Department of Colorectal Surgery, University Hospital 'Gregorio Marañón', Madrid.
Department of Colorectal Surgery, University Clinic of Navarre, Madrid & Pamplona, Spain.
Int J Surg. 2023 Apr 1;109(4):689-697. doi: 10.1097/JS9.0000000000000213.
There are no specific recommendations regarding the optimal management of this group of patients. The World Society of Emergency Surgery suggested a nonoperative strategy with antibiotic therapy, but this was a weak recommendation. This study aims to identify the optimal management of patients with acute diverticulitis (AD) presenting with pericolic free air with or without pericolic fluid.
A multicenter, prospective, international study of patients diagnosed with AD and pericolic-free air with or without pericolic free fluid at a computed tomography (CT) scan between May 2020 and June 2021 was included. Patients were excluded if they had intra-abdominal distant free air, an abscess, generalized peritonitis, or less than a 1-year follow-up. The primary outcome was the rate of failure of nonoperative management within the index admission. Secondary outcomes included the rate of failure of nonoperative management within the first year and risk factors for failure.
A total of 810 patients were recruited across 69 European and South American centers; 744 patients (92%) were treated nonoperatively, and 66 (8%) underwent immediate surgery. Baseline characteristics were similar between groups. Hinchey II-IV on diagnostic imaging was the only independent risk factor for surgical intervention during index admission (odds ratios: 12.5, 95% CI: 2.4-64, P =0.003). Among patients treated nonoperatively, at index admission, 697 (94%) patients were discharged without any complications, 35 (4.7%) required emergency surgery, and 12 (1.6%) percutaneous drainage. Free pericolic fluid on CT scan was associated with a higher risk of failure of nonoperative management (odds ratios: 4.9, 95% CI: 1.2-19.9, P =0.023), with 88% of success compared to 96% without free fluid ( P <0.001). The rate of treatment failure with nonoperative management during the first year of follow-up was 16.5%.
Patients with AD presenting with pericolic free gas can be successfully managed nonoperatively in the vast majority of cases. Patients with both free pericolic gas and free pericolic fluid on a CT scan are at a higher risk of failing nonoperative management and require closer observation.
目前对于此类患者，尚无明确的最佳治疗方案。世界急诊外科学会（World Society of Emergency Surgery）建议采用非手术治疗策略，即抗生素治疗，但这只是一个弱推荐。本研究旨在确定伴有或不伴有结肠旁游离气体的急性憩室炎（acute diverticulitis，AD）患者的最佳治疗方法。
本研究为多中心、前瞻性国际研究，纳入 2020 年 5 月至 2021 年 6 月期间 CT 扫描显示伴有或不伴有结肠旁游离液的 AD 患者。如果患者存在腹腔远处游离气体、脓肿、弥漫性腹膜炎或随访时间不足 1 年，则排除在外。主要结局为指数住院期间非手术治疗失败率。次要结局包括 1 年内非手术治疗失败率及失败的相关危险因素。
共纳入来自 69 个欧洲和南美洲中心的 810 例患者；744 例（92%）患者接受非手术治疗，66 例（8%）患者立即接受手术。两组基线特征相似。影像学诊断为 Hinchey II-IV 级是指数住院期间手术干预的唯一独立危险因素（比值比：12.5，95%CI：2.4-64，P=0.003）。接受非手术治疗的患者中，81%（95%CI：77%-85%）于指数住院期间出院，且无任何并发症，35 例（4.7%）需行急诊手术，12 例（1.6%）行经皮引流。CT 扫描显示结肠旁游离液与非手术治疗失败风险增加相关（比值比：4.9，95%CI：1.2-19.9，P=0.023），有游离液者的治疗成功率为 88%，无游离液者为 96%（P<0.001）。随访 1 年内非手术治疗失败率为 16.5%。
大多数情况下，伴有结肠旁游离气体的 AD 患者可成功接受非手术治疗。CT 扫描显示既有结肠旁游离气体又有游离液的患者非手术治疗失败风险更高，需要密切观察。
