Cirocchi Roberto, Trastulli Stefano, Vettoretto Nereo, Milani Diego, Cavaliere Davide, Renzi Claudio, Adamenko Olga, Desiderio Jacopo, Burattini Maria Federica, Parisi Amilcare, Arezzo Alberto, Fingerhut Abe
From the Department of Digestive Surgery (RC, ST, OA, JD, AP), St. Maria Hospital, University of Perugia, Terni; Laparoscopic Surgical Unit (NV), M. Mellini Hospital, Chiari, Italy; University of Notre Dame (DM), Fremantle, Australia; Forlì Hospital (DC), Surgical Oncology, Forlì; Department of General and Oncologic Surgery (CR, MFB), University of Perugia, Perugia; Department of Surgical Sciences (AA), University of Torino, Torino, Italy; First Department of Surgery (AF), Hippokration Hospital, University of Athens, Athens, Greece; and Section for Surgical Research (AF), Department of Surgery, Medical University of Graz, Graz, Austria.
Medicine (Baltimore). 2015 Jan;94(1):e334. doi: 10.1097/MD.0000000000000334.
To this day, the treatment of generalized peritonitis secondary to diverticular perforation is still controversial. Recently, in patients with acute sigmoid diverticulitis, laparoscopic lavage and drainage has gained a wide interest as an alternative to resection. Based on this backdrop, we decided to perform a systematic review of the literature to evaluate the safety, feasibility, and efficacy of peritoneal lavage in perforated diverticular disease.A bibliographic search was performed in PubMed for case series and comparative studies published between January 1992 and February 2014 describing laparoscopic peritoneal lavage in patients with perforated diverticulitis.A total of 19 articles consisting of 10 cohort studies, 8 case series, and 1 controlled clinical trial met the inclusion criteria and were reviewed. In total these studies analyzed data from 871 patients. The mean follow-up time ranged from 1.5 to 96 months when reported. In 11 studies, the success rate of laparoscopic peritoneal lavage, defined as patients alive without surgical treatment for a recurrent episode of diverticulitis, was 24.3%. In patients with Hinchey stage III diverticulitis, the incidence of laparotomy conversion was 1%, whereas in patients with stage IV it was 45%. The 30-day postoperative mortality rate was 2.9%. The 30-day postoperative reintervention rate was 4.9%, whereas 2% of patients required a percutaneous drainage. Readmission rate after the first hospitalization for recurrent diverticulitis was 6%. Most patients who were readmitted (69%) required redo surgery. A 2-stage laparoscopic intervention was performed in 18.3% of patients.Laparoscopic peritoneal lavage should be considered an effective and safe option for the treatment of patients with sigmoid diverticulitis with Hinchey stage III peritonitis; it can also be consider as a "bridge" surgical step combined with a delayed and elective laparoscopic sigmoidectomy in order to avoid a Hartmann procedure. This minimally invasive staged approach should be considered for patients without systemic toxicity and in centers experienced in minimally invasive surgery techniques. Further evidence is needed, and the ongoing RCTs will better define the role of the laparoscopic peritoneal lavage/drainage in the treatment of patients with complicated diverticulitis.
时至今日，憩室穿孔继发弥漫性腹膜炎的治疗仍存在争议。近来，在急性乙状结肠憩室炎患者中，腹腔镜灌洗引流作为切除术的替代方法已引起广泛关注。基于这一背景，我们决定对文献进行系统回顾，以评估腹膜灌洗在穿孔性憩室病中的安全性、可行性和疗效。
在PubMed上进行了文献检索，查找1992年1月至2014年2月间发表的描述穿孔性憩室炎患者腹腔镜腹膜灌洗的病例系列和对照研究。
共有19篇文章符合纳入标准并进行了回顾，其中包括10项队列研究、8个病例系列和1项对照临床试验。这些研究总共分析了871例患者的数据。报告的平均随访时间为1.5至96个月。在11项研究中，腹腔镜腹膜灌洗的成功率（定义为患者存活且无需因憩室炎复发而接受手术治疗）为24.3%。在Hinchey III期憩室炎患者中，中转开腹率为1%，而在IV期患者中为45%。术后30天死亡率为2.9%。术后30天再次干预率为4.9%，而2%的患者需要经皮引流。首次住院后因憩室炎复发的再入院率为6%。大多数再次入院的患者（69%）需要再次手术。18.3%的患者接受了两阶段腹腔镜干预。
对于患有Hinchey III期腹膜炎的乙状结肠憩室炎患者，腹腔镜腹膜灌洗应被视为一种有效且安全的治疗选择；它也可被视为与延迟性择期腹腔镜乙状结肠切除术相结合的“桥梁”手术步骤，以避免Hartmann手术。对于没有全身中毒症状且在微创外科技术方面经验丰富的中心的患者，应考虑采用这种微创分期方法。还需要进一步的证据，正在进行的随机对照试验将更好地明确腹腔镜腹膜灌洗/引流在复杂憩室炎患者治疗中的作用。
