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- a randomised multicenter study

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1 - a randomised multicenter study
Laparoscopic lavage versus primary resection in acute perforated diverticulitis - a randomised multicenter study

2 Pseudo diverticula: Colonic diverticula are of the propulsion type, called false diverticula, - They are mucousal pouches traversing the gut wall musculature through a tunnel created by the vasa recta, small arteries that supply blood to the mucosa alongside any of the three taeniae. 95% of people with diverticulosis have the sigmoid colon involved. - Diverticula do not develop in the rectum, possibly because of the coalescence of taeniae into a longitudinal muscle layer there. 2

3 Prevalence Diverticulosis Diverticulitis >60 years of age: 30-50%
10-30% of those with diverticulosis: Conservative/medical treatment: 75-90% Surgical intervention: 10-30% 10 – 30 % of all patients with diverticulosis will experience one or more episodes of diverticulitis through their lifetime. 50% divertikulos 20% divertikulit = 10% Kirurgi 20 % = 2/100 3

4 Hinchey grading

5 Complicated diverticulitis
Obstruction Abscess formation Fistula formation Perforation - Peritonitis Mortality (historical): Purulent peritonitis 6%; Faecal peritonitis 35% (Nagorny et al 1985) If the condition deteriorates with such complications, - traditionally that has mandated resuscitation, broad-spectrum antibiotics, and emergency open surgical exploration, Even though Incidence of acute perforated diverticulitis 3-5 / 5

6 Surgical options Three stage
Transverse colostomy with lavage and suture of defect ’ Sigmoid reection and anastomosis Closure of stoma Hartmann Sigmoid resection with sigmoidostomy Closed rectum (or mucous fistula) Primary anastomosis with or with out covering stoma Lavage using the laparoscope

7 Netherlands: Five teaching hospitals 291pts 1995 – 2005
Hospital mortality after emergency surgery for perforated diverticulitis Netherlands: Five teaching hospitals 291pts – 2005 Overall in-hospital mortality 29% Ned Tijdschr Geeneskd. 2009;153:B195 Southeast England: One hosp 110pts – 2006 Mortality 10.9% World J Emerg Surg Jan 24;3-5

8 Hospital mortality after emergency surgery for perforated diverticulitis
England: ’Hospital Episode Statistics’ database between 1996 and 2006 Emergency surgery for sigmoid diverticular disease 30 -day death 1923/10198 pts = 15.9% Alim Pharm Therapeutics 2009;30:

9 Rationale • E. Myers et. al., BJS 2008
“Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis” Laparoscopy in 100 patients with perforated diverticulitis - laparoscopic lavage in 92 patients - 8 patients converted to Hartmann due to faecal peritonitis Mortality 3%, morbidity 4% • Similar results reported in other papers with fewer patients

10 No randomized studies

11 Primary endpoint Secondary endpoints
severe complications within 90 days (Clavien-Dindo >IIIa ) power analysis 30 % v.s. 10 % complications = 130 pts Aim = 150 patients Secondary endpoints -duration of procedure -time spent in hospital -complications individually -enterostoma one year after initial surgery - “Cleveland Global Quality of Life” -costs

12 Inclusion criteria : Exclusion criteria:
- age >18 years - clinical signs of perforated diverticulitis and need for surgery - CT displays free gas and do not contradict the clinical diagnosis - the patient tolerates general anesthesia - the patient has given written informed consent Exclusion criteria: - pregnancy - bowel obstruction

13 Log in with hospital name and password
The patient will be informed on used technique only postoperatively

14 Sigmoid resection with or without stoma
Techniques In all cases, lavage with minimum 4 l saline, wound drain and Hinchey grading Laparoscopic lavage usual port placement: umbilicus, suprapubic, right lower quadrant faecal peritonitis (including visible hole) convert to Hartmann adhesions to the sigmoid should not be dealt with Sigmoid resection with or without stoma

15 Case report forms

16 Case report form, follow-up

17 Patient information and consent






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