Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
Int J Colorectal Dis. 2010 Jun;25(6):767-74. doi: 10.1007/s00384-010-0887-8. Epub 2010 Feb 11.
Perforated diverticulitis with advanced generalized peritonitis is a life-threatening condition requiring emergency operation. To reduce the rate of colostomy formation, a new treatment algorithm with damage control operation, lavage, limited closure of perforation, abdominal vacuum-assisted closure (VAC; V.A.C.), and second look to restore intestinal continuity was developed.
This algorithm allowed for three surgical procedures: primary anastomosis +/- VAC in stable patients (group I), but damage control with lavage, limited resection of the diseased colonic segment, VAC and second-look operation with delayed anastomosis in patients with advanced peritonitis or septic shock (group II), and Hartmann procedure was done for social reasons in stable patients (group III) RESULTS: All 27 consecutive patients (16 women; median age 68 years) requiring emergency laparotomy for perforated diverticulitis (Hinchey III/IV) between October 2006 and September 2008 were prospectively enrolled in the study. No major complications were observed in group I (n = 6). Nine patients in group II (n = 15) had intestinal continuity restored during a second-look operation, of whom one patient developed anastomotic leakage. The median length of stay at intensive care unit was 5 days. Considering an overall mortality rate of 26% (n = 7), the rate of anastomosis in surviving patients was 70%.
Damage control with lavage, limited bowel resection, VAC, and scheduled second-look operation represents a feasible strategy in patients with perforated diverticulitis (Hinchey III and IV) to enhance sepsis control and improve rate of anastomosis.
合并弥漫性腹膜炎的穿孔性憩室炎是一种危及生命的病症，需要紧急手术。为了降低结肠造口术的形成率，我们开发了一种新的治疗算法，包括损伤控制性手术、冲洗、穿孔的有限闭合、腹部负压辅助闭合（VAC；V.A.C.）以及恢复肠连续性的二次探查。
该算法允许进行三种手术：稳定患者行一期吻合术 +/- VAC（I 组），但对于腹膜炎或感染性休克进展的患者，采用损伤控制性冲洗、病变结肠段有限切除、VAC 和延期吻合的二次探查手术（II 组），以及出于社会原因行 Hartmann 手术（III 组）。
2006 年 10 月至 2008 年 9 月，我们前瞻性地纳入了 27 例因穿孔性憩室炎（Hinchey III/IV）而需要紧急剖腹手术的连续患者（16 例女性；中位年龄 68 岁）。I 组（n=6）中无重大并发症。II 组（n=15）中有 9 例患者在二次探查手术中恢复了肠连续性，其中 1 例发生吻合口漏。在重症监护病房的中位住院时间为 5 天。考虑到总体死亡率为 26%（n=7），存活患者的吻合率为 70%。
对于穿孔性憩室炎（Hinchey III 和 IV）患者，采用冲洗、有限肠切除、VAC 和计划性二次探查手术的损伤控制性手术策略，能够增强对脓毒症的控制，提高吻合术的成功率。
