Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25124, Brescia, Italy.
Unit of Coloproctology, Department of Surgery, Borea Hospital, Sanremo, Italy.
Tech Coloproctol. 2021 Feb;25(2):153-165. doi: 10.1007/s10151-020-02346-y. Epub 2020 Nov 5.
Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann's procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.
穿孔性憩室炎是一种紧急的临床情况，其治疗具有挑战性且仍存在争议。本立场文件的目的是批判性地回顾穿孔性憩室炎和弥漫性腹膜炎治疗的现有证据，以便为治疗策略提供循证建议。四个意大利科学学会（SICCR、SICUT、SIRM、AIGO）选择了专家，他们确定了穿孔性憩室炎伴弥漫性腹膜炎治疗中需要多学科审查的 5 个临床相关问题。以下是解决的 5 个问题：1）穿孔性憩室炎伴腹膜炎时决定保守治疗与手术治疗的标准；2）弥漫性腹膜炎确诊时选择最合适手术方案的标准或评分系统；3）血流动力学稳定或稳定的弥漫性腹膜炎患者的适当手术程序；4）弥漫性腹膜炎伴感染性休克患者的适当手术程序；5）穿孔性憩室炎引起的弥漫性腹膜炎患者术前和术后的最佳药物治疗。在穿孔性憩室炎中，如果存在弥漫性腹膜炎或保守治疗失败，则需要手术治疗，手术决策不取决于是否存在腔外气体。如果确诊弥漫性腹膜炎，则选择手术技术基于术中发现以及是否存在或有发生严重感染性休克的风险。进一步需要考虑的预后因素包括生理紊乱、年龄、合并症和免疫状态。在血流动力学稳定的患者中，急诊腹腔镜检查优于剖腹手术。选择包括切除和吻合、Hartmann 手术或腹腔镜灌洗。在弥漫性腹膜炎伴感染性休克中，首选开腹手术。非修复性切除术和/或损伤控制性手术似乎是唯一可行的选择，具体取决于血流动力学不稳定的严重程度。应采用多学科医疗管理，主要目标是控制感染、缓解术后疼痛以及预防和/或治疗术后肠梗阻。总之，憩室穿孔伴弥漫性腹膜炎患者的复杂性和多样性需要个体化策略，包括对生理紊乱进行彻底分类、对腹腔内感染进行分期以及选择最合适的手术程序。
