General Surgery Unit, Hospital of Desio, ASST Brianza, Desio, MB, Italy.
IRCCS Humanitas Research Hospital, ASST Melegnano-Martesana, Rozzano, Milan, Italy.
Updates Surg. 2022 Oct;74(5):1665-1673. doi: 10.1007/s13304-022-01324-3. Epub 2022 Jul 8.
The paradigm of emergency laparotomy with sigmoid resection and protective stoma has been challenged for perforated diverticular disease (PDD) with free extraluminal air. Early clinical stabilization could lead to interval laparoscopic resection without stoma within 2 weeks from perforation. Patients admitted for acute diverticulitis underwent abdominal computed tomography (CT) scan. When free air was seen, endoluminal enema was administred. All patients underwent assessement of clinical stability. In unstable patients, upfront emergency surgery was performed. Stable patients underwent a conservative management consisting in fasting, central line intravenous fluids, antibiotic therapy, pain management, O therapy and percutaneous radiological drainage when indicated. In successful conservative management early interval surgery was planned within 15 days. Early delayed definitive laparoscopic treatment (EDDLT) was defined as laparoscopic resection of the affected colon without ostomy. A total of 235 patients were admitted to the emergency department for PDD. Among these, 142 had pericolic free air and were excluded from the study. Ninety-three had distant free air. Thirty-seven were hemodynamically unstable and underwent upfront surgery. Fifty-six patients showed a clinical stability and started on EDDLT. EDDLT was successfully performed in 36 patients (64.3%). In 20 patients (35.7%) EDDLT was unsuccessful. At multivariate analysis, distant CT extravasation of endoluminal contrast was independently associated with unsuccessful EDDLT (OR 2.1, CI 0.94-5.32). Patients with distant extraluminal free air after PDD may be treated with early delayed surgery after intensive medical therapy. Distant spread of endoluminal contrast at CT was a risk factor for unsuccessful EDDLT often indicating fecal peritonitis.
对于有游离腔外气的穿孔性憩室炎（PDD），传统的手术方式是急症剖腹手术并进行乙状结肠切除和保护性造口术，但这一模式正面临挑战。穿孔后 2 周内，如果患者的临床状况稳定，可进行间隔期腹腔镜下切除，无需造口术。因急性憩室炎入院的患者接受腹部计算机断层扫描（CT）检查。如果发现游离气，可进行腔内灌肠。所有患者均进行临床稳定性评估。不稳定患者立即行急症手术。稳定患者接受保守治疗，包括禁食、中心静脉补液、抗生素治疗、疼痛管理、氧疗和有指征时行经皮放射科引流。在成功的保守治疗后，计划在 15 天内进行早期间隔手术。早期延迟确定性腹腔镜治疗（EDDLT）定义为无造口的受累结肠的腹腔镜切除。共有 235 名患者因 PDD 入住急诊科。其中，142 名患者有结肠旁游离气，被排除在研究之外。93 名患者有远处游离气。37 名患者血流动力学不稳定，行急症手术。56 名患者临床稳定，开始 EDDLT。36 名患者（64.3%）成功进行了 EDDLT。20 名患者（35.7%）的 EDDLT 不成功。多变量分析显示，腔内对比剂的 CT 远处外渗与 EDDLT 不成功独立相关（OR 2.1，95%CI 0.94-5.32）。PDD 后有远处游离腔外气的患者可在强化内科治疗后行早期延迟手术。CT 显示远处腔外游离对比剂扩散是 EDDLT 不成功的危险因素，常提示粪便腹膜炎。
