Discussion
cancers, failure of laparoscopic lavage, carcinoma, perforated carcinoma, Peritonitis, diverticulitis, Hinchey III disease, sigmoid cancer, failure of laparoscopic peritoneal lavage
CANCERS, CARCINOMA, PERITONITIS, SECONDARY, PERFORATED DIVERTICULITIS, DIVERTICULITIS, SIGMOID CANCER, LIVER METASTASIS
By combining two of the largest randomized trials of treatment of perforated diverticulitis, a large prospectively collected data set within a trial setting of patients with Hinchey III disease could be assessed. Main risk factors for treatment failure in the laparoscopic lavage group were smoking and corticosteroid use. No other factors analysed were associated with treatment failure. Smoking is known to impair wound healing and is a well acknowledged risk factor for complicationsConcerns have been raised regarding patients who were diagnosed with cancers and misdiagnosed as having Hinchey III perforated diverticulitis initially. In the SCANDIV study, five patients were assessed as having Hinchey III perforated diverticulitis and three of these were randomized to the laparoscopic lavage arm. Two of these patients had failure of lavage, and both were diagnosed with sigmoid cancer and had surgery within 90 days of laparoscopic lavage (1 sigmoid resection and 1 transversostomy before neoadjuvant treatment for sigmoid cancer with liver metastasis). Of the nine patients who experienced treatment failure after lavage in the LADIES trial, one was diagnosed with an underlying carcinoma during pathological assessment. In both studies, these patients were included in the analysis, as this best reflects clinical practice with the inherent difficulty in differentiating correctly between perforated diverticulitis and perforated carcinoma.In recent years, trialsOther studies have examined risk factors for failure of laparoscopic lavage. In a study by Radé The strength of this study lies in the inclusion of the two largest randomized cohorts studying Hinchey III diverticulitis in a prospective manner. Nevertheless, there are several methodological differences between the SCANDIV and LOLA studies which limit interpretation of the results. For example, the set of baseline characteristics collected and secondary outcomes studied were different. Hence, not all baseline characteristics could be considered in the risk factor analyses. To correct for study heterogeneity in the statistical analyses, care was taken to adjust for study population. As exclusion criteria were different, many patients with high corticosteroid use were excluded from the LOLA study, but were included in the SCANDIV study, making the baseline populations different. Furthermore, both trials did not register Mannheim Peritonitis Index and it was therefore not possible to assess this as a risk factor in the present analysis. Although this is the largest cohort of patients with Hinchey III diverticulitis who underwent laparoscopic lavage in a trial setting, the total number of included patients and variables still limited the extent of multivariable analyses.In the largest assessment of risk factors for treatment failure of laparoscopic peritoneal lavage in a prospectively collected Hinchey III cohort, active smoking and corticosteroid use at index surgery were found to be statistically significant. Smoking and corticosteroid use are, therefore, factors that should be considered when assessing surgical options for patients with perforated Hinchey III diverticulitis.