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Avancées récentes dans la prise en charge chirurgicale des péritonites diverticulaires Hinchey III et IV

Recent advances in the management of diverticulitis with Hinchey III and IV peritonitis

  • Dossier Thématique / Thematic File
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Côlon & Rectum

Résumé

Les perforations diverticulaires touchent 3 à 4/100 000 personnes par an. Les recommandations françaises de 2007 concluent que le traitement des péritonites Hinchey III et IV doit privilégier une résection colique première. L’intervention de Hartmann était le traitement de référence, mais pour les péritonites Hinchey III, certaines données de la littérature discutent la résection anastomose d’emblée. Dès le début des années 2000, de nombreuses séries rétrospectives ont montré l’efficacité du traitement par lavage drainage laparoscopique (LDL) des péritonites Hinchey III. Récemment, deux essais randomisés prospectifs ont échoué à prouver la supériorité du LDL par rapport à la résection colique. Dans la pratique courante, plus de 70 % des résections coliques pour péritonite diverticulaire sont réalisées avec Hartmann. Les études randomisées comparant le Hartmann à la résection anastomose protégée sont affublées d’importants biais de sélection et ne parviennent pas à départager les deux stratégies sur leur résultat postopératoire immédiat. Les mauvais résultats à long terme du Hartmann et le taux de stomie à distance font préférer la résection anastomose protégée pour les malades Hinchey III lorsque les constatations peropératoires le permettent. Pour les malades Hinchey IV, aucune donnée ne permet de surseoir à l’intervention de Hartmann.

Abstract

Perforated diverticulitis occurs in 3 to 4/100.000 persons each year. French guidelines published in 2006 recommend colonic resection in case of peritonitis (Hinchey 3 and 4). Hartmann’s procedure used to be the gold standard but remains debated particularly in case of Hinchey 3 peritonitis. Primary anastomosis has been suggested in several articles as an alternative to Hartmann’s procedure with promising results. Early in the 2000’s, several articles reported initial experience of laparoscopic lavage and drainage in case of Hinchey 3 peritonitis also. Two recent randomized studies failed to demonstrate the superiority of this innovative approach. To date, colonic resection with primary anastomosis seems to be feasible and secure and can be proposed instead of Hartmann’s procedure in case of Hinchey 3 peritonitis. In case of Hinchey 4 peritonitis, no clear conclusion can be drawn after exhaustive analysis of the literature.

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  1. Service de chirurgie générale et digestive, hôpital Saint-Antoine, Université Paris VI, F-75012, Paris, France

    C. Hobeika & J. Lefevre

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  1. C. Hobeika
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  2. J. Lefevre
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Correspondence to J. Lefevre.

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Hobeika, C., Lefevre, J. Avancées récentes dans la prise en charge chirurgicale des péritonites diverticulaires Hinchey III et IV. Colon Rectum 11, 19–24 (2017). https://doi.org/10.1007/s11725-017-0691-5

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  • DOI: https://doi.org/10.1007/s11725-017-0691-5

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