Azhar 2021 — SCANDIV 5-Year Outcomes
Citation: Azhar N, Johanssen A, Sundström T, et al; for the SCANDIV Study Group. Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial. JAMA Surg. 2021;156(2):121-127. doi:10.1001/jamasurg.2020.5618. (Published online Dec 23, 2020; corrected Jul 28, 2021.)
Study design
- Long-term (5-year) follow-up report of the SCANDIV Trial — a pragmatic, open-label, multicenter (21 hospitals, Sweden/Norway) RCT.
- Population: adults with CT-verified perforated diverticulitis requiring emergency surgery; randomized 1:1 to laparoscopic peritoneal lavage vs. primary sigmoid resection.
- This report restricts analysis to patients with confirmed Hinchey stage <IV (purulent, not fecal, peritonitis) at index surgery — 74 randomized to lavage, 71 to resection; 145 total, 3 lost to follow-up → 73 lavage / 69 resection analyzed. Median follow-up 59 months (IQR 51-78).
- Primary outcome: severe complications (Clavien-Dindo >IIIa) within 5 years. Secondary: mortality, secondary operations, recurrence, stoma prevalence, functional outcomes/QoL (EQ-5D, Cleveland Global QoL).
Key findings
| Outcome | Lavage (n=73) | Resection (n=69) | p |
|---|---|---|---|
| Severe complications | 29% (21) | 25% (17) | .58 |
| Overall mortality | 32% (23) | 25% (17) | .36 |
| Stoma prevalence (alive pts) | 8% (4) | 33% (17) | .002 |
| Secondary reoperations (incl. stoma reversal) | 36% (26) | 35% (24) | .92 |
| Unplanned reoperations | 26% (19) | 12% (8) | .03 |
| Diverticulitis recurrence | 21% (15) | 4% (3) | .004 |
| Cleveland Global QoL, mean | 0.72 | 0.69 | .61 |
- No significant difference in severe complications, mortality, or QoL/functional outcomes at 5 years.
- 30% of lavage patients ultimately underwent sigmoid resection (recurrence-driven in most cases; a few for missed cancer or index-admission failure).
- Colon cancer missed at index workup: 4.2% overall (4 lavage, 2 resection) — supports mandatory post-lavage colonoscopy.
- Most secondary operations/complications occurred within the first year; very few new events years 2-5.
Limitations
- ~50% of eligible patients were not enrolled (emergency-setting RCT logistics; possible selection against the sickest/frailest patients) — limits generalizability to the most severe cases.
- Underpowered for some secondary/QoL comparisons.
- Open-label (not blinded) — inherent to the intervention.
Guideline context (as discussed in this paper)
- ASCRS (2020) — strong recommendation for colectomy over lavage in purulent peritonitis, citing lavage's higher secondary-intervention rate and lack of standardized selection criteria.
- ESCP guidelines — consider lavage feasible in selected Hinchey III patients.
- Related trials referenced but not yet in this wiki: DILALA (2-yr results, stoma 7% lavage vs 23% resection-Hartmann-only), Ladies trial (30-day reintervention 35% lavage vs 7% resection).
Relevance
First source in the wiki and the basis for the initial Diverticulitis condition page. Central tension it establishes: lavage trades a lower stoma rate for a meaningfully higher recurrence/ reoperation rate, with no difference in mortality, severe complications, or QoL at 5 years — framed by the authors as a shared-decision-making choice rather than a settled answer. Future sources should be checked against this trade-off (e.g., does a new paper support ASCRS's resection-preferred stance, or add nuance for specific Hinchey III subgroups?).