Treatment of perforated diverticular disease of the colon.
Treatment of perforated diverticular disease of the colon.
复制标题
治疗结肠穿孔憩室病。
作者：
E. Hinchey;P. G. Schaal;G. Richards
结肠憩室病现在被认为是结肠神经肌肉活动改变引起的功能性疾病。炎性并发症，当它们发生时，通常由单个憩室周围的炎症引起。这可能导致形成结肠周围或盆腔脓肿。游离穿孔导致化脓性腹膜炎。与肠腔的原始交通通常被闭塞。更罕见的是，随着憩室颈的迅速发展或未能闭塞，肠腔和腹膜腔之间形成自由连通，导致粪便性腹膜炎。粪便性腹膜炎导致极高的死亡率。穿孔性憩室病患者的手术方法应个体化，并取决于疾病的阶段，患者的一般状况，外科医生在结肠手术中的经验以及提供重症监护的设施和人员的可用性。在较大的机构，当这些条件是最佳的，原发性切除病变肠吻合或不吻合正在成为程序的选择。在较小的机构或如果条件不是最佳的，右横结肠造口术与引流的穿孔段可以依靠控制疾病的死亡率相比，主要切除。如果存在游离穿孔和粪便性腹膜炎，必须进行穿孔节段的外置术或一期切除术。在这种情况下，我们不建议进行一期吻合术。
Diverticular disease of the colon now is recognized to be functional disease resulting from altered neuromuscular activity in the colon. Inflammatory complications, when they occur, usually result from inflammation around a single diverticulum. This may lead to the formation of a pericolic or pelvic abscess. Free perforation of these leads to purulent peritonitis. The original communication with the lumen of the bowel usually is obliterated. More rarely, with either rapid evolution or failure of the diverticular neck to obliterate, a free communication develops between the bowel lumen and the peritoneal cavity, leading to fecal peritonitis. Fecal peritonitis results in an extremely high mortality rate. The operative approach for a patient with perforated diverticular disease should be individualized and depends on the stage of the disease present, the general condition of the patient, the experience of the surgeon in colon surgery and the availability of facilities and personnel to provide intensive care. In larger institutions when these conditions are optimal, primary resection of the diseased bowel with or without anastomosis is becoming the procedure of choice. In smaller institutions or if conditions are not optimal, right transverse colostomy with drainage of the perforated segment can be relied on to control the disease with a mortality rate compared to that of primary resection. If free perforation and fecal peritonitis are present, exteriorization or primary resection of the perforated segment must be carried out. We would not recommend primary anastomosis under these circumstances.