背景:本研究旨在比较腹腔镜灌洗和乙状结肠切除术治疗穿孔憩室炎合并化脓性腹膜炎的疗效。
方法:在国际组织的LOLA分支机构中,多中心女士试验,穿孔憩室炎合并化脓性腹膜炎的患者随机分为腹腔镜灌洗和乙状结肠切除术.结果收集到长达36个月。本研究的主要结果是累积发病率和死亡率。次要结果包括再次手术(包括气孔逆转),气孔率,灌洗组的乙状结肠切除术率。
结果:在最初纳入的88例患者中,有77例进行了长期随访,39例随机接受乙状结肠切除术(51%),38例随机接受腹腔镜灌洗(49%)。36个月后,总累积发病率(乙状结肠切除术28/39(72%)与灌洗32/38(84%),p=0·272)和死亡率(乙状结肠切除术7/39(18%)与灌洗6/38(16%),p=1·000)没有差异。与乙状结肠切除术相比,进行再手术的患者人数明显减少(乙状结肠切除术27/39(69%)与灌洗17/38(45%),p=0·039)。36个月后,灌洗组存在原位造口的患者比例较低(根据Kaplan-Meier生命表计算,乙状结肠切除术17%vs灌洗11%,对数秩p=0·0268)。最终,38例(45%)的患者进行了乙状结肠切除术。
结论:长期结果显示,与乙状结肠切除术相比,腹腔镜灌洗术与36个月后再次手术的患者较少相关,且存活患者造口率较低。在累积发病率或死亡率方面没有发现差异。应改进患者选择,以降低短期并发症的风险,此后灌洗仍可能是一种有价值的治疗选择。
This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.
Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.
Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan-Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.
Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.