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Long-term severe complications were similar with laparoscopic lavage and primary resection in perforated purulent diverticulitis patients, researchers reported, although recurrence was more frequent after lavage.

At a median follow-up of just under 5 years, new results from the ongoing showed no difference in severe complications (primary outcome) or in mortality, quality of life (QoL), and functional outcomes (secondary outcomes) between treatment groups, according to Najia Azhar, MD, of Skåne University Hospital in Malmö, Sweden, and colleagues.

Severe complications occurred in 36% (n=26/73) in the laparoscopic lavage group and 35% (n=24/69) in the resection group (P=0.92), they stated in .

But diverticulitis recurrence was more frequent after lavage, often leading to sigmoid resection (30% in the lavage group went on to sigmoid resection), yet with a lower stoma prevalence, the authors added, reporting that stoma prevalence was 8% (n=4) in the lavage group versus 33% (n=17, P=0.002) in the resection arm.

"Shared decision-making that takes both short-term and long-term consequences into account will be the key to better management of patients with perforated purulent diverticulitis," Azhar's group wrote.

Conducted at 21 hospitals in Sweden and Norway, the study enrolled patients from February 2010 to June 2014, with follow-up from March 2018 to November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need, and CT-verified free air were eligible. Those available for trial intervention (Hinchey stages <IV) were included in long-term follow-up.

Of 199 randomized patients, 101 were assigned to laparoscopic peritoneal lavage and 98 to colonic 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 months. A final cohort of 73 patients (mean age 66.4; 53% men) received lavage, while 69 (mean age 63.5; 52% men) underwent resection.

The authors also reported that overall mortality was 32% (n=23) in lavage recipients and 25% (n=17) in the resection group (P=0.36).

After 5 years, approximately one in three patients still had a stoma in the resection group. Secondary operations, including stoma reversal, were performed in 36% (n=26) versus 35% (n=24, P=0.92), respectively.

Recurrence was 21% (n=15) in the lavage arm versus 4% (n=3) in the surgery arm (P=0.004).

There were no significant differences in the EuroQoL-5D questionnaire or Cleveland Global QoL scores emerged between the two groups.

Finally, the colon cancer rate in this study was 4.2%, including four patients in the lavage group diagnosed within the first year and two in the resection group.

The authors recommended a cost analysis for assessing the best treatment option, noting that both the DILALA trial and the Laparoscopic Lavage arm of the found laparoscopic lavage to be more cost-effective. Laparoscopic lavage is associated with shorter operating time and hospital stays.

But they cautioned that the question of which surgical approach should be the treatment of choice for patients in the emergency department with perforated purulent diverticulitis remains unanswered.

"Laparoscopic lavage is faster and cost-effective but leads to a higher reoperation rate and recurrence rate, often requiring secondary sigmoid resection," Azhar's group wrote, but since stoma prevalence is lower with lavage in both the short and long terms, they noted that "laparoscopic lavage may be used as a bridge to overcome the emergency septic state and lead to an elective sigmoid resection."

This approach should be discussed with the patient, they added, taking into account that preoperative differentiation between purulent and fecal peritonitis (Hinchey stage III vs IV) is impossible. "Therefore, all patients selected for laparoscopic lavage should have consent secured for resection surgery as well," they wrote.

The primary study limitation was that "of all eligible patients, approximately 50% were not included. This can be attributed to the difficulties in conducting randomized clinical trials in an emergency clinical setting, where time constraints, patient involvement, and consent can be difficult to achieve," the authors noted. Also, those with the most severe illness and frailty might not have been included, and the results are not generalizable to them.

While previous research has also found laparoscopic lavage to be a safe and feasible option, have been raised whether any treatment other than antibiotics is necessary for this population.

In an , Brian S. Zuckerbraun, MD, and Kellie E. Cunningham, MD, both of the University of Pittsburgh Medical Center, noted that trade-offs between the two procedures remain, despite equal rates of morbidity, mortality, and secondary procedures as well as similar QoL. These include potentially missed cancers and higher diverticulitis recurrence in lavage patients versus higher stoma prevalence rates in those given resection.

"The issue still remains regarding when and how, if ever, this therapeutic approach should be considered for purulent peritonitis," they wrote, pointing out that the American Society of Colon and Rectal Surgeons guidelines strongly recommend colectomy, while the European Society of Coloproctology guidelines consider laparoscopic lavage feasible in some patients.

"Based on these data, we believe laparoscopic lavage continues to be a tool in the surgeon's armamentarium, yet there are several considerations," Zuckerbraun and Cunningham wrote. "Patients who are immunosuppressed or would be expected to have a higher mortality rate with failure to achieve definitive source control should likely not be offered this therapy."

Additionally, the rate of concurrent carcinomas in these patients underscores the need for postoperative colonoscopy in patients offered non-surgical resection therapy.

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