Again LLD appeared effective for source control and had better outcome than a laparoscopic HP. Interesting, they treated 5 cases of stage IV disease with LLD

combined with laparoscopic closure of the sigmoid colon perforation. Most recently the Dutch have reviewed their experience with LLD check details in 38 patients and reported notably less impressive outcomes [28]. In 31 patients the LLD controlled the sepsis. These patients had low mortality (1 died), acceptable morbidity and relatively rapid recovers. However, in the remaining 7 patients LLD did not control abdominal sepsis, two died of multiple organ failure (MOF) and 5 required further surgical interventions (3 HPs, 1 diverting stoma and 1 perforation closure). One of these died from Selumetinib cell line aspiration and the remaining four experienced prolonged complicated recoveries. These authors concluded that patient selection is of utmost importance. PD0325901 They believe it is contraindicated in stage IV disease. Additionally they noted that patients with stage III disease who have multiple co-morbidities, immunosuppression, a high C reactive protein level and/or a high Mannheim Peritonitis Index are at high risk of failure and concluded that a HP as a first step is the best option in these patients. Figure 1 Experience with laporoscopic lavage and drainage. Table 2 Laparoscopic lavage

and drainage (LLD) compared to laparoscopic hatman’s procedure (LHP)   LLD LHP p value # of patient 47 41   OR time (minutes) 100 ± 40 182 ± 55 0.001 Conversion 2% 15% 0.05 Complications 4% 13% 0.05 Mortality 0% 2.4% ns Hospital stay (days) 6.6 ± 2.4 16.6 ± 10 0.01 Colostomy closure na 72% na Elective resection 45% na na Nonoperative management (NOM) More recently, Costi et al. added more controversy to management options when they reported their experience with NOM of 39 hemodynamically stable patients with Aprepitant stage III diverticulitis [31]. Three (8%) required an emergency operation because of clinical deterioration and underwent an HP. Seven (18%) required later CT-guided PCD of abscesses, while amazingly

29 (74%) required no early operative intervention and hospital mortality was zero. Half of the discharged patients underwent a delayed elective sigmoid resection and of the remaining half, five had recurrent diverticulitis successfully treated medically (with later elective resection). Of note, patients who underwent delayed elective resection experienced higher than expected morbidity leading the authors to conclude that perhaps delayed resection is not necessary and causes more harm than good. It is surmised with resolution of an acute perforation; local fibrosis prevents the recurrent perforation of the diverticulum. Dr Costi has cautioned that it is imperative to differentiate stage III from stage IV disease.