CURRENT STATUS

W. Donald Buie, M.S., Editor

Acute Complicated Diverticulitis Managed byLaparoscopic Lavage

Mahdi Alamili, M.S. • Ismail Gogenur, M.D. • Jacob Rosenberg, M.D., D.Sc.

Department of Surgery D, Herlev Hospital, Herlev, Denmark

PURPOSE: The classic surgical treatment of acutecomplicated sigmoid diverticulitis with peritonitis isoften a two-stage operation with colon resection and atemporary stoma. This approach is associated with highmortality and morbidity and the reversal of the stoma isin many cases not performed because of concurrentdiseases and age. Recently, several studies haveexperimented with laparoscopic lavage as a treatment ofacute complicated diverticulitis. The aim of this reviewwas to give an overview of the literature for this newapproach and to determine the safety compared withHartmann’s procedure for patients with acutecomplicated sigmoid diverticulitis.

METHODS: A PubMed search was performed forpublications between 1990 and May 2008. The termsacute, perforated, diverticulitis, lavage, drainage, andlaparoscopy were used in combination. The EMBASEand Cochrane databases were also searched.

RESULTS: Eight studies met the inclusion criteria andreported 213 patients with acute complicateddiverticulitis managed by laparoscopic lavage. None ofthese studies were randomized. The patients’ mean agewas 59 years and most patients had Hinchey Grade 3disease. All patients were treated with antibiotics andlaparoscopic lavage. Conversion to laparotomy was madein six (3%) patients and the mean hospital stay was ninedays. Ten percent of the patients had complications.During the mean follow-up of 38 months, 38% of the

patients underwent elective sigmoid resection withprimary anastomosis.

CONCLUSION: Primary laparoscopic lavage forcomplicated diverticulitis may be a promising alternativeto more radical surgery in selected patients. Largerstudies have to be made before clinical recommendationscan be given.

KEY WORDS: Acute/perforated diverticulitis;Lavage/drainage; Laparoscopy

The prevalence of diverticular disease of the sigmoidcolon has increased over the past century.1 One-third of the Western population older than 50 years

and more than 60% of the population older than 70 yearsare affected.2 Approximately 20% of patients with divertic-ulosis develop diverticulitis.3

The management of diverticulitis depends on the ex-tent of the disease (Table 1).4 For patients with compli-cated diverticulitis with localized abscess (Hinchey Grade2) percutaneous drainage seems to be an effective initialtherapeutic approach.5– 8 The emergency surgical man-agement has changed in the past 20 years for patients withgeneralized peritonitis (Hinchey Grades 3 and 4), but theideal treatment remains controversial. The standard forthese patients may be a one-stage, two-stage, or three-stageprocedure. The procedure most often used in Denmark is aHartmann’s procedure (HP) where the diseased sigmoidcolon is resected and the oral colon is placed as a temporaryor permanent stoma. However, this procedure involves amajor laparotomy with significant morbidity and mortal-ity and, most of the patients never undergo colostomy re-versal. The controversial management, primary resectionand anastomosis, emerged as an alternative to HP, but theoutcomes remain suboptimal with an overall morbidityrate of 29%9 and mortality rates of 10 to 20%.10

Address of correspondence: Mahdi Alamili, M.S., Department of Sur-gery D, Herlev Hospital, 2730 Herlev, Denmark. E-mail: mahdi_alamili@hotmail.com

Dis Colon Rectum 2009; 52: 1345–1349DOI: 10.1007/DCR.0b013e3181a0da34©The ASCRS 2009

DISEASES OF THE COLON & RECTUM VOLUME 52: 7 (2009) 1345

In recent years published studies have shown that pa-tients with acute complicated diverticulitis with peritonitismay be successfully managed by laparoscopic lavage with-out sigmoid resection in the acute setting. In this system-atic review we present the current literature where laparo-scopic treatment for acute complicated diverticulitis withperitonitis has been used.

METHODS

A systematic literature search was performed to identify allEnglish-language publications where laparoscopic treat-ment for acute complicated diverticulitis with peritonitishad been reported. The search was made in the followingdatabases: MEDLINE, EMBASE, and The Cochrane Li-brary. The search period was 1990 to May 2008. The searchconsisted of the following key word combinations: acute/perforated diverticulitis AND lavage/drainage AND lapa-roscopy. Studies where laparoscopic lavage as treatmentfor complicated diverticulitis, including purulent or fecalperitonitis, were used. Studies with less than five patientswere not included in the review. Reference lists from theincluded articles were manually checked and additionalstudies were included when appropriate.

RESULTS

The database search gave seven studies where laparoscopiclavage had been used in the treatment for complicated di-verticulitis.11–17 An additional study was found in themanual search of the reference lists.18 No related Cochrane

review relevant to this subject was found. Thus, the totalnumber of studies found was eight. None of the studieswere controlled or randomized. Only one study was pro-spective16 and the other seven were retrospective.11–15,18

Data concerning the number of patients in the studies, themean age of the patients, the Hinchey classification basedon the operative findings, the preoperative American So-ciety of Anesthesiologists’ (ASA) grade, the mean length ofhospital stay, the number of patients converted to laparot-omy (during the primary operation and in the immediatepostoperative period caused by failure of laparoscopic la-vage), the rates and the number of patients treated withresection after the primary laparoscopic lavage, the mor-bidity, and the mortality can be seen in Tables 2 and 3.

The inclusion period for the studies was 3 years in onestudy,18 4 years in two studies,11,14 5 years in two stud-ies,12,17 7 years in two studies,13,16 and 15 years in onestudy.15 The total number of patients was 213 with a meanage of 59 years; most of the patients were in ASA Class 3.

The inclusion criterion was surgically confirmed acutecomplicated diverticulitis with localized or generalizedperitonitis. The diagnosis was based on clinical signs indi-cating perforated diverticulitis with supplementary com-puted tomography (CT) or ultrasound (US). Patientswithout peritonitis were excluded. Patients with acute di-verticulitis that responded to conservative treatment or ra-diologic drainage were excluded in all studies. Two studiesexcluded patients with fecal peritonitis,13,16 one study ex-cluded patients with spontaneously visible perforation andpatients with extensive generalized peritonitis13, and onestudy excluded a patient with rheumatoid arthritis, whowas taking corticosteroids.18

All patients in the eight studies were classified accord-ing to the Hinchey classification based on the opera-tive findings. The majority of the patients were HincheyGrade 3.

Emergency SurgeryThe surgical treatment in the emergency surgical settingconsisted of laparoscopic peritoneal lavage, and drains

TABLE 1. The Hinchey classification4

Grade Definition

I Diverticulitis with a phlegmonous or a pericolic abscess2 Diverticulitis with a pelvic abscess or a retroperitoneal

abscess3 Diverticulitis with diffuse/generalized purulent peritonitis4 Diverticulitis with fecal peritonitis

TABLE 2. Patient demographics

Authors Year CountryNo. of

patientsAge

mean

Hinchey classification

ASA2 3 4

O’Sullivan et al.18. 1996 Ireland 8 57 – 8 – –Faranda et al. .11 2000 France 18 54 – 16 2 2–3Da Rold et al.12 2004 Italy 7 65 1 6 – –Mutter et al.13 2006 France 10 60 (5)a (5)a – I–3Taylor et al.14 2006 Australia 14 57 2 10 2 3–5Myers et al.16 2008 Ireland 92 63 25 67 – 2–5Franklin et al.15 2008 USA 40 60 5 32 3 I–4Bretagnol et al.17 2008 France 24 55 5 18 1 2–3Total – – 213 59 43 162 8 –

ASA � American Society of Anesthesiologists’ risk classification.aUnspecified classification of the 10 patients in this study.

1346 ALAMILI ET AL: COMPLICATED DIVERTICULITIS MANAGED BY LAPAROSCOPIC LAVAGE

were placed near the affected colon. No resection of thecolon was made in the acute setting and colostomy wasnever performed (Table 3). Intravenous antibiotics andliquids were administered in the perioperative period andthe choice of antibiotics differed between the studies.

Conversion to laparotomy was necessary in four of theeight studies and was performed in six patients, resulting inan overall conversion rate of 3%. Intestinal obstructionmaking insufflation impossible was the reason for conver-sion in one patient.12 Reoperations with laparotomy wereperformed in five patients. One patient had peritonitisthree weeks after primary laparoscopic lavage and, becauseof the presence of local adhesions, the procedure had to bedone open.13 One patient with Hinchey Grade 2 diseasehad a laparotomy and HP after a failure in the laparoscopicintervention because of a pelvic abscess that did not resolveafter percutaneous drainage.16 In one study three patientshad a laparotomy: an 86-year-old and a 78-year-old pa-tient, both with fecal peritonitis (Hinchey Grade 4), under-went Hartmann’s procedure on the fifth and on the secondpostoperative day, respectively, and a 39-year-old patientwith obesity who had Hinchey Grade 3 disease requiredopen resection with primary anastomosis because of feverand tenderness.14 Thus, overall, the operation was con-verted to laparotomy during the initial laparoscopic inter-vention in one patient, and five patients underwent lapa-rotomy days to weeks after the initial laparoscopy becauseof treatment failure.

Morbidity after laparoscopic drainage consisted ofcardiopulmonary complications (myocardial infarction,respiratory infection, pulmonary embolus, and atelecta-sis), gastrointestinal complications (paralytic ileus and an-tibiotic-related diarrhea), and other (lymphangitis). Inone study two patients developed pelvic abscess and weremanaged by radiologic drainage.17 The total number ofpatients with postoperative complications was 22 corre-sponding to an overall complication rate of 10%. In theonly prospective study with the largest number of patients,three patients, where two were immunoincompetent, of 92

(3.3%) died after laparoscopic drainage.16 No deaths oc-curred in the other studies. The overall mortality is 1.4%(Table 3).

Follow-Up PeriodThe patients were monitored after the laparoscopic drain-age with a mean follow-up period of 38 (range, 2–96)months. The interventions in this period consisted of ab-dominal CT, double-contrast barium enema, and colonos-copy to rule out colorectal carcinomas and to plan electiveresection of the diseased colon. There were three strategies:1) Surgery to all patients: four institutions performed sec-ondary elective surgery in 53 of 62 patients (the rest of thepatients refused, were rejected by the anesthetist, or be-cause of other reasons).11,13,14,17 2) Surgery to the compli-cated patients: This policy was supported by the study withthe longest mean follow-up period.15 Inclusion criteriawere defined by age, presence of severe diverticulitis, com-plicated diverticulitis, and the presence of three episodes ofmild diverticulitis.15 In this study 24 of 40 patients under-went elective laparoscopic resection. 3) Conservative ap-proach: In the three remaining studies (a total of 105 whounderwent a successful laparoscopic lavage), resectionwere only performed if a readmission required a resectionor if the colonoscopy revealed a colorectal carcinoma. As aresult, in two of these three studies, no patients had resec-tions, whereas in the third study one patient had a colonicresection because of a carcinoma of the descending colonduring the follow-up period.12,16,18 During the follow-upperiod four patients from two of these three studies werereadmitted with acute diverticulitis and responded to con-servative management.16,18 No readmissions occurred inthe rest of the six studies. The total number of patients thathad an elective colon resection was 78 (38%).

DISCUSSION

The basic finding of the present study was that the majorityof patients with Hinchey Grade 3 diverticulitis (diffuse pu-

TABLE 3. The outcomes of laparoscopic lavage management in the published studies

Authors Morbidity MortalityLOS

Conversion ratea Resection ratebMean (range)

O’Sullivan et al.18 2/8 (25%) 0/8 (0%) 10 (7–17) 0/8 (0%) 0/8 (0%)Faranda et al.11 3/18 (17%) 0/18 (0%) 8 (7–14) 0/18 (0%) 15/18 (83%)Da Rold et al.12 2/7 (28%) 0/7 (0%) 8 (4–12) 1/7 (14%) 0/6 (0%)Mutter et al.13 0/10 (0%) 0/10 (0%) 9 (4–16) 1/10 (10%) 6/9 (67%)Taylor et al.14 0/14 (0%) 0/14 (0%) 7 (5–32) 3/14 (21%) 8/11 (73%)Myers et al.16 5/92 (5%) 3/92 (3%) 9 (7–22) 1/92 (1%) 1/91 (1%)Franklin et al.15 8/40 (20%) 0/40 (0%) 7 (1–10) 0/40 (0%) 24/40 (60%)Bretagnol et al.17 2/24 (8%) 0/24 (0%) 12 (7–35) 0/24 (0%) 24/24 (100%)Total 22/213 (10.3%) 3/213 (1,4%) – 6/213 (2,8%) 78/207 (38%)

LOS � length of hospital stay.aFive of the patients had reoperations within weeks after the primary treatment because of failure of the original procedure, and the treatment of one patient was convertedto laparotomy during the original procedure.bResection rate � secondary elective sigmoideum resection rate.

DISEASES OF THE COLON & RECTUM VOLUME 52: 7 (2009) 1347

rulent peritonitis) can effectively be managed by laparo-scopic lavage in the acute setting. The overall conversion rateto laparotomy (including five treatment failures) was 3%, themean length of stay was 9 days, 10% of the patients devel-oped complications, and the overall mortality was 1.4%.

The standard procedure for patients with acute com-plicated diverticulitis with peritonitis in many hospitalsis an acute HP. The advantages and disadvantages of HPhave been thoroughly investigated.19 –24 HP has decreasedmortality and morbidity compared with the previousthree-stage surgical intervention that dominated until the1980s and consisted of a first stage with establishmentof a colostomy and drainage, a second stage with colonicresection, and a third stage with the reversal of the sto-ma.9,19 The disadvantages of HP are high mortality (10 –28%), high risk of surgical site infection (25%), reanasto-mosis that is often not performed (30 –75%), risk of fistula(7–16%), and a high risk for cardiovascular complications(25%) because of comorbidities the result of the typicallyhigh age for patients with diverticulitis.13,21,23–25 Patientsundergoing HP have a typical length of hospital stay (LOS)of 20 to 38 days,21 but the patients who undergo laparo-scopic lavage have an average LOS of 9 days during theirprimary treatment.

The laparoscopic approach with lavage, drainage, andno resection seems to have a low mortality and morbidityrate despite patient comorbidity and disease severity. Co-lostomy and the occurrence of wound infection areavoided, and subsequent development of incisional herniais not seen. Subsequent elective resection, laparoscopic oropen, may be unnecessary in many patients, and readmis-sion is unusual. The studies included in this article, how-ever, may reflect the experience from specialist centerswith a high level of expertise in this field, and inclusioncriteria for laparoscopic lavage was not always clear. Themean age of the patients included in the studies were also inthe lower range. The present data may therefore be biased,and future studies should clarify which patient groups canbenefit from this minimally invasive approach for treat-ment of peritonitis caused by complicated diverticulitis.

The eight studies included in this review are compara-ble with respect to the reported outcome parameters.However, the number of included patients has generallybeen low and no randomized controlled trials have yetbeen performed. The inclusion criteria were not the samein the studies. Patients with Hinchey Grade 2 and 3 diseasewere included in all studies, but patients with HincheyGrade 4 disease were only included in four stud-ies.11,14,15,17 Only two of the eight patients with fecal diver-ticulitis who underwent a laparoscopic lavage were con-verted to HP (conversion rate, 25%). This is very lowconsidering that these patients have a higher ASA gradeand higher mortality than all other patients with acute di-verticulitis and that the intervention is very simple, con-sisting of laparoscopic lavage and intravenous antibiotics.

Thus, the number of Hinchey Grade 4 patients in the eightstudies was low, although the clinical gain may be largest inthis group of patients. Larger studies have to be made be-fore clinical recommendations can be given regarding thispatient group.

The follow-up period lasted for a mean period of 38months where 38% of the patients underwent an electiveresection of the sigmoid colon. Elective resection is meantto prevent complications and readmission of diverticulardisease and is based on the assumption that, without sur-gical management, complications and readmission aremore likely to occur. The criteria for resection were differ-ent in the studies. In four studies (n � 62), where all pa-tients were offered laparoscopic resection, 85% of the pa-tients underwent resection. In the study with the longestmean follow-up period, where elective resection was per-formed in patients with complicated disease, 60% of thepatients underwent elective resection. In three other stud-ies (n � 105) where laparoscopic resection was performedselectively only, 1% of the patients underwent resection.Readmission was only seen in four patients, all from stud-ies that performed laparoscopic resection if needed, whichcorresponds to 4%. An important issue is whether the pa-tients without resections will be readmitted if they aremonitored for a longer period. A recent review highlightedthat there is no evidence to support the idea that electivesurgery should follow two attacks of diverticulitis.26 Fur-thermore, there is no association between recurrent epi-sodes of diverticulitis and increased risk of complicateddiverticulitis, and there is no association between multipleattacks of diverticulitis and a less favorable outcome or anincreased mortality risk if complications develop.27–30

The outcomes from the eight studies show that thenew intervention with laparoscopic lavage combined withintravenous antibiotics apparently had a low morbidityrate, low mortality, and short LOS, and it can be performedwithout placing a colostomy. Other advantages comparedwith acute HP are shorter operation time and lower eco-nomic costs. Thus, laparoscopic lavage without sigmoidresection in the acute setting for patients with purulentperitonitis caused by complicated diverticulitis could beconsidered a valid alternative to more radical procedures,including the Hartmann’s procedure. However, this needsto be investigated more thoroughly: preoperative and in-traoperative indications should be specified, whether elec-tive colonic resection should be performed for all patientsor for a selected group in the follow-up period, and finallyrandomized clinical trials are needed before clinical refer-ences can be given precisely.

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