Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital and IDIBELL, University of Barcelona, Barcelona, Spain.
Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital and IDIBELL, University of Barcelona, Barcelona, Spain.
Int J Surg. 2018 Jul;55:175-181. doi: 10.1016/j.ijsu.2018.05.732. Epub 2018 May 29.
Management of left colonic perforation in emergency depends largely upon the attending surgeon. The primary endpoint of this observational, retrospective study analyses surgical technique chosen by the colorectal specialized (CS) or general surgeon (GS) and changes over time.
Interventions for left colonic perforation from 2004 to 2015 are grouped for CS or GS. Type of operation (Hartmann (HP), primary anastomosis (RPA) ±covering ileostomy (IL)), year, Peritonitis Severity Score (PSS), morbidity, mortality, anastomotic dehiscence and stoma closure were recorded.
190 patients were included. CS performed RPA ± IL in 83 pts (74.1%) and HP in 29 pts (25.9%) while GS performed RPA ± IL in 26 pts (33.3%) and HP in 52 pts (66.7%), (p < 0.001). CS performed over time more RPA with covering ileostomy to the detriment of HP. No differences were observed between the two surgeon-groups in terms of overall morbidity and mortality. Anastomotic dehiscence was higher among GS (20% vs 4.8%, p = 0.046). Mortality after HP overtrumped RPA (26.8% versus 11.0%, p = 0.009). Regression analysis showed that HP's probability increased 3.7 times by GS, 2.3 times by each PSS point and decreased 32.5% every forthcoming year (p < 0.001). A multinomial logistic model illustrates evolution of surgical management over time, CS leading towards extension of reconstructive techniques, subsequently adopted by GS.
CS attempt bowel reconstruction in more patients than GS in left colonic perforation without differences in overall postoperative morbidity or mortality. CS introduced covering IL to further indicate primary anastomosis avoiding HP. GS stepwise adopted this management although results are improved by CS. These findings favor primary anastomosis with/without covering ileostomy in left colonic perforation in selected patients where PSS can be used as a tool to discriminate best candidates.
左结肠穿孔的紧急处理在很大程度上取决于主治外科医生。本观察性、回顾性研究的主要终点分析了结肠直肠专科医生（CS）或普通外科医生（GS）选择的手术技术，并随着时间的推移而变化。
将 2004 年至 2015 年的左结肠穿孔干预措施分为 CS 或 GS。手术类型（Hartmann（HP）、一期吻合（RPA）±覆盖性回肠造口术（IL））、年份、腹膜炎严重程度评分（PSS）、发病率、死亡率、吻合口裂开和造口关闭。
共纳入 190 例患者。CS 行 RPA±IL 83 例（74.1%），行 HP 29 例（25.9%）；GS 行 RPA±IL 26 例（33.3%），行 HP 52 例（66.7%），差异有统计学意义（p<0.001）。CS 随着时间的推移，更多地采用 RPA 加覆盖性回肠造口术，而不是 HP。两组外科医生在总发病率和死亡率方面无差异。GS 组吻合口裂开发生率较高（20%比 4.8%，p=0.046）。HP 后死亡率高于 RPA（26.8%比 11.0%，p=0.009）。回归分析显示，GS 使 HP 的概率增加了 3.7 倍，PSS 每增加 1 分增加 2.3 倍，每年减少 32.5%（p<0.001）。多变量逻辑模型表明，随着时间的推移，手术管理发生了演变，CS 倾向于扩展重建技术，随后被 GS 采用。
CS 在左结肠穿孔患者中尝试肠重建的患者多于 GS，且术后总体发病率或死亡率无差异。CS 采用覆盖性 IL 进一步指示一期吻合术，避免 HP。GS 逐步采用这种治疗方法，尽管 CS 的结果有所改善。这些发现支持在选择的患者中进行左结肠穿孔的一期吻合术/带覆盖性回肠造口术，其中 PSS 可用作区分最佳候选者的工具。
