Department of General, Vascular and Thoracic Surgery, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany.
J Gastrointest Surg. 2010 May;14(5):812-7. doi: 10.1007/s11605-009-1054-9. Epub 2010 Feb 25.
The indications for prophylactic surgery for phlegmonous and covered perforated type of acute sigmoid diverticulitis (SD) are currently matters of debate, and a more conservative approach has been advocated. However, it has not yet been clarified to what extent CT findings indicative of acute SD correlate with histological findings, and it is still uncertain how these findings change in the time interval between initial antibiotic treatment and late elective surgery. The aim of this study was to record time-course changes of inflammation in phlegmonous and abscess-forming diverticulitis after conservative treatment in order to check the indication for surgery.
This study included all patients who underwent surgery for CT morphologically phlegmonous and covered perforated SD from January 2002 to June 2007. Two groups were formed to record time-course changes: early elective surgery (7-10 days after antibiotic treatment) and late elective surgery (4-6 weeks after conservative treatment). Exclusion criteria were emergency interventions, free perforations (Hinchey III and IV), recurrent inflammations, and contrast allergy. The extent of the inflammation recorded preoperatively by CT scan was compared with histological findings.
A total of 257 patients (142 male and 115 female; mean age, 56.6 years) underwent surgery (116 early elective and 141 late elective) for phlegmonous and covered perforated SD. Phlegmonous SD was seen in 127 cases and covered perforated SD in 130 cases. In the phlegmonous type of SD, early surgery led to conformity with the preoperative stage in 56%, to more extensive findings in 11%, and to subsided inflammation in 33%. Late surgery led to conformity in 0% and to signs of subsided inflammation in 100%. In the covered perforated type of SD, early surgery led to conformity in 90%, to subsided inflammation in 10%, and to milder manifestation in 0%. In contrast, late surgery here led to conformity in 26% of the cases and to subsided inflammation in 74%. Considerable histological changes can be detected under conservative therapy. The acute inflammation subsides under antibiotic therapy as awaited. It must be clarified whether the phlegmonous form of SD should, in principal, be regarded as an indication for surgery, since it shows early and nearly complete regression of the inflammation. Otherwise, the covered perforated type of SD still shows marked inflammatory changes after conservative therapy in a high percentage of patients and should thus preferably be treated by surgery. However, the clinical appearance of the patient with sigmoid diverticulitis still remains the most important part of decision making.
对于脓性和包裹性穿孔型急性乙状结肠憩室炎（SD）的预防性手术指征目前存在争议，主张采取更保守的方法。然而，CT 显示的急性 SD 指征与组织学发现之间的相关性仍不清楚，并且在初始抗生素治疗和晚期择期手术之间的时间间隔内这些发现如何变化尚不确定。本研究的目的是记录保守治疗后脓性和脓肿形成性憩室炎的炎症时间变化，以检查手术指征。
本研究纳入了 2002 年 1 月至 2007 年 6 月期间因 CT 形态学表现为脓性和包裹性穿孔性 SD 而接受手术的所有患者。为了记录时间变化，将患者分为两组：早期择期手术（抗生素治疗后 7-10 天）和晚期择期手术（保守治疗后 4-6 周）。排除标准为急诊干预、自由穿孔（Hinchey III 和 IV）、复发炎症和造影剂过敏。术前 CT 扫描记录的炎症程度与组织学发现进行比较。
共有 257 例患者（男性 142 例，女性 115 例；平均年龄 56.6 岁）接受了手术治疗（116 例早期择期手术和 141 例晚期择期手术），用于治疗脓性和包裹性穿孔性 SD。其中 127 例为脓性 SD，130 例为包裹性穿孔性 SD。在脓性 SD 中，早期手术导致与术前分期相符的比例为 56%，更广泛发现的比例为 11%，炎症消退的比例为 33%。晚期手术导致与术前分期相符的比例为 0%，炎症消退的比例为 100%。在包裹性穿孔性 SD 中，早期手术导致与术前分期相符的比例为 90%，炎症消退的比例为 10%，表现为轻度的比例为 0%。相比之下，晚期手术导致与术前分期相符的比例为 26%，炎症消退的比例为 74%。在保守治疗下可以检测到明显的组织学变化。急性炎症在抗生素治疗下消退。应该明确的是，SD 的脓性形式是否应该作为手术指征，因为它显示出炎症的早期和几乎完全消退。否则，包裹性穿孔性 SD 在接受保守治疗后仍有相当大比例的患者表现出明显的炎症变化，因此最好通过手术治疗。然而，乙状结肠憩室炎患者的临床症状仍然是决策的最重要部分。
