Service de Chirurgie Digestive, Hôpital Antoine Béclère, Clamart, Assistance Publique-Hôpitaux de Paris, Université Paris XI, Clamart, France.
Surg Endosc. 2012 Jul;26(7):2061-71. doi: 10.1007/s00464-012-2157-z. Epub 2012 Jan 25.
In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of "perforated" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA.
The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed.
There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas "distant" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23).
Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.
在出现急性憩室炎（AD）和急性腹膜炎体征的患者中，计算机断层扫描（CT）扫描上存在消化道外气（EDA）通常被认为需要紧急手术。虽然传统的“穿孔”AD 治疗方法是开放性乙状结肠切除术，但最近，腹腔镜引流/灌洗（通常随后进行择期乙状结肠切除术）已被报道。本回顾性研究旨在评估非手术治疗伴有 EDA 的 AD 急症患者的结果。
回顾性收集和分析了 2001 年 1 月至 2010 年 6 月期间在一家三级大学医院因 AD 和 EDA 而接受非手术治疗（抗生素和支持治疗）的 39 例血流动力学稳定的连续患者（23 名男性，平均年龄=54.7 岁）的结果。这些结果包括发病率（Clavien-Dindo）和治疗失败（需要紧急手术或死亡）。对与治疗失败相关的临床、影像学和实验室标准进行了单因素分析。还分析了延迟性腹腔镜乙状结肠切除术的结果。
无死亡病例。39 例患者中有 36 例（92.3%）无需手术（7 例需要 CT 引导下脓肿引流）。平均住院时间为 8.1 天。症状持续时间、既往抗生素使用、严重脓毒症、PCR 水平、白细胞计数以及腹部积液的存在与治疗失败相关，而 EDA 的“远处”位置和游离腹腔积液则没有。5 例患者出现 AD 复发，给予药物治疗。17 例患者（47.2%）接受了择期腹腔镜乙状结肠切除术，平均手术时间为 246 分钟（范围=100-450），转化率为 11.8%。死亡率为零，发病率为 41.2%。平均术后住院时间为 7.1 天（范围=4-23）。
在大多数出现 AD 和 EDA 的急症患者中，即使存在腹膜炎症状或实验室检查异常，非手术治疗也是可行的选择。在某些情况下，延迟性腹腔镜乙状结肠切除术可能无效，其结果不如预期。
