Laparoscopic Peritoneal Lavage versus Sigmoidectomy for Management of Perforated Diverticulitis: Meta-Analysis of Randomized Controlled Trials

Abstract

Introduction: Controversy exists regarding the role of laparoscopic peritoneal lavage in patients with perforated diverticulitis. Our objective was to conduct the first meta-anal ysis of Randomized Controlled Trials (RCT’s) to compare the outcomes of patient undergoing laparoscopic peritoneal lavage with sigmoidectomy in patients with perforated di verticulitis. Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) state ment standards, we conducted a systematic search of elec tronic information sources, including MEDLINE; EMBASE; CINAHL; CENTRAL; The World Health Organization Inter national Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Overall morbidity, mortality, and postoperative complications were defined as the prima ry outcome parameters. Procedure time and length of hos pital stay were secondary outcomes. The combined overall effect sizes were calculated using fixed-effect or random-ef fects models. Results: We identified 4 RCT’s comparing outcomes of lap aroscopic peritoneal lavage and open sigmoidectomy for perforated diverticulitis. All studies included only Hinchey grade III diverticulitis. The subsequent analysis, including 390 patients, demonstrated that laparoscopic peritoneal lavage of perforated diverticulitis was associated with significantly increased rates of overall morbidity (OR: 1.30, 95% CI 1.07-1.57, p = 0.007) and intra-abdominal abscess (OR: 3.10, 95% CI 1.71-5.63, p = 0.0002) compared to sig -moidectomy. However, there was no significant difference in mortality (OR: 0.86, 95% CI 0.42-1.77, p = 0.69) and re-operation (OR: 1.20, 95% CI 0.36-4.02, p = 0.77) rates between the two groups. Between-study heterogeneity was non-significant in all analyses, except reoperation rate (I 2 = 79%, p = 0.002). The available data did not allow an appro priate analysis of procedure time, length of hospital stay and other postoperative complications. Conclusions: Our analysis of randomised trials demon strated that laparoscopic peritoneal lavage of perforated diverticulitis may lead to more adverse events than open sigmoid resection. Future high quality RCT’s are indeed re quired to provide stronger evidence as no definitive conclu sion can be drawn considering the limited number of avail able RCT’s.