, whereas eight patients had sigmoid diverticulitis, and four patients had ulcerative colitis. Anastomotic leakage was identified in 3 (5.1%) patients. In one patient, laparoscopic peritoneal lavage was performed, and ghost ileostomy was converted to diverting stoma, whereas in the other two patients, ghost ileostomy was converted to diverting stoma under local anesthesia. Ghost ileostomy can easily be converted to diverting stoma in some patients with no need for general anesthesia to reduce the morbidity of anastomotic leakage. With this method in selected patients, it is possible to avoid diverting stoma and unwanted complications of ileostomy.

Emergency Surgery in Acute Diverticulitis: A Systematic Review.

Acute diverticulitis is a common disease with public health significance. Many studies with a high level of evidence have been published recently on the surgical management of acute diverticulitis. The aim of this systematic review was to define the accurate surgical management of acute diverticulitis. Medline, Embase, and the Cochrane Library were sources used. One reviewer conducted a systematic study with combinations of key words for the disease and the surgical procedure. Additional studies were searched in the reference lists of all included articles. The results of the systematic review were submitted to a working group composed of 13 practitioners. All of the conclusions were obtained by full consensus and validated by an external committee. The interventions assessed were laparoscopic peritoneal lavage, primary resection with anastomosis with or without ileostomy, and the Hartmann procedure, with either a laparoscopic or an open approach. Morbidity, mortality, long-term stoma rates, and quality of life were measured. Seventy-one articles were included. Five guidelines were retrieved, along with 4 meta-analyses, 14 systematic reviews, and 5 randomized controlled trials that generated 8 publications, all with a low risk of bias, except for blinding. Laparoscopic peritoneal lavage showed concerning results of deep abscesses and unplanned reoperations. Studies on Hinchey III/IV diverticulitis showed similar morbidity and mortality. A reduced length of stay with Hartmann procedure compared with primary resection with anastomosis was reported in the short term, and in the long term, more definite stoma along with poorer quality of life was reported with Hartmann procedure. No high-quality data were found to support the laparoscopic approach. Trials specifically assessing Hinchey IV diverticulitis have not yet been completed. High-quality studies showed that laparoscopic peritoneal lavage was associated with an increased morbidity and that Hartmann procedure was associated with poorer long-term outcomes than primary resection with anastomosis with ileostomy, but Hartmann procedure is still acceptable, especially in high-risk patients.

LAPAROSCOPIC PERITONEAL LAVAGE IN TREATMENT OF PURULENT AND FECAL PERITONITIS AS COMPLICATIONS OF THE COLONIC DIVERTICULAR DISEASE

Summary. The incidence of diverticular colon disease has increased significantly. Complications are found in 40-42 % of patients, the frequency of perforation of the diverticulum is about 3.3 %.&#x0D; Materials and methods. The article presents the results of the treatment of 129 patients who were operated on for peritonitis complicated forms of diverticular colon disease .&#x0D; Research results. The study found that surgical treatment of patients with complication in the Hinchey III-IV stage is best performed by the method of laparoscopic peritoneal lavage.&#x0D; Discussion of research results. The laparoscopic approach has demonstrated a number of advantages: a smaller wound size, a shorter period of disability, an early recovery of enteral nutrition, and a shorter hospital stay.&#x0D; Conclusions. Performing laparoscopic peritoneal lavage in patients with perforated diverticulitis complicated by purulent peritonitis is an alternative to Hartmann surgery or bowel resection with primary anastomosis.

Hot Topics in Surgical Management of Acute Diverticulitiss.

In this session different issues for the surgical management of diverticular disease DD) were considered. The first session debated about the antibiotic treatment for acute uncomplicated diverticulitis (AUD), and supports their use selectively rather than routinely in patients with AUD. The second session discussed the best surgical treatment for those patients. Open approach is a valid choice especially in acute setting, while the laparoscopic approach should be individualised according to the level of skills of the surgeon and the risk factors of the patient (such as obesity and state of health at the time of the operation). The third session debated about the peritoneal lavage and drainage, which is still a safe surgical procedure. However, it requires longer follow-up and results of other trials to draw an adequate conclusion. The last session covers the current surgical certainties in managing complicated DD: 1. urgent colectomy has higher mortality in immune-compromised patients, while in elective surgery is comparable with other populations; 2. laparoscopic peritoneal lavage (LPL) should be the choice in young/fit patients; 3. elective resection is safer in an inflammation free interval; 4. laparoscopic resection shows advantages in several outcomes (such as post-operative morbidity and lower stoma and re-operation rate); 5. in Hinchey III/fecal peritonitis, primary sigmoid resection and anastomosis (open or laparoscopic) could be proposed in young/ fit patient; 6. in case of emergency surgery, Hartmann procedure (open or laparoscopic) must be considered in critically ill/unstable patient.

Sump syndrome following choledochoduodenostomy

Sump syndrome is a rare long-term complication of side-to-side choledochoduodenostomy (CDD), a common surgical procedure in patients with biliary tract disease in the era before endoscopic retrograde cholangiopancreatography (ERCP). In the setting of a side-to-side CDD, the bile does not drain through the distal common bile duct (CBD) anymore. Therefore, the part of the CBD distal from the CDD anastomosis consequently transforms into a poorly drained reservoir, making this so-called “sump” prone to accumulation of debris. These patients are prone to cholangitis. We present a case of a 56-year-old woman with a history of side-to-side CDD 8 years ago who presented with cholangitis and ruptured liver abscess. Sump syndrome was diagnosed by magnetic resonance cholangiopancreatography. Laparoscopic peritoneal lavage was done for the ruptured liver abscess. After endoscopic debris removal and antibiotic treatment, the patient recovered well. In the ERCP era, little is known about CDD and its long-term complications. Therefore, this report provides an opportunity to refresh the knowledge and raise awareness of this syndrome.

Лапароскопія у лікуванні пацієнтів з ускладненою дивертикулярною хворобою товстої кишки

SummaryPurpose – to study the results of treatment of colon diverticular disease bylaparoscopy.Materials and methods. During 2004–2020 the treatment of 221 patients hospitalized inthe Department of Abdominal, Emergency Surgery and Coloproctology Clinic of the MilitaryMedical Clinical Center of the Southern Region of Odessa was analysed. Patients underwent263 surgeries for diverticular colon disease (DCD) and its complications. There were 118 men(53.4%) and 103 women (46.6%). Complicated forms of DCD were diagnosed in 186 (84.5%)patients. 164 (62.4%) operations were performed as an emergency, of which 102 (61.7%) wereperformed using video endoscopic equipment.Results and discussion. 49 patients were treated in 2 stages. At the first stage,during the hospitalization of patients with urgent indications with a clinical picture ofacute abdomen, radical surgery was not performed. The purpose of this stage was tosave live and stabilize the patient’s condition. Preference was given to minimallyinvasive operations (diagnostic laparoscopy, laparoscopic peritoneal lavage,sigmostomy). In the second stage, radical interventions were performed in the intervalsfrom 9 days to 6 months after the first operation including left hemicolectomy orsigmoidectomy. In 19 patients, radical operations of the second stage were performedwithout discharge from the hospital after first stage treatment.Conclusions. 1. Surgical treatment of patients with complicated DCD is better tocarry out using video endoscopic equipment, as evidenced by the shorter duration of theoperation (73.4±6.2) minutes compared with open surgery – (118.4±7.3) minutes andless bed-day – (6.1± 0.7) days compared to open transactions – (11.3±1.2) days.2. Repeated planned radical operations on DCD is better to perform laparoscopically, as evidenced by fewer complications (6.7% compared to open operations –10.1%)3. Two-stage treatment of complicated DCD is considered the best approach if thesecond stage (left hemicolectomy) is performed routinely within 10 days to 6 monthsafter surgery for urgent indications.

Is the Failure of Laparoscopic Peritoneal Lavage Predictable in Hinchey III Diverticulitis Management?

Laparoscopic peritoneal lavage is an alternative to sigmoid resection in Hinchey III diverticulitis (generalized purulent peritonitis). The main limitation of laparoscopic peritoneal lavage is the higher rate of reoperation for persistent sepsis in comparison with sigmoid resection. The purpose of the current study was to identify risk factors for laparoscopic peritoneal lavage failure in patients who have Hinchey III diverticulitis. This was a retrospective multicenter study. The study was conducted in 3 clinical sites in France. From 2006 to 2015, all consecutive patients undergoing emergent surgery for diverticulitis were reviewed. All patients operated on with laparoscopic peritoneal lavage for laparoscopically confirmed Hinchey III diverticulitis were included. The main outcome was laparoscopic peritoneal lavage failure, defined as reoperation or death at 30 postoperative days. A series of 71 patients (43 men, mean age 58 ± 15 years) were operated on with laparoscopic peritoneal lavage for Hinchey III diverticulitis. Laparoscopic peritoneal lavage failed in 14 (20%) of them: 1 died and 13 underwent reoperations. No major complication (Dindo-Clavien score ≥3) occurred after reoperation. Immunosuppressive drugs (p = 0.01) and ASA grade ≥3 (p = 0.02) were associated with laparoscopic peritoneal lavage failure after univariate analysis. Multivariate analysis identified only immunosuppressive drug intake (steroids or chemotherapy for cancer) as an independent predictive factor. Mean length of stay was 14.9 days (5-67). At the end of the 30 first postoperative days, 12 (17%) patients had a stoma. The study was limited by its retrospective nature and the small size of the cohort. Our results highlight immunosuppressive drug intake as a major risk factor for laparoscopic peritoneal lavage failure in patients who have Hinchey III diverticulitis. Immunosuppression and severe comorbidities (ASA ≥3) should be considered when selecting a surgical option in patients with Hinchey III diverticulitis. See Video Abstract at http://links.lww.com/DCR/A423.

Complicated Diverticular Disease: Position Statement on Outpatient Management, Hartmann's Procedure, Laparoscopic Peritoneal Lavage and Laparoscopic Approach. Consensus Document of the Spanish Association of Coloproctology and the Coloproctology Section of the Spanish Association of Surgeons

The Spanish Association of Coloproctology (AECP) and the Coloproctology Section of the Spanish Association of Surgeons (AEC), propose this consensus document about complicated diverticular disease that could be used for decision-making. Outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage, and the role of a laparoscopic approach in colonic resection are exposed.