Bretagnol Frédéric, Panis Yves
Service de chirurgie colorectale, SAMU 93, EA 3409, Hôpital Beaujon, F-92110 Clichy, France.
Presse Med. 2008 May;37(5 Pt 2):827-30. doi: 10.1016/j.lpm.2007.07.032. Epub 2008 Feb 20.
Computed tomography (CT) with contrast enhancement for vascular and bowel opacification is the reference examination for suspected sigmoid diverticulitis because it makes it possible to confirm the diagnosis and look for signs of severity (pericolic abscess, or presence of air or extraintestinal contrast product). Therapeutic management depends on the patient's general condition and on the severity of the intraperitoneal infection, assessed according to Hinchey's 4-stage classification. For Hinchey stages I and II (pericolic or pelvic abscess), radiologically guided puncture-drainage is an effective treatment, combined with antibiotic therapy. Emergency surgery is only indicated if this drainage fails. Two to three months later, elective prophylactic sigmoidectomy, by laparoscopy, is indicated. In stage III or IV diverticulitis (generalized purulent or fecal peritonitis), the surgical treatment of reference is a Hartmann procedure (sigmoidectomy and left iliac colostomy with closure of the rectal stump). But because of burden of the procedure and the risk of failing to re-establish gastrointestinal continuity, it is preferable, if local conditions allow, to propose resection-anastomosis with a temporary protective stoma. Prophylactic sigmoidectomy is controversial. It is indicated regardless of the number of episodes and regardless of age in patients at high risk of recurrence, that is, those with a complicated clinical form or radiologic signs of severity. There is no consensus for patients aged younger than 75 years with a first uncomplicated episode, for whom the risk of recurrence is also elevated. Finally, for patients older than 50 years with an uncomplicated episode on CT, the role of prophylactic surgery, even after 2 or 3 episodes, has not been demonstrated, because of the very low risk (<5%) of subsequent complications. More than 80% of diverticular hemorrhages stop spontaneously but their rate of recurrence is high (25% of cases) and they sometimes require emergency colectomy.
增强CT用于血管和肠腔显影，是疑似乙状结肠憩室炎的参考检查方法，因为它能够确诊并寻找严重程度的迹象（结肠周围脓肿、气体或肠外造影剂的存在）。治疗方案取决于患者的一般状况以及根据欣奇（Hinchey）4期分类评估的腹腔内感染的严重程度。对于欣奇I期和II期（结肠周围或盆腔脓肿），在抗生素治疗的基础上，放射学引导下的穿刺引流是一种有效的治疗方法。只有在这种引流失败时才需要进行急诊手术。两到三个月后，建议通过腹腔镜进行择期预防性乙状结肠切除术。对于III期或IV期憩室炎（弥漫性脓性或粪性腹膜炎），标准的手术治疗是哈特曼手术（乙状结肠切除术和左髂结肠造口术，同时封闭直肠残端）。但由于该手术的负担以及无法重建胃肠道连续性的风险，如果局部条件允许，更可取的是进行切除吻合术并设置临时保护性造口。预防性乙状结肠切除术存在争议。对于复发风险高的患者，即那些具有复杂临床形式或严重放射学体征的患者，无论发作次数和年龄，均建议进行预防性乙状结肠切除术。对于首次发作且无并发症、年龄小于75岁的患者，复发风险也会升高，对此尚无共识。最后，对于CT检查显示首次发作且无并发症、年龄大于50岁的患者，即使发作2或3次后，预防性手术的作用也未得到证实，因为后续并发症的风险非常低（<5%）。超过80%的憩室出血会自行停止，但其复发率很高（25%的病例），有时需要进行急诊结肠切除术。
