Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 674 - файл

It has been widely described that laparoscopic peritoneal lavage has represented a potentially viable option for patients with purulent diverticulitis. By itself, the pro­cedure presents quite simple steps: placement of three ports, complete evacuation of the purulent collection, accurate visualization of the descending colon and sigma, execution of a hydropneumatic or methylene bleu test to rule out eventual visceral discontinuity, and nally putting some drains in situ. In the 1990s, several retrospec­tive studies showed very promising results that started a “hot” debate about the efcacy of this procedure in the treatment of peritonitis due to acute perforated diverticulitis. The discussion is heavily still going on [12–14]. These rst studies reported very low rates of morbidity (0–4%), mortality (<2%), reoperation (2–7%), and diverticulitis recurrence (0–5%) during 12- to 48-month follow-up. As a result, the conclusions were very optimistic: the laparoscopic peritoneal lavage was con­sidered a safe and effective alternative to traditional surgical resection allowing to avoid elective colon resection in most cases [14]. However, during the second decade of this century, the scientic community raised a need to clarify the real benet deriving from laparoscopic peritoneal lavage. Thus, three randomized stud­ies from northern Europe were conducted: LADIEs, SCANDIV, and DILALA trials [15–17]. The rst one in chronological order, the LADIEs with the LOLA arm, was prematurely interrupted because of an exceedingly high rate of complications in laparoscopic lavage [15]. The Scandinavian SCANDIV study reported a higher complication rate, short-term morbidity, and mortality in laparoscopic lavage, even though long-term follow-up showed no differences in severe complications [18]. Furthermore, the authors identied that recurrence of diverticulitis after laparo­scopic lavage was more common (21% vs. 4%), often leading to sigmoid resection (30%). The authors agreed that a higher resection rate must be weighed against the lower stoma prevalence in laparoscopic lavage, encouraging to take “shared” deci­sions, considering both short-term and long-term consequences. On the other hand, the DILALA trial reported better results for laparoscopic lavage, identifying shorter operative time, and hospital stay with no differences in terms of morbidity and mor­tality [17]. At the 2-year follow-up, the laparoscopic lavage was associated with a 45% reduced risk of undergoing operations than Hartmann’s. In the study by Kohl etal., the authors considered the laparoscopic lavage a better option for perforated diverticulitis with purulent peritonitis than open resection and colostomy [19]. However, an important criticism merging from the literature versus these encourag­ing results was represented by the very limited number of patients per arm enrolled in the DILALA: 39in the lavage group and 36in Hartmann’s procedure [20]. A multicentric prospective international study was conducted in 2018: the LLO Study, which included 231 patients affected by purulent peritonitis caused by acute diver­ticulitis. Among 212 patients who underwent lavage, the postoperative morbidity rate was 33%, the mortality rate was 2%, and the readmission rate was 10%. Overall, the technique was successful in 172 patients (81%): there were no signs of sepsis and no need for further surgery during the hospital stay and 60days after discharge.