Constantinides Vasilis A, Heriot Alexander, Remzi Feza, Darzi Ara, Senapati Asha, Fazio Victor W, Tekkis Paris P
Imperial College London, Department of Biosurgery and Surgical Technology, St. Mary's Hospital London, UK.
Ann Surg. 2007 Jan;245(1):94-103. doi: 10.1097/01.sla.0000225357.82218.ce.
To compare primary resection and anastomosis (PRA) with and without defunctioning stoma to Hartmann's procedure (HP) as the optimal operative strategy for patients presenting with Hinchey stage III-IV, perforated diverticulitis.
The choice of operation for perforated diverticulitis lies between HP and PRA. Postoperative mortality and morbidity can be high, and the long-term consequences life-altering, with no established criteria guiding clinicians towards selecting a particular procedure.
Probability estimates for 6879 patients with Hinchey III-IV perforated diverticulitis were obtained from two databases (n = 204), supplemented by expert opinion and summary data from 12 studies (n = 6675) published between 1980 and 2005. The primary outcome was quality-adjusted life-years (QALYs) gained from each strategy. Factors considered were the risk of permanent stoma, morbidity, and mortality from the primary or reversal operations. Decision analysis from the patient's perspective was used to calculate the optimal operative strategy and sensitivity analysis performed.
A total of 135 PRA, 126 primary anastomoses with defunctioning stoma (PADS), and 6619 Hartmann's procedures (HP) were considered. The probability of morbidity and mortality was 55% and 30% for PRA, 40% and 25% for PADS, and 35% and 20% for HP, respectively. Stomas remained permanent in 27% of HP and in 8% of PADS. Analysis revealed the optimal strategy to be PADS with 9.98 QALYs, compared with 9.44 QALYs after HP and 9.02 QALYs after PRA. Complications after PRA reduced patients QALYs to a baseline of 2.713. Patients with postoperative complications during both primary and reversal operations for PADS and HP had QALYs of 0.366 and 0.325, respectively. HP became the optimal strategy only when risk of complications after PRA and PADS reached 50% and 44%, respectively.
Primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis as may represent a good compromise between postoperative adverse events, long-term quality of life and risk of permanent stoma. HP may be reserved for patients with risk of complications >40% to 50% after consideration of long-term implications.
比较一期切除吻合术（PRA）（有或无减张造口）与哈特曼手术（HP），以确定其作为 Hinchey Ⅲ-Ⅳ期穿孔性憩室炎患者的最佳手术策略。
穿孔性憩室炎的手术选择在 HP 和 PRA 之间。术后死亡率和发病率可能很高，且长期后果会改变生活，目前尚无既定标准指导临床医生选择特定手术。
从两个数据库（n = 204）中获取 6879 例 Hinchey Ⅲ-Ⅳ期穿孔性憩室炎患者的概率估计值，并辅以 1980 年至 2005 年间发表的 12 项研究（n = 6675）的专家意见和汇总数据。主要结局是每种策略获得的质量调整生命年（QALY）。考虑的因素包括永久性造口的风险、初次或回纳手术的发病率和死亡率。从患者角度进行决策分析以计算最佳手术策略，并进行敏感性分析。
共考虑了 135 例 PRA、126 例带减张造口的一期吻合术（PADS）和 6619 例 HP。PRA 的发病率和死亡率概率分别为 55%和 30%，PADS 为 40%和 25%，HP 为 35%和 20%。HP 中有 27%的造口永久性保留，PADS 中有 8%。分析显示最佳策略为 PADS，QALY 为 9.98，而 HP 后为 9.44，PRA 后为 9.02。PRA 后的并发症使患者的 QALY 降至 2.713 的基线水平。PADS 和 HP 的初次及回纳手术期间有术后并发症的患者，QALY 分别为 0.366 和 0.325。仅当 PRA 和 PADS 后并发症风险分别达到 50%和 44%时，HP 才成为最佳策略。
带减张造口的一期吻合术可能是特定憩室性腹膜炎患者的最佳策略，因为它可能是术后不良事件、长期生活质量和永久性造口风险之间的良好折衷。考虑到长期影响，HP 可保留给并发症风险>40%至 50%的患者。
