Department of Coloproctology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
University of Valencia, Valencia, Spain.
Int J Colorectal Dis. 2024 Nov 4;39(1):178. doi: 10.1007/s00384-024-04753-1.
The main aim of this study was to determine the short- and long-term outcomes of the non-operative management of acute left-sided complicated diverticulitis (ALCD) in severely immunocompromised patients (IMS group) and compare them with immunocompetent patients (IC group). The secondary aim was to assess the necessity of an elective surgery following a successful prior non-operative management in the IMS group after a non-operative management of the first episode of ALCD.
Patients presented with their first episode of ALCD between 2012 and 2018 were retrospectively reviewed. Only severely immunosuppressed patients were considered for the analysis, including the following: long-term oral or intravenous steroid intake, current malignancy undergoing chemotherapy, chronic kidney disease on hemodialysis, or solid organ transplant with immunosuppressive medication. For each group, demographic data, severity of the episode, management decisions (conservative or operative), and short- and long-term outcomes were recorded and compared. A sub-analysis of patients with ALCD associating and abscess (modified Hinchey classification Ib/II) was performed.
A total of 290 patients were included in the study: 50 among the IMS and 240 among the IC group. The rate of emergent surgery was higher in the IMS group (50.0% vs. 22.5%, p < 0.001) and was associated with increased morbidity (72.4% vs. 50.0%, p = 0.041) and mortality (24.1% vs. 4.3%, p = 0.003). The duration of the hospital stay was significantly longer in the IMS group (15 vs. 8 days, p < 0.001). The final stoma rate was significantly higher in the IMS group (82.1% vs. 22.9, p < 0.001), with a median follow-up of 51.4 months. A total of 141 patients presented ALCD with an abscess; 25 in the IMS and 116 in the IC group. There was a higher rate of surgical intervention among the IMS group as the initial treatment approach (24.0% vs. 5.2%, p = 0.002), even though the conservative treatment had a similar rate of success (81.3% vs. 92.0%, p = 0.178). The recurrence rate following a non-operative approach was similar (IMS: 31.2% vs. 35.4% in the IC group, p = 0.169). Furthermore, 81.2% of non-operatively managed IMS patients (13 out of 16) did not require a surgical intervention at the end of the follow-up, with similar findings in the IC group (78/96, 81.2%, p = 0.148).
Medical treatment of immunosuppressed patients during their first ALCD episode associated with an abscess is feasible, with a high success rate and results comparable with the IC group. Moreover, taking into account the readmission rates, the need for emergent surgery of the recurrence, and the perioperative mortality and morbidity in the IMS group, conservative management with no differed scheduled surgery seems to be a safe option in this subgroup of patients.
本研究的主要目的是确定严重免疫抑制患者（IMS 组）中急性左侧复杂憩室炎（ALCD）的非手术治疗的短期和长期结局，并将其与免疫功能正常的患者（IC 组）进行比较。次要目的是评估在首次 ALCD 发作的非手术治疗成功后，在 IMS 组中对首次 ALCD 发作进行非手术治疗后进行选择性手术的必要性。
回顾性分析 2012 年至 2018 年间首次出现 ALCD 的患者。仅考虑严重免疫抑制的患者进行分析，包括：长期口服或静脉类固醇治疗、当前正在接受化疗的恶性肿瘤、血液透析的慢性肾脏病或伴有免疫抑制药物的实体器官移植。记录并比较每组的人口统计学数据、发作严重程度、管理决策（保守或手术）以及短期和长期结局。对合并脓肿的 ALCD 患者（改良 Hinchey 分类 Ib/II）进行了亚分析。
共纳入 290 例患者：IMS 组 50 例，IC 组 240 例。IMS 组急诊手术率较高（50.0% vs. 22.5%，p<0.001），且与更高的发病率（72.4% vs. 50.0%，p=0.041）和死亡率（24.1% vs. 4.3%，p=0.003）相关。IMS 组的住院时间明显更长（15 天 vs. 8 天，p<0.001）。最终造口率明显更高（82.1% vs. 22.9%，p<0.001），中位随访时间为 51.4 个月。共有 141 例患者出现脓肿合并 ALCD；IMS 组 25 例，IC 组 116 例。尽管保守治疗的成功率相似（81.3% vs. 92.0%，p=0.178），但 IMS 组初始治疗方法中手术干预率更高（24.0% vs. 5.2%，p=0.002）。非手术治疗后的复发率相似（IMS 组：31.2% vs. IC 组 35.4%，p=0.169）。此外，16 例接受非手术治疗的 IMS 患者中有 13 例（81.2%）在随访结束时无需手术干预，IC 组也有类似发现（78/96，81.2%，p=0.148）。
对合并脓肿的首次 ALCD 发作的免疫抑制患者进行药物治疗是可行的，成功率高，结果与 IC 组相当。此外，考虑到再入院率、复发时需要急诊手术以及 IMS 组围手术期死亡率和发病率，在该亚组患者中，非手术管理而不进行预定手术似乎是一种安全的选择。
