Riansuwan Woramin, Hull Tracy L, Millan Monica M, Hammel Jeffrey P
Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
Dis Colon Rectum. 2009 Aug;52(8):1400-8. doi: 10.1007/DCR.0b013e3181a79575.
A Hartmann's procedure is performed in perforated diverticulitis, but in some patients the colostomy is never closed. Identification of patients at risk for Hartmann's nonreversal would be helpful to determine the extent of resection. The aim of this study was to quantify the risk of nonclosure by deriving a predictive score.
Patients undergoing a Hartmann's procedure for diverticulitis were identified from database. They were separated into those who underwent Hartmann's reversal within one year of the initial operation, and those who did not. The data were analyzed in univariable and multivariable logistic regression. A predictive scoring system of Hartmann's reversal was created. The predictive power of the multivariable models, the predictive scoring system, and colorectal POSSUM physiology scores were compared.
Eighty of 117 patients (68.4%) had their colostomy reversed. Multivariate analysis identified age, American Society of Anesthesiologists' score, pulmonary comorbidity, preoperative blood transfusion, perforation, and anticoagulants as the factors of failure for stoma reversal. All 36 patients with a predictive score of less than 14 had their stoma reversed. Twenty-two of 25 patients (88%) with scores greater than 18 did not have a reversal. Predictive power was similar when using only colorectal POSSUM physiology scores alone, or with preoperative data.
More than 30% of patients undergoing a Hartmann's procedure for diverticulitis will not have their stoma reversed within a year. If this scoring system can be validated in an independent group of patients, it will be useful in allowing surgeons to strategize accurately and to counsel patients realistically.
在穿孔性憩室炎患者中施行哈特曼手术，但部分患者的结肠造口术从未关闭。识别有哈特曼手术不回纳风险的患者，有助于确定切除范围。本研究旨在通过得出一个预测评分来量化不关闭的风险。
从数据库中识别出因憩室炎接受哈特曼手术的患者。将他们分为在初次手术后一年内接受哈特曼手术回纳的患者和未接受回纳的患者。对数据进行单变量和多变量逻辑回归分析。创建了哈特曼手术回纳的预测评分系统。比较了多变量模型、预测评分系统和结直肠POSSUM生理评分的预测能力。
117例患者中有80例（68.4%）进行了结肠造口回纳。多变量分析确定年龄、美国麻醉医师协会评分、肺部合并症、术前输血、穿孔和抗凝剂是造口回纳失败的因素。所有预测评分低于14分的36例患者均进行了造口回纳。25例评分高于18分的患者中有22例（88%）未进行回纳。单独使用结直肠POSSUM生理评分或结合术前数据时，预测能力相似。
超过30%因憩室炎接受哈特曼手术的患者在一年内不会进行造口回纳。如果该评分系统能在独立的患者群体中得到验证，将有助于外科医生准确制定策略并切实地为患者提供咨询。
