Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Department of Colorectal Surgery, Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida.
Dis Colon Rectum. 2018 Dec;61(12):1442-1453. doi: 10.1097/DCR.0000000000001149.
The traditional approach for perforated diverticulitis, the Hartmann procedure, has considerable morbidity and the challenge of stoma reversal. Alternative procedures, including primary resection and anastomosis and laparoscopic lavage, have been proposed but remain controversial.
The purpose of this study was to compare operative strategies for perforated diverticulitis.
MEDLINE, Embase, Cochrane Library, and the grey literature were searched from inception to October 2017.
We included randomized clinical trials evaluating operative strategies for perforated diverticulitis.
Hartmann procedure, primary resection and anastomosis, and laparoscopic lavage were included.
Data were independently extracted by 2 investigators. Risk of bias was evaluated using the Cochrane risk-of-bias tool. Pooled risk ratios for major complications, reoperation, and mortality were determined using random-effects models.
Six trials including 626 patients with perforated diverticulitis were identified. Laparoscopic lavage and sigmoidectomy had comparable rates of early reoperation and postoperative mortality; major complications (Clavien-Dindo >IIIa) were more frequent after laparoscopic lavage (RR = 1.68 (95% CI, 1.10-2.56); 3 trials, 305 patients). Comparing approaches for sigmoidectomy, primary resection and anastomosis had similar rates of major complications (RR = 0.88 (95% CI, 0.49-1.55); 3 trials, 255 patients) and postoperative mortality (RR = 0.58 (95% CI, 0.20-1.70); 3 trials, 254 patients) compared with the Hartmann procedure. However, patients who underwent primary resection and anastomosis were more likely to be stoma free at 12 months compared with the Hartmann procedure (RR = 1.40 (95% CI, 1.18-1.67); 4 trials, 283 patients) and to experience fewer major complications related to the stoma reversal procedure (RR = 0.26 (95% CI, 0.07-0.89); 4 trials, 186 patients).
There were no limitations to this study.
Laparoscopic lavage is associated with increased risk of major complications versus primary resection for Hinchey III diverticulitis. The lower rate of stoma reversal and higher rate of complications after the Hartmann procedure suggest primary resection and anastomosis as the optimal management of perforated diverticulitis.
传统的穿孔性憩室炎治疗方法——Hartmann 手术，具有相当大的发病率，且存在造口逆转的挑战。其他方法，包括一期切除吻合术和腹腔镜灌洗术，已被提出，但仍存在争议。
本研究旨在比较穿孔性憩室炎的手术策略。
从建库到 2017 年 10 月，检索了 MEDLINE、Embase、Cochrane 图书馆和灰色文献。
纳入评估穿孔性憩室炎手术策略的随机临床试验。
Hartmann 手术、一期切除吻合术和腹腔镜灌洗术。
由 2 名研究者独立提取数据。使用 Cochrane 偏倚风险工具评估偏倚风险。使用随机效应模型确定主要并发症、再次手术和死亡率的汇总风险比。
纳入了 6 项涉及 626 例穿孔性憩室炎患者的临床试验。腹腔镜灌洗术和乙状结肠切除术的早期再次手术和术后死亡率相当；腹腔镜灌洗术后更常见严重并发症（Clavien-Dindo >IIIa）（RR = 1.68（95% CI，1.10-2.56）；3 项试验，305 例）。比较乙状结肠切除术的不同方法，一期切除吻合术与 Hartmann 手术的严重并发症发生率相似（RR = 0.88（95% CI，0.49-1.55）；3 项试验，255 例）和术后死亡率（RR = 0.58（95% CI，0.20-1.70）；3 项试验，254 例）。然而，与 Hartmann 手术相比，一期切除吻合术患者在 12 个月时更有可能无造口（RR = 1.40（95% CI，1.18-1.67）；4 项试验，283 例），且造口逆转相关严重并发症更少（RR = 0.26（95% CI，0.07-0.89）；4 项试验，186 例）。
本研究无局限性。
与一期切除吻合术相比，腹腔镜灌洗术治疗 Hinchey III 型憩室炎的严重并发症风险更高。Hartmann 手术后造口逆转的发生率较低，并发症发生率较高，提示一期切除吻合术是穿孔性憩室炎的最佳治疗方法。
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