在辛奇 III 型憩室炎的治疗中，腹腔镜腹膜灌洗失败是否可预测？

Is the Failure of Laparoscopic Peritoneal Lavage Predictable in Hinchey III Diverticulitis Management?

作者信息

Greilsamer Tristan, Abet Emeric, Meurette Guillaume, Comy Michel, Hamy Antoine, Lehur Paul-Antoine, Venara Aurélien, Duchalais Emilie

机构信息

1 Department of Digestive and Endocrine Surgery, University Hospital of Nantes, Nantes, France 2 Department of Digestive Surgery, Vendée Medical Center, La-Roche-Sur-Yon, France 3 Department of Visceral Surgery, University Hospital of Angers, Angers, France.

出版信息

Dis Colon Rectum. 2017 Sep;60(9):965-970. doi: 10.1097/DCR.0000000000000891.

DOI:10.1097/DCR.0000000000000891

PMID:28796735

Abstract

BACKGROUND

Laparoscopic peritoneal lavage is an alternative to sigmoid resection in Hinchey III diverticulitis (generalized purulent peritonitis). The main limitation of laparoscopic peritoneal lavage is the higher rate of reoperation for persistent sepsis in comparison with sigmoid resection.

OBJECTIVE

The purpose of the current study was to identify risk factors for laparoscopic peritoneal lavage failure in patients who have Hinchey III diverticulitis.

DESIGN

This was a retrospective multicenter study.

SETTINGS

The study was conducted in 3 clinical sites in France.

PATIENTS

From 2006 to 2015, all consecutive patients undergoing emergent surgery for diverticulitis were reviewed. All patients operated on with laparoscopic peritoneal lavage for laparoscopically confirmed Hinchey III diverticulitis were included.

MAIN OUTCOME MEASURES

The main outcome was laparoscopic peritoneal lavage failure, defined as reoperation or death at 30 postoperative days.

RESULTS

A series of 71 patients (43 men, mean age 58 ± 15 years) were operated on with laparoscopic peritoneal lavage for Hinchey III diverticulitis. Laparoscopic peritoneal lavage failed in 14 (20%) of them: 1 died and 13 underwent reoperations. No major complication (Dindo-Clavien score ≥3) occurred after reoperation. Immunosuppressive drugs (p = 0.01) and ASA grade ≥3 (p = 0.02) were associated with laparoscopic peritoneal lavage failure after univariate analysis. Multivariate analysis identified only immunosuppressive drug intake (steroids or chemotherapy for cancer) as an independent predictive factor. Mean length of stay was 14.9 days (5-67). At the end of the 30 first postoperative days, 12 (17%) patients had a stoma.

LIMITATIONS

The study was limited by its retrospective nature and the small size of the cohort.

CONCLUSION

Our results highlight immunosuppressive drug intake as a major risk factor for laparoscopic peritoneal lavage failure in patients who have Hinchey III diverticulitis. Immunosuppression and severe comorbidities (ASA ≥3) should be considered when selecting a surgical option in patients with Hinchey III diverticulitis. See Video Abstract at http://links.lww.com/DCR/A423.

摘要

背景

在欣奇 III 型憩室炎（弥漫性化脓性腹膜炎）中，腹腔镜下腹腔灌洗是乙状结肠切除术的一种替代方法。与乙状结肠切除术相比，腹腔镜下腹腔灌洗的主要局限性在于持续性脓毒症的再次手术率较高。

目的

本研究的目的是确定患有欣奇 III 型憩室炎的患者腹腔镜下腹腔灌洗失败的危险因素。

设计

这是一项回顾性多中心研究。

地点

该研究在法国的 3 个临床地点进行。

患者

对 2006 年至 2015 年期间所有因憩室炎接受急诊手术的连续患者进行了回顾。纳入所有因腹腔镜确诊的欣奇 III 型憩室炎而接受腹腔镜下腹腔灌洗手术的患者。

主要观察指标

主要结局是腹腔镜下腹腔灌洗失败，定义为术后 30 天内再次手术或死亡。

结果

一组 71 例患者（43 名男性，平均年龄 58±15 岁）因欣奇 III 型憩室炎接受了腹腔镜下腹腔灌洗手术。其中 14 例（20%）腹腔镜下腹腔灌洗失败：1 例死亡，13 例接受了再次手术。再次手术后未发生重大并发症（Dindo-Clavien 评分≥3）。单因素分析显示，免疫抑制药物（p = 0.01）和美国麻醉医师协会（ASA）分级≥3（p = 0.02）与腹腔镜下腹腔灌洗失败相关。多因素分析仅确定免疫抑制药物摄入（类固醇或癌症化疗）为独立预测因素。平均住院时间为 14.9 天（5 - 67 天）。术后 30 天结束时，12 例（17%）患者有造口。