Sohn M, Agha A, Heitland W, Gundling F, Steiner P, Iesalnieks I
Department of General, Abdominal, Vascular and Thoracic Surgery, Städtisches Klinikum München Bogenhausen, Englschalkinger Strasse 77, 81925, Munich, Germany.
Department of General-, Abdominal and Minimally Invasive Surgery, Isarklinikum München, Munich, Germany.
Tech Coloproctol. 2016 Aug;20(8):577-83. doi: 10.1007/s10151-016-1506-7. Epub 2016 Jul 22.
The best surgical strategy for the management of perforated diverticulitis with generalized peritonitis of the sigmoid colon is not clearly defined. The aim of this retrospective cohort study was to evaluate the value of a damage control strategy.
All patients who underwent emergency laparotomy for perforated diverticular disease of the sigmoid colon with generalized peritonitis between 2010 and 2015 were included. The damage control strategy (study group), included a two- stage procedure: limited resection of the diseased colonic segment, closure of proximal colon and distal stump, and application of an abdominal vacuum at the initial surgery followed by second-look laparotomy 24-48 h later At this point a choice was made between anastomosis and Hartmann's procedure. The control group consisted of patients receiving definitive reconstruction (anastomosis or Hartmann's procedure) at the initial operation.
Thirty-seven patients were included in the study. Damage control strategy was applied in 19 patients and the control group consisted of 18 patients. Both groups were comparable in terms of demographics, severity of peritonitis, and comorbidities. The overall postoperative mortality was 11 % (n = 4). There were no statistically significant differences between both groups regarding postoperative morbidity and mortality; however, a significantly higher proportion of patients in the control group had a stoma after the initial hospital stay (83 vs. 47 %, p = 0.038). This difference was still significant after adjustment for sex, age, Mannheim Peritonitis Index, American Society of Anesthesiologists class and presence of septic shock at presentation. At the end of the follow-up period, 15 of 17 survivors in the study group and 13 of 16 survivors in the control group had their intestinal continuity restored (p = 0.66).
Damage control strategy in patients with generalized peritonitis due to perforated diverticulitis leads to a significantly reduced stoma rate after the initial hospital stay without an increased risk of postoperative morbidity.
对于乙状结肠穿孔性憩室炎合并弥漫性腹膜炎的最佳手术策略尚无明确定义。这项回顾性队列研究的目的是评估损伤控制策略的价值。
纳入2010年至2015年间因乙状结肠穿孔性憩室病合并弥漫性腹膜炎而接受急诊剖腹手术的所有患者。损伤控制策略（研究组）包括两阶段手术：在初次手术时对病变结肠段进行有限切除、近端结肠和远端残端闭合，并应用腹腔负压，然后在24 - 48小时后进行二次剖腹探查。此时在吻合术和哈特曼手术之间做出选择。对照组由在初次手术时接受确定性重建（吻合术或哈特曼手术）的患者组成。
37例患者纳入研究。19例患者采用损伤控制策略，对照组有18例患者。两组在人口统计学、腹膜炎严重程度和合并症方面具有可比性。总体术后死亡率为11%（n = 4）。两组在术后发病率和死亡率方面无统计学显著差异；然而，对照组中初次住院后有造口的患者比例显著更高（83%对47%，p = 0.038）。在对性别、年龄、曼海姆腹膜炎指数、美国麻醉医师协会分级以及就诊时是否存在感染性休克进行调整后，这种差异仍然显著。在随访期末，研究组17名幸存者中的15名和对照组16名幸存者中的13名恢复了肠道连续性（p = 0.66）。
对于穿孔性憩室炎所致弥漫性腹膜炎患者，损伤控制策略可使初次住院后造口率显著降低，且不增加术后发病风险。
