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Article 1
Is the Failure of Laparoscopic Peritoneal Lavage Predictable in Hinchey III Diverticulitis Management? Greilsamer T, Abet E, Meurette G, Comy M, Hamy A, Lehur PA, Duchalais E. Diseases of the Colon & Rectum. 2017 Sep;60(9):965-970.
Several studies have examined the use of laparoscopic lavage (LPL) in the management of Hinchey III diverticular perforation (purulent peritonitis alone). In randomized trials, LPL had a higher rate of postoperative reoperation for peritonitis or abscess compared to the standard Hartmann procedure. The goal of this retrospective multicenter observational study was to identify risk factors that predict LPL failure in patients with Hinchey III diverticulitis. Operations for Hinchey III diverticulitis at 3 clinical sites in France from 2006 to 2015 were reviewed. 156 patients had operation for Hinchey III diverticulitis (71 had LPL). The 85 patients that did not receive LPL had Hartmann procedure (62 patients), sigmoid resection with anastomosis (21 patients) and lavage drainage with colostomy (2 patients). LPL failed in 14 patients (20%) with 1 death from heart failure. Other indications for failure were either peritonitis, fecal leak in the abdominal drain, or an undrainable pelvic abscess. One patient had a small bowel obstruction that required surgery. Immunosuppression and ASA grades of 3 and 4 were found to be significantly associated with LPL failure. Age, obesity, diabetes and history of abdominal surgery were not significant.
The study is limited by sample size and a retrospective design. The failure rate of LPL in immunocompetent patients (subgroup) was 15%. In a one year review of the SCANDIV1 trial, unplanned reoperation in their LPL group was as high as 20% and in the DILALA2 trial group reoperation within 30 days was 13% so this study had comparable outcomes to the randomized trials. I have concerns about validity in applying their findings to a US population (their BMI was 25+-5 as an example) but the study suggests that we should be selective about who should undergo LPL and that the immunocompromised or patients with multiple comorbidities should have a Hartman’s.
- One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis. Schultz JK, Wallon C, Forsmo HM, Folkesson J, Buchwald P, Korner H, Dahl FA, Oresland T, Yaqub S. British Journal of Surgery. 2017 Sep;104(10):1382-1392.
- Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis: the first results from the randomized controlled trial DILALA. Ponzano C, Huscher CGS, Overi D. Ann Surg. 2017 May;265(5):e66-e67.
Article 2
Laparoscopic repair of perforated peptic ulcer: simple closure versus omentopexy. Lin BC, Liao CH, Wang SY, Hwang TL. J Surg Res. 2017 Dec;220:341-345.
This is an interesting article about the use of laparoscopy that compares two laparoscopic approaches to manage peptic ulcer perforation rather than comparing a laparoscopic approach to an open approach. The research question was to determine if simple repair was comparable to omental patch repair (which is the widely accepted laparoscopic standard). This is a single center retrospective review at a university hospital in Taiwan. 518 patients required operation and 136 underwent laparoscopic approach. No patients with shock, generalized peritonitis, non-pyloric ulcers, large ulcers (>12mm) or outlet obstruction were considered for laparoscopy. 18 patients were excluded. 118 patients underwent laparoscopic repair with either simple closure of a perforation (27 patients) or omentopexy (91 patients). Simple interrupted sutures were placed and intracorporeally tied or a modified Cellen-Jones omentopexy was used (This entails securing am omental patch over the ulcer and is similar to a Graham patch but was described earlier in the literature. I have included a reference below with the description1). There were no deaths. There were 3 leaks (one in simple repair group) that required a laparotomy. The two groups differed significantly in median age (49 vs 53), and median size of perforation (4mm in the simple repair group vs 5mm in the omental repair group). As expected median operative times were significantly different (90 vs 139 minutes). Leak rates were not statistically different: 3.7 % compared to 2.2%. When they looked at subgroup analysis of size of perforations (less than 5mm vs 5mm and greater in size up to 12mm) there were no leaks in the smaller ulcer group.
Other studies have suggested that simple laparoscopic closure is associated with shorter OR times and has comparable outcomes to omental patch repair. The leak rate in the literature is 6.3%. It is unclear from the methods and results if the 2.5% leak rate in the study includes subclinical leaks or contained leaks. It is not clear what the protocol for leak detection was (mandatory fluoroscopic study vs expectant management) but drains were left routinely. Patient selection bias existed in the study and only one surgeon performed the simple repair in the group. Future studies with more patients or expanded criteria would be interesting as we move towards more laparoscopy in acute care surgery.
Article 3
Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. Patel SV, Paskar DD, Nelson RL, Vedula SS, and Steele SR. Cochrane Database Syst Rev. 2017 Nov 3;11(11):CD005661.
This Cochrane database review attempted to answer the age-old surgical question regarding the choice of suture material and closure method that is preferred for closure of laparotomy incisions. The objectives of this study were to identify the best techniques and materials that are available. Comparisons were made by assessing absorbable versus non-absorbable sutures; mass versus layered closure; continuous versus interrupted techniques; monofilament versus multifilament sutures; and slow absorbable versus fast absorbable sutures. The research team queried the CENTRAL, MEDLINE, Embase, two trial registries, and Science Citation Index on February of 2017. Included were randomized controlled trials (RCTS) that compared suture material or closure techniques, or both. Excluded trials included those that compared only skin closure or those with the use of retention sutures. Fifty-five RCTs were chosen which included 19,174 patients that met the inclusion criteria and were used in the meta-analysis. The proportion of participants that developed incisional hernia at one year or more following laparotomy, they did not find evidence that suture absorption, closure method, or closure technique resulted in a difference. They did, however, find that monofilament sutures reduced the risk of incisional hernia when compared to multifilament sutures (RR 0.76, 95% CI 0.59 to 0.98, I2 =30% moderate quality evidence). None of the interventions reduced the risk of wound infection or wound dehiscence. Absorbable sutures, compared to non-absorbable sutures (RR 0.49, 95% CI 0.26 to 0.94, low quality evidence) reduced the risk of sinus or fistula tract formation. The authors concluded that monofilament sutures may reduce the risk of incisional hernia and that absorbable sutures may reduce the formation of fistula tracts or sinuses. This study was limited as the authors had concerns about the design or reporting of several of the 55 included trials. The comparator arms in several of the arms were different which made it impossible to attribute differences between the groups to any one component. Therefore, larger, and high quality trials are required to further address this question are warranted.
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