Department of Surgery, University of Utah, Salt Lake City, Utah 84132, USA.
J Trauma Acute Care Surg. 2012 Apr;72(4):807-14; quiz 1124. doi: 10.1097/TA.0b013e31824ef90b.
The emergency surgical treatment of acute diverticulitis with feculent or purulent peritonitis has traditionally been the Hartmann's procedure (HP). Debate continues over whether primary resection with anastomosis and proximal diversion may be performed in the setting of a high-risk anastomosis in complicated diverticular disease. In contrast to a loop ileostomy takedown, the morbidity of a Hartmann's reversal is preventative for many patients, leaving them with a permanent stoma. Our study compared the surgical outcomes of patients with perforated diverticulitis who underwent a HP to primary anastomosis with proximal diversion (PAPD).
The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2009 to identify all cases of perforated diverticulitis classified as contaminated or dirty/infected. Patients were stratified into HP or PAPD, and logistic regression models were created to control for patient demographics, comorbidities, perioperative risk, and illness severity to determine the impact of surgical procedure on outcome.
There were 2,018 patients meeting the inclusion criteria of which 340 (17%) underwent PAPD and the remainder underwent HP. Significant independent predictors of infectious outcomes were alcohol use, preoperative sepsis, and operative time. There was no significant difference in risk of infectious complications, return to the operating room, prolonged ventilator use, death, or hospital length of stay between the two procedures. When considering only dirty/infected cases, the mortality risk was twofold greater when PAPD was performed.
The treatment of acute diverticulitis in the setting of contamination can be safely treated with resection, primary anastomosis, and proximal diversion as opposed to a HP in certain circumstances. Given the decreased morbidity of subsequent loop ileostomy takedown compared with a Hartmann's reversal, this procedure should be given consideration in the management of acute, perforated diverticulitis but may not be warranted in cases of feculent peritonitis.
急性憩室炎合并粪便或脓性腹膜炎的紧急手术治疗传统上是 Hartmann 手术（HP）。在复杂憩室病中，对于高风险吻合口，是否可以进行直接切除吻合和近端转流术，目前仍存在争议。与回肠造口术相比，Hartmann 手术的逆转对于许多患者来说是预防性的，因为这会导致永久性造口。我们的研究比较了接受 HP 与直接切除吻合和近端转流术（PAPD）治疗穿孔性憩室炎患者的手术结果。
从 2005 年至 2009 年，国家外科质量改进计划（NSQIP）数据库中检索到所有穿孔性憩室炎病例，这些病例被归类为污染或脏/感染。患者分为 HP 或 PAPD 组，建立逻辑回归模型来控制患者人口统计学、合并症、围手术期风险和疾病严重程度，以确定手术程序对结果的影响。
符合纳入标准的患者有 2018 例，其中 340 例（17%）接受了 PAPD，其余患者接受了 HP。感染结果的显著独立预测因素是饮酒、术前败血症和手术时间。两种手术方法在感染并发症、返回手术室、延长呼吸机使用时间、死亡或住院时间方面无显著差异。仅考虑脏/感染病例时，行 PAPD 的死亡率是行 HP 的两倍。
在污染的情况下，急性憩室炎的治疗可以安全地采用切除、直接吻合和近端转流术，而不是在某些情况下采用 HP。与 Hartmann 手术的逆转相比，随后的回肠造口术的发病率较低，因此在急性穿孔性憩室炎的治疗中应考虑这种手术，但在粪便性腹膜炎的情况下可能没有必要。
