Song Liang, Morris E Franklin. The Texas Endosurgery Institute
BACKGOUND AND OBJECTIVES: Both emergent laparoscopic Hartmann’s (LHP) and laparoscopic lavage and drainage (LL&D) have been postulated as two alternative approaches to manage acute perforated diverticulitis with generalized purulent peritonitis. Differing from LHP, LL&D is considered as an abbreviated operation for the purpose of damage control rather than pathogenic control. This cohort study is designed on a prospectively collected database of our institute to compare LL&D with LHP in the management of severe perforated diverticulitis, and aimed at establishing a safer and more effective emergent laparoscopic method for operating on the patients with acute perforated diverticulitis with generalized peritonitis.
METHODS: A consecutive series of patients undergoing either emergent LHP or LL&D for perforated diverticulitis were identified from a prospectively designed Laparoscopic Colorectal Procedure Database of the Texas Endosurgery Institute (LCPD-TEI). The inclusive criteria of case selection for this study were all emergent patients with the clinical diagnosis of generalized peritonitis from acute diverticulitis and failed nonoperative treatment with antibiotics. The choice of procedure (LHP vs LL&D) depended upon clinical manifestations, radiological diagnosis, intraoperative findings at diagnostic laparoscopy, and patient tolerance for the procedure.
RESULTS: 83 emergent patients underwent emergent laparoscopic procedures (42 LL&D and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 67 (81.7%) patients as Hinchey III or IV perforated diverticulitis. The operating time for LHP was 141.1± 37.1 minutes, and blood loss during the procedures was 141.8 ± 76.6 ml. Two patients (4.9%) had bowel injury during LHP and six patients (14.6%) had been converted to open Hartmann’s for various reasons. Postoperatively, three patients developed wound infection, one patient developed evisceration, and one patient was expired from sepsis induced multiple organ failure. Taken together LHP-associated postoperative mortality and morbidity rates were (2.4%) and (9.6%) respectively. For LL&D, the operating time was 71.1 ± 19 minutes, and blood loss was very minimal. Despite none of the patients with LL&D developing remarkable intra- as well as postoperative complications, three patients (7.5%) were re-operated (one relavage and two open Hartmann’s) for the worsening of septic symptoms during post-LL&D course. Moreover, the patients with LHP were found to have significantly longer hospital stay than the ones with LL&D (16.3 ± 10.1 vs 6.7±2.2 days, P<0.01). Lastly, long-term follow-up was fulfilled on 78 patients with the rate of 94%. 26 of 36 follow-up patients with LHP had their colostomy closed with the colostomy closure rate of 72.2% while 25 of 42 patients who underwent LL&D had elective sigmoidectomy for the source control, and the remaining 17 have been doing well without further surgical intervention.
CONCLUSIONS: The results from this study deliver two-fold information. First, both laparoscopic Harmann’s procedure and laparoscopic lavage and drainage can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Secondly, in comparison with LHP, LL&D does not remove the pathogenic source, however the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcome for managing perforated diverticulitis with various Hinchey classifications.
Program Number: S085