Laparoscopic Lavage for Acute Non-Faeculant Diverticulitis

Background and Current Knowledge:

Until recently, the natural history of diverticular disease was poorly understood and evidence suggesting a link between recurrent presentations with diverticulitis and perforation is almost forty years old rendering its relevance to modern day practice questionable at best . More recently, these questions have been clarified and it seems that risk of perforation following a single (treated) episode of diverticulitis is in the order of 2% per year with a risk of requiring an emergency Hartmann's procedure in this cohort being 1 in 2000 patient years of follow-up . As with all surgical interventions, there is a certain risk profile associated with elective resection and morbidity is estimated at 25-50% (including stoma formation in 10-14%) and mortality at 1-2% . The current vogue (despite some dissention ) is towards a more conservative approach to management of non-perforated acute diverticulitis and away from elective sigmoid colectomy in the absence of perforation .

Management of perforated diverticulitis continues to evolve. The last 50 years has seen standard of care shift from a three stage procedure (1.Drainage and defunctioning colostomy, 2.Excision of diseased segment, 3.Colostomy reversal and restoration of continuity) , to Hartmann's procedure , to resection and primary anastomosis , to treatment with antimicrobial therapy alone in a carefully selected (Hinchey Grade 2) population . Since the learning curve for laparoscopic surgery has begun to plateau, resections for perforated diverticular disease have been shown to be as safe and effective as conventional open techniques .

Irish surgeons have pioneered the institution of laparoscopic lavage for acute non-faeculant diverticulitis. The operative method described involves laparoscopy, copious washout, drain placement and treatment with antimicrobial therapy (intravenous for 72hours followed by oral for one week). Benefits include low mortality, stoma avoidance, minimal wound infection, shorter operative time and no difference in recurrence when compared to primary resection and anastomosis. Having demonstrated a clear clinical advantage of laparoscopic lavage over standard of care (Hartmann's procedure or primary resection and anastomosis) for acute non faeculant perforated diverticulitis, we feel the time is ripe to formalise these findings through performance of a multicentre national randomised controlled trial- LapLAND (LAParoscopic Lavage for Acute Non-faeculant Diverticulitis).

Relevance: