Laparoscopic surgery versus open surgery for acute sigmoid diverticulitis

Background

Diverticular disease is a condition in which the inner layer of the intestinal wall (mucosa) protrudes through weak points in the muscular layer of the wall, forming small pouches (diverticula) that bulge out of the large bowel. The inflammation of diverticula is defined as diverticulitis. Diverticulitis is more common in the sigmoid colon than in the other tracts of the large bowel. In Western countries, diverticular disease is very common, affecting about 60% of the population over 70 years of age. Most individuals with diverticular disease have no symptoms or experience only mild pain in the lower abdomen, accompanied by a slight change in bowel habits. Individuals with acute diverticulitis may experience pain in the lower abdomen and other symptoms such as fever, nausea, vomiting, and shivering. Diverticulitis generally is treated medically with antibiotics and diet. However, for individuals who experience recurrent abdominal pain or complications, surgical resection of the affected bowel segment is required; this can be performed through conventional open or laparoscopic surgery techniques.

In open surgery, a large abdominal incision is made at the midline to gain access to the abdominal cavity, but via laparoscopy, only small parietal incisions (usually 5 to 12 mm long) are made through the abdominal wall, allowing positioning of gas laparoscopic parietal cannulas (tubes that are inserted into the body) that provide access to the abdominal cavity with long-handled dedicated surgical instruments used under vision of an endoscopic camera. A laparoscopic parietal cannula is a sharp-pointed surgical instrument that is fitted with a tight cannula and is used to insert the tight cannula into a body cavity.

This review addresses the question of whether laparoscopy is more effective and/or safer than open surgery in the treatment of individuals with diverticulitis of the sigmoid colon who require a surgical resection.

Study characteristics

We identified three trials that compared the efficacy of laparoscopic surgery and open surgery. These studies included 392 participants (195 in the laparoscopic group vs 197 in the open surgery group). The method used to allocate participants based on randomisation, that is, the choice of treatment that participants received, was determined by a method similar to coin tossing, so the two groups were as similar as possible.

Key findings

We found that laparoscopic surgical resection may lead to little or no difference in mean hospital stay when compared with open surgical resection. Operating time was longer in the laparoscopic group by an average of 49 minutes. No important differences were observed in terms of 30-day postoperative mortality, early overall morbidity, major and minor complications, surgical complications, postoperative times to liquid and solid diets, and reoperations due to anastomotic leak. To assess quality of life, researchers used different scales at different periods of time. Although one trial reported that patients who received laparoscopic surgery had better quality of life, the other two trials showed no benefit favouring either laparoscopic surgery or open surgery.

Quality of the evidence

The quality of the evidence varied from low to very low owing to risk of bias (i.e. conclusions may overestimate benefits or underestimate harms because of biased study design and conduct) and limitations in the patient population sample. Well-designed trials are necessary to obtain a more accurate estimate of the benefits and safety of laparoscopic surgery over open surgery.

Authors' conclusions: 

Results from the present comprehensive review indicate that evidence to support or refute the safety and effectiveness of laparoscopic surgery versus open surgical resection for treatment of patients with acute diverticular disease is insufficient. Well-designed trials with adequate sample size are needed to investigate the efficacy of laparoscopic surgery towards important patient-oriented (e.g. postoperative pain) and health system-oriented outcomes (e.g. mean hospital stay).

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Background: 

Diverticular disease is a common condition in Western industrialised countries. Most individuals remain asymptomatic throughout life; however, 25% experience acute diverticulitis. The standard treatment for acute diverticulitis is open surgery. Laparoscopic surgery - a minimal-access procedure - offers an alternative approach to open surgery, as it is characterised by reduced operative stress that may translate into shorter hospitalisation and more rapid recovery, as well as improved quality of life.

Objectives: 

To evaluate the effectiveness of laparoscopic surgical resection compared with open surgical resection for individuals with acute sigmoid diverticulitis.

Search strategy: 

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2) in the Cochrane Library; Ovid MEDLINE (1946 to 23 February 2017); Ovid Embase (1974 to 23 February 2017); clinicaltrials.gov (February 2017); and the World Health Organization (WHO) International Clinical Trials Registry (February 2017). We reviewed the bibliographies of identified trials to search for additional studies.

Selection criteria: 

We included randomised controlled trials comparing elective or emergency laparoscopic sigmoid resection versus open surgical resection for acute sigmoid diverticulitis.

Data collection and analysis: 

Two review authors independently selected studies, assessed the domains of risk of bias from each included trial, and extracted data. For dichotomous outcomes, we calculated risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes, we planned to calculate mean differences (MDs) with 95% CIs for outcomes such as hospital stay, and standardised mean differences (SMDs) with 95% CIs for quality of life and global rating scales, if researchers used different scales.

Main results: 

Three trials with 392 participants met the inclusion criteria. Studies were conducted in three European countries (Switzerland, Netherlands, and Germany). The median age of participants ranged from 62 to 66 years; 53% to 64% were female. Inclusion criteria differed among studies. One trial included participants with Hinchey I characteristics as well as those who underwent Hartmann’s procedure; the second trial included only participants with "a proven stage II/III disease according to the classification of Stock and Hansen"; the third trial considered for inclusion patients with "diverticular disease of sigmoid colon documented by colonoscopy and 2 episodes of uncomplicated diverticulitis, one at least being documented with CT scan, 1 episode of complicated diverticulitis, with a pericolic abscess (Hinchey stage I) or pelvic abscess (Hinchey stage II) requiring percutaneous drainage."

We determined that two studies were at low risk of selection bias; two that reported considerable dropouts were at high risk of attrition bias; none reported blinding of outcome assessors (unclear detection bias); and all were exposed to performance bias owing to the nature of the intervention.

Available low-quality evidence suggests that laparoscopic surgical resection may lead to little or no difference in mean hospital stay compared with open surgical resection (3 studies, 360 participants; MD -0.62 (days), 95% CI -2.49 to 1.25; I² = 0%).

Low-quality evidence suggests that operating time was longer in the laparoscopic surgery group than in the open surgery group (3 studies, 360 participants; MD 49.28 (minutes), 95% CI 40.64 to 57.93; I² = 0%).

We are uncertain whether laparoscopic surgery improves postoperative pain between day 1 and day 3 more effectively than open surgery. Low-quality evidence suggests that laparoscopic surgery may improve postoperative pain at the fourth postoperative day more effectively than open surgery (2 studies, 250 participants; MD = -0.65, 95% CI -1.04 to -0.25).

Researchers reported quality of life differently across trials, hindering the possibility of meta-analysis. Low-quality evidence from one trial using the Short Form (SF)-36 questionnaire six weeks after surgery suggests that laparoscopic intervention may improve quality of life, whereas evidence from two other trials using the European Organization for Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) v3 and the Gastrointestinal Quality of Life Index score, respectively, suggests that laparoscopic surgery may make little or no difference in improving quality of life compared with open surgery.

We are uncertain whether laparoscopic surgery improves the following outcomes: 30-day postoperative mortality, early overall morbidity, major and minor complications, surgical complications, postoperative times to liquid and solid diets, and reoperations due to anastomotic leak.

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