INTRODUCTION  介紹 — 

Diverticular disease of the colon is an important cause of hospital admissions and a significant contributor to health care costs in industrialized nations [1,2]. In Western countries, the majority of patients present with sigmoid diverticulitis [3,4].
結腸憩室病是導致住院的重要原因，也是工業化國家醫療費用的重要貢獻者[1,2]。在西方國家，大多數患者表現為乙狀結腸憩室炎[3,4]。

Most patients with acute sigmoid diverticulitis are treated medically; surgery is only indicated to treat severe complications, persistent symptoms despite best medical therapy, or recurrent attacks (algorithm 1) [5-7]. Approximately 15 percent of patients will require surgery for diverticular disease [5]; up to 32 percent of patients hospitalized for diverticulitis will require emergency surgery [8,9].
大多數急性乙狀結腸憩室炎患者接受藥物治療;手術僅適用於治療嚴重併發症、儘管藥物治療效果最好，但癥狀持續存在或反覆發作 （ 流程圖 1）[5-7]。約 15%的患者因憩室病需要手術治療[5];高達 32%的憩室炎住院患者需要緊急手術[8,9]。

In the United States, diverticular disease is the leading indication for elective colon surgery [10]. For patients who require surgery for diverticulitis, the choice of techniques depends upon the patient's hemodynamic stability, extent of peritoneal contamination, and surgeon experience/preference [7].
在美國，憩室病是擇期結腸手術的主要指征[10]。對於憩室炎需要手術的患者，技術的選擇取決於患者的血流動力學穩定性、腹膜污染程度和外科醫生的經驗/偏好[7]。

Surgical treatment of acute colonic diverticulitis and its acute complications (perforation, abscess formation, or intractability) are described here. Diverticular fistulas, bleeding, and stricture/obstruction, which are typically subacute or chronic sequelae of diverticulitis, are discussed in other topics:
本文將介紹急性結腸憩室炎及其急性併發症（穿孔、膿腫形成或頑固性）的手術治療。憩室瘺、出血和狹窄/梗阻通常是憩室炎的亞急性或慢性後遺症，詳見其他專題：

●(See "Diverticular fistulas".)
（參見 “憩室瘺”）

●(See "Colonic diverticular bleeding".)
（參見 “結腸憩室出血”）

●(See "Large bowel obstruction".)
（參見 “大腸梗阻”）

The diagnosis and medical management of acute diverticulitis are discussed separately. (See "Clinical manifestations and diagnosis of acute colonic diverticulitis in adults" and "Acute colonic diverticulitis: Triage and inpatient management" and "Acute colonic diverticulitis: Outpatient management and follow-up".)
急性憩室炎的診斷和內科治療詳見其他專題。（參見 “成人急性結腸憩室炎的臨床表現和診斷” 和 “急性結腸憩室炎的分診和住院治療” 和 “急性結腸憩室炎的門診治療和隨訪”）

SURGERY FOR COMPLICATIONS
併發症手術

Perforation — The Hinchey classification is the most widely recognized system for categorizing the severity of perforated diverticulitis [11]:
穿孔  — Hinchey 分類是用於對穿孔性憩室炎嚴重程度進行分類的最廣泛認可的系統[11]：

●Stage I – Pericolic or mesenteric abscess
第一階段 – 結腸周或腸系膜膿腫

●Stage II – Walled-off pelvic abscess
第二階段 – 圍壁式盆腔膿腫

●Stage III – Generalized purulent peritonitis
第三階段 – 全身性化膿性腹膜炎

●Stage IV – Generalized feculent peritonitis
第四期 – 全身性糞便性腹膜炎

In general, the majority of microperforations (not included in the Hinchey classification), Hinchey I perforations, and Hinchey II perforations can be managed nonoperatively, while most Hinchey III and IV perforations require emergency surgical intervention.
一般來說，大多數微穿孔（不包括在 Hinchey 分類中）、Hinchey I 穿孔和 Hinchey II 穿孔可以非手術治療，而大多數 Hinchey III 和 IV 穿孔需要緊急手術干預。

Perforation with generalized peritonitis — Perforated diverticulitis with generalized peritonitis (Hinchey III or IV) is a life-threatening condition that mandates emergency surgery [5,6,12-14]. The primary goal of surgery is to achieve source control by removing the perforated segment of the colon. A secondary objective is to restore intestinal continuity, which depends on the patient's hemodynamic stability and the extent of peritoneal contamination [15-19].
穿孔伴全身性腹膜炎  —  穿孔性憩室炎伴全身性腹膜炎（Hinchey III.型或 IV.型）是一種危及生命的疾病，需要緊急手術[5,6,12-14]。手術的主要目標是通過切除結腸的穿孔部分來實現源控制。次要目標是恢復腸道連續性，這取決於患者的血流動力學穩定性和腹膜污染程度[15-19]。

Unstable patients with generalized peritonitis — Patients who are hemodynamically unstable due to perforated diverticulitis may not have the physiologic reserve to tolerate a colon resection and reconstruction. As such, damage control surgery should be expedited to obtain source control of their sepsis, while delaying less critical portions of the operation until after appropriate resuscitation [20-23]. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury".)
全身性腹膜炎  患者不穩定 —  穿孔性憩室炎導致血流動力學不穩定的患者可能沒有耐受結腸切除和重建的生理儲備。因此，應加快損傷控制手術，以控制膿毒症的來源，同時將手術中不太關鍵的部分推遲到適當的復甦后[20-23]。（參見 “重傷患者的損傷控制手術和復甦概述”）

In this setting, damage control surgery is performed in two stages [20]:
在這種情況下，損傷控制手術分兩個階段進行[20]：

●In the first stage, the perforated portion of the colon is resected and left in discontinuity, the peritoneum is lavaged, and the abdomen is temporarily closed.
在第一階段，結腸的穿孔部分被切除並保持不連續，腹膜被清洗，腹部暫時閉合。

●After the patient is further resuscitated, they are brought back for the second stage during which they are either definitely reconstructed (typically with a loop ileostomy) or with an end colostomy (ie, Hartmann procedure).
患者進一步復甦后，將患者帶回第二階段，在此期間，他們要麼進行明確重建（通常使用環形迴腸造口術），要麼進行終末結腸造口術（即 Hartmann 手術）。

Employing a staged approach permits the reconstruction to be performed with less time pressure and the patient to have more physiologic reserve to avoid potential complications (eg, anastomotic leak). In a meta-analysis of 256 patients, an anastomosis was possible in 73 percent of second-look surgeries, and over half of surviving patients were stoma free at discharge [22,24].
採用分階段方法可以在更小的時間壓力下進行重建，並且患者有更多的生理儲備以避免潛在的併發症（例如，吻合口漏）。一項 meta 分析納入了 256 例患者，發現 73%的二次手術可吻合，超過一半的存活患者在出院時造口無造口[22,24]。

Stable patients with generalized peritonitis — Stable patients with generalized peritonitis can generally tolerate a formal colon resection with either reconstruction or diversion. There is no widely accepted standard procedure here due to the extreme heterogeneity in patient presentations [14]. Options of surgical therapy include [7]:
病情穩定的全身性腹膜炎  患者 —  病情穩定的全身性腹膜炎患者通常可以耐受正式的結腸切除術，包括重建或改道。由於患者就診的極度異質性，這裡沒有被廣泛接受的標準程式[14]。手術治療的選擇包括[7]：

●The Hartmann procedure involves resecting the diseased colonic segment, creating an end colostomy and a rectal stump, and then reversing the colostomy in the future (figure 1) [16]. It is the most commonly performed surgery for colonic perforation because it eliminates the risk of an anastomotic leak when the patient is least able to tolerate it [25]. However, subsequent closure of the colostomy is a technically difficult operation associated with high morbidity and mortality rates [26,27]. As a result, colostomy closure is only performed in approximately 50 to 60 percent of all patients after a Hartmann procedure [28-30].
Hartmann 手術包括切除病變的結腸段，創建末端結腸造口術和直腸殘端，然後在未來逆轉結腸造口術 （ 圖 1）[16]。它是最常進行的結腸穿孔手術，因為它在患者最不能耐受時消除了吻合口漏的風險[25]。然而，隨後的結腸造口術閉合是一項技術上困難的手術，併發症發生率和死亡率高[26,27]。因此，在 Hartmann 手術后，約 50%-60%的患者才會進行結腸造口術閉合術[28-30]。

●Primary colorectal anastomosis can be performed with or without proximal diversion with a loop ileostomy (figure 2).
結直腸原發性吻合術可聯合或不聯合近端改道，採用環形迴腸造口術 （ 圖 2）。

●Laparoscopic lavage has been proposed as a less invasive alternative to colon resection in patients with Hinchey III perforated diverticulitis.
腹腔鏡灌洗已被提議作為 Hinchey III 穿孔性憩室炎患者結腸切除術的侵入性較小的替代方法。

For stable patients with generalized peritonitis, we suggest performing a primary anastomosis with or without proximal diversion rather than a Hartmann procedure. A 2018 systematic review and meta-analysis of randomized trials [31-33] found that primary resection and anastomosis had a similar major complication rate (relative risk [RR] 0.88, 95% CI 0.49-1.55) and mortality rate (RR 0.58, 95% CI 0.20-1.70) compared with the Hartmann procedure. However, patients were more likely to be stoma free (RR 1.4, 95% CI 1.18-1.67) and avoid major complications related to the stoma reversal procedure (RR 0.26, 95% CI 0.07-0.89) [34].
對於病情穩定的全身性腹膜炎患者，我們建議進行初次吻合術，伴或不伴近端分流，而不是 Hartmann 手術。2018 年一項隨機試驗的系統評價和 meta 分析[31-33]發現，與 Hartmann 手術相比，一期切除術和吻合術的主要併發症發生率（相對風險（relative risk [RR] 0.88,95%CI 0.49-1.55）和死亡率（RR 0.58,95%CI 0.20-1.70）相似。然而，患者更有可能無造口（RR 1.4,95%CI 1.18-1.67），並避免與造口逆轉手術相關的重大併發症（RR 0.26,95%CI 0.07-0.89）[34]。

A 2023 meta-analysis of two trials with long-term follow-up associated primary anastomosis with lower odds of long-term ostomy (odds ratio [OR] 0.02, 95% CI 0.003-0.195), long-term complications (OR 0.195, 95% CI 0.113-0.335), reoperations (OR 0.2, 95% CI 0.108-0.384), and incisional hernias (OR 0.184, 95% CI 0.102-0.333) compared with the Hartmann procedure [35].
一項 2023 年的 meta 分析納入了 2 項長期隨訪相關初次吻合術的試驗，與 Hartmann 手術相比，長期造口術（OR 0.02,95%CI 0.003-0.195）、長期併發症（OR 0.195,95%CI 0.113-0.335）、再手術（OR 0.2,95% CI 0.108-0.384）和切口疝（OR 0.184,95% CI 0.102-0.333）的幾率較低[35]。

The Hartmann procedure may be necessary for patients with a large burden of intra-abdominal contamination with stool, serious underlying comorbidities (eg, immunosuppression) that would render an anastomotic leak unsalvageable, or severely inflamed or edematous rectum that precludes a safe anastomosis.
對於腹腔內糞便污染負擔較大、有嚴重的基礎合併症（如免疫抑制）導致吻合口漏無法挽救，或直腸嚴重發炎或水腫導致無法安全吻合的患者，可能需要進行 Hartmann 手術。

Whether to protect a primary anastomosis with a diverting loop ileostomy depends on patient and intraoperative factors and surgeon experience. In a systematic review and meta-analysis of 17 nonrandomized studies comparing primary anastomosis with or without a diverting stoma, the 30-day mortality, major morbidity, anastomotic leak, reoperation rates, and length of stay were similar between the two groups [36]. Fewer patients had a permanent stoma after primary anastomosis without a diverting stoma than with a diverting stoma. The ongoing DIVERTI-2 trial is attempting to address this issue with higher-level evidence [37].
是否使用分流環迴腸造口術保護初次吻合口取決於患者和術中因素以及外科醫生的經驗。一項系統評價和 meta 分析納入了 17 項非隨機研究，比較了初次吻合口有無分流造口，結果顯示兩組的 30 日死亡率、主要併發症發生率、吻合口漏、再手術率和住院時間相近[36]。初次吻合后沒有分流造口的永久性造口的患者比有分流造口的患者要少。正在進行的 DIVERTI-2 試驗試圖用更高層次的證據來解決這個問題[37]。

Laparoscopic lavage should only be contemplated in the absence of fecal contamination (ie, Hinchey III), and patients should be advised that a reoperation (usually Hartmann procedure) may be necessary if lavage alone fails to control the sepsis or if a sigmoid carcinoma is later found. Despite earlier enthusiasm for this procedure in the 1990s [38], later randomized trials (SCANDIV [39,40], LOLA [41], DILALA [42-44]) found that major complications were more frequent after laparoscopic lavage than sigmoidectomy, whereas postoperative mortality rates (RR 1.03, CI 0.45-2.34) were not different between the two procedures [34,45,46]. Lavage is also associated with a higher recurrence rate of diverticulitis than colonic resection (OR 5.8, 95% CI 2.33-14.42) [35].
只有在沒有糞便污染的情況下（即 Hinchey III.）才應考慮腹腔鏡灌洗，並且應告知患者，如果單獨灌洗無法控制膿毒癥或後來發現乙狀結腸癌，則可能需要再次手術（通常是 Hartmann 手術）。儘管 1990 年代早些時候人們對這種手術充滿熱情[38]，但後來的隨機試驗（SCANDIV[39,40]、LOLA[41]、DILALA[42-44]）發現，腹腔鏡灌洗后主要併發症比乙狀結腸切除術更常見，而術后死亡率（RR 1.03，CI 0.45-2.34）在兩種手術之間沒有差異[34,45,46].與結腸切除術相比，灌洗憩室炎的復發率也更高（OR 5.8,95%CI 2.33-14.42）[35]。

Selecting an operative approach for perforated diverticulitis involves balancing two key objectives: reducing surgical morbidity (such as risks of anastomotic leaks and reoperations) and minimizing the need for stoma creation, particularly permanent stomas. The Hartmann procedure is frequently performed as it eliminates the risk of an anastomotic leak when the patient is acutely ill, yet it also carries the highest rate of permanent stomas. By contrast, laparoscopic lavage can avoid stoma formation if successful; however, it often requires subsequent rescue reoperations due to limited efficacy. Primary anastomosis may offer a lower stoma rate than the Hartmann procedure while also reducing the risk of septic complications and reoperations associated with laparoscopic lavage. The choice of surgical strategy must be individualized to best meet each patient's needs. For example, the Hartmann procedure may be preferable in an older patient with multiple comorbidities who is at high risk of dying if an anastomotic leak occurs, while laparoscopic lavage could benefit a fit patient with no signs of sepsis at presentation.
選擇穿孔性憩室炎的手術方法涉及平衡兩個關鍵目標：降低手術發病率（例如吻合口滲漏和再次手術的風險）和盡量減少造口的需要，尤其是永久性造口。哈特曼手術經常進行，因為它消除了患者急性疾病時吻合口漏的風險，但它的永久性造口率也最高。相比之下，腹腔鏡灌洗如果成功，可以避免造口形成;然而，由於療效有限，它通常需要隨後的搶救再次手術。與 Hartmann 手術相比，初次吻合術的造口率可能更低，同時還可以降低與腹腔鏡灌洗相關的膿毒症併發症和再次手術的風險。手術策略的選擇必須個體化，以最好地滿足每位患者的需求。例如，對於患有多種合併症的老年患者，如果發生吻合口漏，死亡風險很高，則 Hartmann 手術可能更可取，而腹腔鏡灌洗可能有益於就診時沒有膿毒癥跡象的健康患者。

Perforation with localized peritonitis — Localized perforations present acutely either as microperforation or as a mesocolic or pelvic abscess (Hinchey I or II). Microperforation can be managed like uncomplicated diverticulitis using antibiotics. For diverticular abscesses, treatment usually involves percutaneous image-guided drainage, or intravenous antibiotics if the abscess is small (<4 cm) or difficult to reach with a drainage catheter. Surgery may be required to salvage patients whose condition does not improve or worsens after antibiotic therapy and percutaneous drainage. (See "Acute colonic diverticulitis: Triage and inpatient management", section on 'Microperforation' and "Acute colonic diverticulitis: Triage and inpatient management", section on 'Abscess'.)
穿孔伴局限性腹膜炎  —  局部穿孔急性表現為微穿孔或結腸系膜或盆腔膿腫（Hinchey I.或 II）。微穿孔可以像使用抗生素一樣治療單純性憩室炎。對於憩室膿腫，治療通常包括經皮圖像引導引流，如果膿腫較小（<4 cm）或引流導管難以觸及，則靜脈注射抗生素。可能需要手術來挽救抗生素治療和經皮引流后病情沒有改善或惡化的患者。（參見 “急性結腸憩室炎的分診和住院治療”，關於'微穿孔'一節和 “急性結腸憩室炎的分診和住院治療”，關於'膿腫'一節 ）

Patients with a localized perforation can usually tolerate a preoperative bowel preparation. Thus, if the phlegmon or abscess can be resected with the colonic segment, a primary anastomosis is usually performed in these patients.
局部穿孔患者通常可以耐受術前腸道準備。因此，如果痰或膿腫可以用結腸段切除，通常會對這些患者進行初次吻合。

If there are concerns about either contamination or inflammation involving the surrounding tissue (eg, with a large pelvic abscess) but the bowel is not edematous, a primary anastomosis with proximal diversion can be performed. This is preferred to a Hartmann procedure as a protective loop ileostomy is easier to reverse than an end colostomy with a rectal stump [47,48].
如果擔心周圍組織受到污染或炎症（例如，有大盆腔膿腫），但腸道沒有水腫，可以進行近端改道的初次吻合術。這比 Hartmann 手術更可取，因為保護環迴腸造口術比直腸殘端末端結腸造口術更容易逆轉[47,48]。

Obstruction or stricture — It is rare for acute diverticulitis to be severe enough to cause a complete colonic obstruction. In patients who present with symptomatic large bowel obstruction, it is more likely that they already have an underlying sigmoid stricture from either a malignant or benign (chronic or recurrent diverticulitis) process.
梗阻或狹窄  —  急性憩室炎很少嚴重到導致結腸完全梗阻的情況。在出現癥狀性大腸梗阻的患者中，他們更有可能已經有惡性或良性（慢性或復發性憩室炎）過程導致的潛在乙狀結腸狹窄。

Regardless of the underlying etiology, patients who present with a symptomatic large bowel obstruction should be evaluated and treated accordingly (see "Large bowel obstruction"). There are two methods of relieving the colonic obstruction: endoscopic stenting and surgical resection/diversion.
無論基礎病因如何，應對有癥狀的大腸梗阻患者進行評估和相應治療（參見 “大腸梗阻”）。緩解結腸梗阻有兩種方法：內窺鏡支架置入術和手術切除/分流。

●Historically, endoscopic stenting is less effective for benign than for malignant colonic strictures [49]. In a 2014 systematic review, treating benign colorectal obstructions (most due to diverticulitis) with self-expanding stents resulted in more cases of perforation (12 versus 4 percent), stent migration (20 versus 10 percent), and recurrent obstruction (14 versus 7 percent) than stenting malignant colorectal obstructions [50]. When stenting was used as a bridging therapy to surgery, only 43 percent of patients with diverticulitis avoided a stoma. However, the success rates were higher in more recent series [51,52].
從歷史上看，內鏡支架置入術對良性結腸狹窄的效果不如惡性結腸狹窄[49]。2014 年的一項系統評價顯示，與支架置入術惡性結直腸梗阻相比，使用自擴張支架治療良性結直腸梗阻（大部分由憩室炎引起的結直腸梗阻）的穿孔（12% vs 4%）、支架移位（20% vs 10%）和復發性梗阻（14% vs 7%）[50]。當支架置入術作為手術的橋接療法時，只有 43% 的憩室炎患者避免了造口。然而，在最近的系列研究中，成功率更高[51,52]。

●In patients who present with large bowel obstruction, colonic resection for diverticular stricture usually requires a Hartmann procedure due to a significant size mismatch between a dilated colon and decompressed rectum.
對於出現大腸梗阻的患者，由於擴張的結腸和減壓的直腸之間存在顯著的大小不匹配，憩室狹窄的結腸切除術通常需要 Hartmann 手術。

Furthermore, a competent ileocecal valve in the context of a sigmoid stricture can set up a closed-loop obstruction, leading to significant colonic, especially cecal, distension. In some cases, this can progress to cecal ischemia or perforation, which adds complexity to the surgical treatment for the stricture.
此外，乙狀結腸狹窄情況下的感受態回盲瓣可能會形成閉環阻塞，導致明顯的結腸擴張，尤其是盲腸擴張。在某些情況下，這可能會發展為盲腸缺血或穿孔，這增加了狹窄手術治療的複雜性。

Depending on the location and extent of the ischemia or perforation, an attempt should be made to save the intervening transverse and left colon by constructing separate ileocolonic and colorectal anastomosis with or without protective ostomy. Some patients may require a subtotal colectomy, after which the terminal ileum can be anastomosed to the upper rectum if the patient is otherwise stable. There is a paucity of evidence guiding the treatment of this patient population as most large bowel obstructions are due to malignant disease. Surgical treatment of large bowel obstruction is discussed in another topic [53]. (See "Large bowel obstruction".)
根據缺血或穿孔的位置和範圍，應嘗試通過構建單獨的迴腸結腸和結直腸吻合口術來挽救中間的橫結腸和左結腸，伴或不帶保護性造口術。一些患者可能需要進行結腸次全切除術，如果患者在其他方面穩定，則可以將迴腸末端吻合到直腸上。缺乏指導該患者群體治療的證據，因為大多數大腸梗阻是由惡性疾病引起的。大腸梗阻的手術治療詳見另一專題[53]。（參見 “大腸梗阻”）

Fistulization — As a result of diverticulitis, a fistula can develop between the colon and another pelvic organ, such as the bladder (65 percent), vagina (25 percent), small bowel (7 percent), uterus (3 percent), or other sites. Diverticular fistulas rarely close spontaneously and therefore require surgical correction. The management of diverticular fistulas is discussed separately. (See "Diverticular fistulas".)
瘺管形成  —  憩室炎可導致結腸和另一個盆腔器官之間形成瘺管，如膀胱（65%）、陰道（25%）、小腸（7%）、子宮（3%）或其他部位。憩室瘺很少自發閉合，因此需要手術矯正。憩室瘺的治療詳見其他專題。（參見 “憩室瘺”）

Bleeding — Colonic diverticular bleeding is the most common cause of overt lower gastrointestinal bleeding in adults, and it often resolves spontaneously. However, if bleeding persists, stable patients may require endoscopic intervention, while hemodynamically unstable patients may need angiographic procedures to locate and control the source of bleeding. (See "Colonic diverticular bleeding", section on 'Management'.)
出血  —  結腸憩室出血是成人明顯下消化道出血的最常見原因，通常可自發消退。然而，如果出血持續存在，病情穩定的患者可能需要內鏡干預，而血流動力學不穩定的患者可能需要進行血管造影手術來定位和控制出血源。（參見 “結腸憩室出血”，關於'治療'一節 ）

Surgery for diverticular bleeding should be considered a last resort, only after all other efforts to identify and manage the bleeding source have been exhausted and the patient remains unstable despite resuscitation [54]. Studies of hospitalized patients with diverticular bleeding show that fewer than 1 percent ultimately require surgical intervention [55].
憩室出血手術應被視為最後的手段，只有在所有其他確定和控制出血源的努力都已用盡，並且患者在復甦后仍保持不穩定后[54]。對憩室出血住院患者的研究表明，最終需要手術干預的患者不到 1%[55]。

Segmental colectomy is performed when the source of bleeding can be localized with colonoscopy or angiography; subtotal colectomy is reserved for patients who continue to bleed without a documented site of bleeding; blind segmental resection should not be performed, due to a high rebleeding rate (approximately 40 percent) [56].
當結腸鏡檢查或血管造影可以定位出血源時，進行節段性結腸切除術;結腸次全切除術僅用於持續出血且沒有記錄出血部位的患者;盲節段切除術不應進行，因為再出血率較高（約 40%）[56]。

SURGERY FOR PERSISTENT SYMPTOMS
持續癥狀的手術 — 

Patients may require colon surgery for diverticulitis because of persistent or chronic symptoms that interfere with quality of life. Such patients generally fall into one of two categories:
由於持續或慢性癥狀影響生活品質，患者可能需要因憩室炎進行結腸手術。此類患者通常分為以下兩類之一：

●Failure of medical treatment – Patients who deteriorate or fail to improve despite three to five days of inpatient medical treatment with intravenous antibiotics may require surgery during the same hospitalization as further medical therapy is unlikely to resolve their diverticulitis. (See "Acute colonic diverticulitis: Triage and inpatient management", section on 'Failure of inpatient medical treatment'.)
藥物治療失敗 – 儘管靜脈注射抗生素住院治療了 3 至 5 天，但病情惡化或未能改善的患者可能需要在同一住院期間進行手術，因為進一步的藥物治療不太可能解決他們的憩室炎。（參見 “急性結腸憩室炎的分診和住院治療”，關於'住院治療失敗'一節 ）

●Chronic smoldering diverticulitis – Patients with acute diverticulitis who initially improve with medical treatment but later experience recurring symptoms, such as left lower quadrant abdominal pain, changes in bowel habits, or rectal bleeding, are considered to have chronic smoldering diverticulitis. If these symptoms persist for more than six weeks, patients should be referred for surgical evaluation. However, conditions like irritable bowel syndrome or other functional gastrointestinal disorders can present with similar symptoms, which should be excluded before any surgical intervention. (See "Acute colonic diverticulitis: Outpatient management and follow-up", section on 'Persistent or recurrent symptoms'.)
慢性冒煙性憩室炎 – 急性憩室炎患者最初通過藥物治療有所改善，但後來出現反覆出現癥狀，例如左下腹痛、排便習慣改變或直腸出血，被認為患有慢性冒煙性憩室炎。如果這些癥狀持續超過六周，應轉診患者進行手術評估。然而，腸易激綜合征或其他功能性胃腸道疾病等疾病可能會出現類似的癥狀，在任何手術干預之前都應排除這些癥狀。（參見 “急性結腸憩室炎的門診治療和隨訪”，關於'持續性或復發性癥狀'一節 ）

In the right patients, there is high-quality evidence that surgical resection may improve short-term functional outcomes and quality of life for those who remain symptomatic despite optimal medical therapy.
在正確的患者中，有高質量的證據表明，手術切除可能會改善那些儘管進行了最佳藥物治療但仍有癥狀的患者，其短期功能結果和生活品質。

●In a multicenter trial (DIRECT) of 109 patients who either had three or more prior episodes of diverticulitis in the past two years or had chronic smoldering symptoms after a single episode, elective laparoscopic colon surgery resulted in superior quality-of-life scores at six months and five years compared with conservative management despite inherent surgical complications (11 percent anastomotic leak; 15 percent reintervention) [57,58] and was found to be cost effective at five years [59]. About half of the patients managed nonoperatively ultimately required surgery due to severe ongoing complaints [58].
一項多中心試驗（multicenter trial， DIRECT）納入了 109 例患者，這些患者在過去 2 年內曾發生過 3 次或 3 次以上憩室炎，或在單次發作后出現慢性冒泡癥狀，結果發現擇期腹腔鏡結腸手術在 6 個月和 5 年時的生活品質評分優於保守治療，儘管存在固有的手術併發症（11%吻合口漏，15%）[57,58]，並發現在 5 年內具有成本效益[59]。約一半的非手術治療患者最終因持續嚴重主訴而需要手術[58]。

●The LASER trial enrolled 85 patients with either three or more episodes of recurrent diverticulitis, complicated diverticulitis, or chronic pain following diverticulitis. At six months, the Gastrointestinal Quality of Life Index (GIQLI) score improved by 11.8 points in patients who underwent sigmoid resection, compared with just 0.2 points in those receiving conservative treatment. This was despite the fact that 10 percent of patients who had surgery experienced severe complications, such as abscesses and anastomotic leaks. At two years, the mean GIQLI score was similar between both groups; fewer patients in the surgery group had recurrent diverticulitis (11 versus 61 percent). At four years, about one-third of patients in the conservative treatment group required surgical intervention [60]. Although elective sigmoid resection did not improve quality of life compared with conservative treatment in a four-year follow-up, it was effective in preventing recurrences of diverticulitis and did not lead to increased rates of postoperative complications.
LASER 試驗招募了 85 名患有 3 次或更多復發性憩室炎、複雜性憩室炎或憩室炎后慢性疼痛的患者。六個月時，接受乙狀結腸切除術的患者胃腸道生活質量指數 （GIQLI） 評分提高了 11.8 分，而接受保守治療的患者僅提高了 0.2 分。儘管事實上 10% 的手術患者出現了嚴重的併發症，例如膿腫和吻合口漏。兩年時，兩組之間的平均 GIQLI 評分相似;手術組復發性憩室炎患者較少（11% vs 61%）。4 年時，保守治療組約 1/3 的患者需要手術干預[60]。雖然在四年的隨訪中，擇期乙狀結腸切除術與保守治療相比沒有改善生活品質，但可有效預防憩室炎的復發，並且不會導致術后併發症發生率增加。

A one-stage colon resection with primary anastomosis is typically performed for patients with persistent or chronic symptoms from diverticulitis. However, intraoperative findings of complications may alter the operative plan to either a Hartmann procedure or the addition of a proximal diversion. In addition, surgeons may choose to protect the anastomosis in patients with poor nutritional status, immunosuppression, or other factors that could lead to anastomotic complications [61].
對於憩室炎持續或慢性癥狀的患者，通常進行一期結腸切除術和初次吻合術。然而，術中併發症的發現可能會改變手術計劃，要麼是 Hartmann 手術，要麼是增加近端改道。此外，對於營養狀況不佳、免疫抑制或其他可能導致吻合口併發症的因素，外科醫生可能會選擇保護吻合口[61]。

SURGERY FOR RECURRENT DIVERTICULITIS
復發性憩室炎的手術 — 

Surgical treatment for nonacute colonic diverticulitis has been de-escalating. The 2020 American Society of Colorectal Surgeons (ASCRS) guidelines advised against surgical resection for a prior history of uncomplicated diverticulitis that is successfully treated medically, regardless of the number of episodes [7]. Age is not a factor in deciding whether to operate as young patients are no longer thought to have more frequent or complicated recurrences [7].
非急性結腸憩室炎的手術治療一直在降級。2020 年美國結直腸外科醫師協會（American Society of Colorectal Surgeons， ASCRS）指南建議，無論發作次數如何，對於既往無併發症憩室炎病史，且經醫學治療成功，不要進行手術切除[7]。年齡不是決定是否手術的因素，因為年輕患者不再被認為復發更頻繁或更複雜[7]。

However, these guidelines recommend elective surgery for patients who have had a previous episode of complicated diverticulitis, even if they are currently asymptomatic, due to the elevated risk of severe complications or mortality from recurrent diverticulitis [7]. Immunosuppression used to be another indication for elective surgery, but the current management is more nuanced.
然而，這些指南建議對既往有複雜性憩室炎發作的患者進行擇期手術，即使他們目前沒有癥狀，因為復發性憩室炎發生嚴重併發症或死亡的風險增加[7]。免疫抑制曾經是擇期手術的另一個適應症，但目前的治療更加細緻入微。

If appropriate, elective surgery should be performed after all infection and inflammation have resolved, typically 10 to 12 weeks after an episode of acute diverticulitis; earlier surgery has been associated with a higher conversion rate and a longer hospital stay [62]. In a retrospective study of 332 patients, those who underwent laparoscopic surgery prior to three months after the latest acute episode were more likely to have residual inflammation (31 versus 11 percent), abdominal morbidities (21 versus 5 percent), and longer hospital stay (7.7 versus 5 days) compared with those who underwent surgery after three months [63]. A primary anastomosis without protective ostomy (ie, a one-stage procedure) is the standard procedure for diverticulitis.
如果合適，應在所有感染和炎症消退後進行擇期手術，通常在急性憩室炎發作后 10 至 12 周;早期手術與更高的轉化率和更長的住院時間有關[62]。一項回顧性研究納入了 332 例患者，發現與 3 個月後接受手術的患者相比，在最近一次急性發作后 3 個月前接受腹腔鏡手術的患者更可能出現殘留炎症（31% vs 11%）、腹部併發症發生率（21% vs 5%）和住院時間更長（7.7 vs 5 日）[63]。無保護性造口術的初次吻合術（即一階段手術）是憩室炎的標準手術。

Patients with prior complicated attack(s) — The 2020 ASCRS guidelines [7] recommend elective surgery for patients with one prior episode of complicated diverticulitis because some studies show that such patients are at a greater risk of developing complications or dying from a recurrent attack and therefore would benefit from early elective surgery [64,65].
既往有複雜性發作  的患者 — 2020 年 ASCRS 指南[7]建議對既往有 1 次複雜性憩室炎發作的患者進行擇期手術，因為一些研究表明，此類患者發生併發症或死於復發的風險更大，因此早期擇期手術可獲益[64,65]。

As an example, in a retrospective study of over 200,000 patients admitted for diverticulitis, 85 percent were managed medically, of whom 16 percent suffered a recurrent attack [64]. The following complications of the initial episode of diverticulitis were independent predictors of mortality during the recurrent episode: bowel obstruction (hazard ratio [HR] 1.33, 95% CI 1.06-1.65), abscess (HR 2.18, 95% CI 1.60-2.97), peritonitis (HR 3.14, 95% CI 1.99-4.97), sepsis (HR 1.88, 95% CI 1.29-2.73), and fistula (HR 3.50, 95% CI 2.17-5.66). The mortality rate with elective surgery after the initial episode was substantially lower than the mortality rate with emergency surgery during the recurrent episode (0.3 versus 4.6 percent).
例如，一項回顧性研究納入了超過 200,000 例憩室炎入院患者，發現 85%的患者接受了藥物治療，其中 16%的患者反覆發作[64]。憩室炎初次發作的以下併發症是復發期間死亡率的獨立預測因素：腸梗阻（HR 1.33,95% CI 1.06-1.65）、膿腫（HR 2.18,95% CI 1.60-2.97）、腹膜炎（HR 3.14,95% CI 1.99-4.97）、膿毒症（HR 1.88,95% CI 1.29-2.73）和瘺管（HR 3.50,95% CI 2.17-5.66）。初次發作后擇期手術的死亡率明顯低於復發發作期間急診手術的死亡率（0.3% vs 4.6%）。

Healed diverticular abscess — Whereas surgery is almost always indicated for complications such as fistula, obstruction, stricture, and free perforation, the optimal management of a healed diverticular abscess is less certain [66], as some evidence suggests that it is not as significant a risk factor for future complicated recurrence [67-73]. For patients who have recovered from a diverticular abscess, surgery may be performed to alleviate any persistent symptoms and their impact on the patient's quality of life rather than solely to prevent future episodes. This is especially true if the patient is medically complicated. The 2018 European Association of Endoscopic Surgery (EAES) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) consensus guidelines also suggested against routine surgery solely to prevent future attacks following a single episode of Hinchey I/II acute diverticulitis successfully treated nonoperatively [14].
憩室膿腫  癒合 —  雖然手術幾乎總是適用於瘺管、梗阻、狹窄和遊走穿孔等併發症，但癒合憩室膿腫的最佳治療不太確定[66]，因為一些證據表明憩室膿腫不是未來複雜復發的重要危險因素[67-73].對於從憩室膿腫中恢復的患者，可以進行手術以減輕任何持續癥狀及其對患者生活質量的影響，而不僅僅是為了預防未來的發作。如果患者病情複雜，則尤其如此。2018 年歐洲內鏡外科協會（European Association of Endoscopic Surgery， EAES）和美國胃腸和內鏡外科醫生協會（American Gastrointestinal and Endoscopic Surgeons， SAGES）的共識指南也建議，在單次 Hinchey I/II 型急性憩室炎成功非手術治療后，不要進行常規手術[14]。

Patients who are immunocompromised — Immunocompromised patients with acute diverticulitis often present late or with atypical symptoms. Although those who do not perforate can be managed nonoperatively, emergency surgery in this patient cohort is associated with very high morbidity and mortality rates [74].
免疫功能低下  的患者 —  免疫功能低下的急性憩室炎患者常晚期出現或出現非典型癥狀。雖然未穿孔的患者可以進行非手術治療，但該患者佇列的急診手術與極高的發病率和死亡率相關[74]。

For these patients, elective surgery is associated with lower morbidity and mortality rates compared with emergency surgery. However, elective surgery in immunosuppressed patients still carries a higher rate of surgical complications compared with elective surgery in immunocompetent patients [75]. Thus, the decision of whether to pursue elective colon surgery after one or more episodes of diverticulitis should be tailored to the individual patient through shared decision making [6,7].
對於這些患者，與急診手術相比，擇期手術的發病率和死亡率較低。然而，與免疫功能正常患者的擇期手術相比，免疫抑制患者的擇期手術手術併發症發生率仍然更高[75]。因此，在憩室炎發作 1 次或 1 次后，應根據患者個體的共同決策，決定是否進行擇期結腸手術[6,7]。

PERIOPERATIVE CONSIDERATIONS
圍手術期注意事項

●Colonoscopy – Whenever possible, colonoscopy should be performed prior to colon resection. This applies to all patients undergoing elective colon resection to prevent recurrent diverticulitis and most patients undergoing semielective colon resection for chronic smoldering diverticulitis. The purpose of the colonoscopy is not to diagnose diverticulitis but to exclude malignancy, which requires a more radical (oncologic) resection [76]. (See "Acute colonic diverticulitis: Outpatient management and follow-up", section on 'Colonoscopy for select patients'.)
結腸鏡檢查 – 只要有可能，應在結腸切除術之前進行結腸鏡檢查。這適用於所有接受擇期結腸切除術以預防復發性憩室炎的患者，以及大多數因慢性冒泡性憩室炎而接受半選擇性結腸切除術的患者。結腸鏡檢查的目的不是診斷憩室炎，而是排除惡性腫瘤，這需要更根治的（腫瘤學）切除術[76]。（參見 “急性結腸憩室炎的門診治療和隨訪”，關於'特定患者的結腸鏡檢查'一節 ）

●Antibiotics – Patients undergoing emergency or urgent surgery for acute diverticulitis should already be on antibiotics (table 1 and table 2 and table 3), the duration of which after surgery is discussed separately. (See "Antimicrobial approach to intra-abdominal infections in adults", section on 'Duration of therapy' and "Acute colonic diverticulitis: Triage and inpatient management", section on 'Intravenous antibiotics'.)
抗生素– 急性憩室炎急診或緊急手術的患者應已使用抗生素（ 表 1、 表 2 和表 3），術后持續時間詳見其他專題。（參見 “成人腹腔內感染的抗菌方法”，關於'治療持續時間'一節和 “急性結腸憩室炎的分診和住院治療”，關於'靜脈注射抗生素'一節 ）

Most patients undergoing elective surgery for diverticular disease receive a single dose of prophylactic antibiotics within one hour before incision, with administration not exceeding 24 hours. Antibiotic selection is discussed separately (table 4). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
大多數因憩室病接受擇期手術的患者在切口前 1 小時內接受單劑量預防性抗生素治療，給葯時間不超過 24 小時。抗生素的選擇詳見其他專題 （ 表 4）。（參見 “預防成人手術部位感染的抗菌藥物預防”）

●Bowel preparation – In general, we recommend mechanical bowel preparation and oral antibiotics before all resectional colorectal procedures when feasible, including those for diverticular disease. Preoperative bowel preparation is possible for all patients undergoing elective surgery and selected patients undergoing urgent surgery for Hinchey I or II diverticulitis. The indications for bowel preparation and the choice of agents are further discussed elsewhere. (See "Overview of colon resection", section on 'Bowel preparation'.)
腸道準備 – 一般來說，我們建議在可行的情況下，在所有結直腸切除手術之前進行機械腸道準備和口服抗生素，包括憩室病的手術。所有接受擇期手術的患者和接受 Hinchey I 或 II 憩室炎緊急手術的特定患者都可以進行術前腸道準備。腸道準備的指征和藥物的選擇詳見其他專題。（參見 “結腸切除術概述”，關於'腸道準備'一節 ）

●Stoma marking – Before surgery, patients should be advised of the possibility of a stoma, and the potential stoma site should be marked by a stoma therapist when available.
造口標記 –手術前，應告知患者造口的可能性，並應由造口治療師（如果有）標記潛在的造口部位。

●Ureteral stent – There is no evidence for or against prophylactic ureteral stent placement. Surgeons may use it selectively based on imaging and patient characteristics (eg, for complex, chronic, or fistulous diverticular disease where anatomic distortion by the diverticular phlegmon is expected) [14]. (See "Overview of colon resection", section on 'Prophylactic ureteral stenting'.)
輸尿管支架 – 沒有證據支持或反對預防性輸尿管支架置入。外科醫生可根據影像學和患者特徵選擇性地使用該療法（例如，對於複雜、慢性或瘺管憩室疾病，預計憩室痰會導致解剖變形）[14]。（參見 “結腸切除術概述”，關於'預防性輸尿管支架置入術'一節 ）

●Patient positioning – We prefer a modified lithotomy or a split leg position, which permits intraoperative proctoscopy and the use of a circular stapler in case an anastomosis is performed.
患者體位 – 我們更喜歡改良的截石術或分腿體位，這允許術中進行直腸鏡檢查，並在進行吻合時使用圓形吻合器。

●Enhanced recovery – Fast-track recovery protocols have been shown to incrementally improve outcomes of gastrointestinal surgeries, including elective colon surgery for diverticular disease (table 5). As an example, a retrospective study showed that managing patients according to a fast-track recovery protocol shortened the time from surgery to the first solid meal (2.3 versus 3.6 days), first bowel movement (2.6 versus 3.5 days), and hospital discharge (3 versus 5 days) compared with traditional postcolectomy care [77]. In addition, patients on a fast-track recovery protocol also suffered fewer complications (15 versus 26 percent). Fast-track protocols in colorectal surgery are discussed elsewhere. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)".)
促進恢復 –快速恢復方案已被證明可以逐步改善胃腸道手術的結局，包括憩室病的擇期結腸手術 （ 表 5）。例如，一項回顧性研究表明，與傳統的結腸切除術后治療相比，根據快速恢復方案管理患者可縮短從手術到第一次固體進餐（2.3 日 vs 3.6 日）、第一次排便（2.6 日 vs 3.5 日）和出院（3 日 vs 5 日）的時間[77]。此外，採用快速康復方案的患者併發症也較少（15% vs 26%）。結直腸手術的快速通道方案詳見其他專題。（參見 “非心臟大手術後加速恢復概述”）

OPERATIVE CONSIDERATIONS  作注意事項

●We prefer anatomic resection of the sigmoid colon. An anatomic resection ensures proper mobilization of the colon, hence the formation of a tension-free anastomosis.
我們更喜歡乙狀結腸的解剖切除術。解剖切除確保結腸的適當活動，從而形成無張力吻合口。

●The descending colon should be fully mobilized to provide sufficient colonic length to ensure a tension-free anastomosis. Although routine splenic flexure mobilization has not been shown to decrease either perioperative morbidities [78] or recurrences [79], it may be required to further increase colonic length in selected patients. In several studies, splenic flexure mobilization was performed in about half of the patients [78,79].
降結腸應充分活動以提供足夠的結腸長度，以確保無張力吻合。雖然尚未顯示常規脾屈動能降低圍手術期併發症[78]或復發[79]，但可能需要進一步增加特定患者的結腸長度。在幾項研究中，約一半的患者進行了脾屈動活動[78,79]。

●The proximal margin is placed where the colon becomes soft and nonedematous. It is not necessary to resect all diverticula-bearing colon proximal to the intended anastomosis to prevent recurrence since diverticula in the transverse or descending colon rarely cause further symptoms [80].
近端邊緣位於結腸變軟且無水腫的地方。由於橫結腸或降結腸憩室很少引起進一步癥狀，因此沒有必要切除擬吻合口近端的所有含憩室結腸以防止復發[80]。

●Distal transection should occur at or below the rectosigmoid junction in the upper third of the rectum where the teniae coli coalesce, at the level of the sacral promontory. A colorectal anastomosis has a four times lower risk of recurrent diverticular disease compared with a colosigmoid anastomosis [79].
遠端橫切應發生在直腸上三分之一的直腸乙狀結腸交界處或下方，大腸細球合併處，骶骨岬水準。結直腸吻合術發生憩室疾病復發的風險是結腸乙狀結腸吻合術的 4 倍[79]。

●To qualify for a one-stage resection, the bowel must be well vascularized and nonedematous, and the anastomosis should be tension free and well prepared.
要獲得一期切除的資格，腸道必須血管化良好且無水腫，吻合口應無張力且準備充分。

●Either a hand-sewn or stapled anastomosis can be performed based on surgeon preference, as there is no difference in outcomes [79]. For stapled anastomoses, the stapler not reaching and effacing the staple line of the rectal stump is indicative of a residual sigmoid colon. In this situation, the residual sigmoid colon should be resected to prevent recurrences, as opposed to advancing the stapler out the anterior wall of the rectum [14]. An intraoperative leak test should be performed to evaluate the integrity of the anastomosis.
根據外科醫生的偏好，可以進行手工縫製或吻合吻合術，因為結局沒有差異[79]。對於吻合吻合口，吻合器沒有到達直腸殘端的釘線並消失表明乙狀結腸殘留。在這種情況下，應切除殘留的乙狀結腸以防止復發，而不是將吻合器推進到直腸前壁[14]。應進行術中滲漏試驗以評估吻合口的完整性。

●As there is no evidence to support routine peritoneal drainage [81], whether to leave such a drain is left to the surgeon's discretion.
由於沒有證據支援常規腹膜引流[81]，是否留下這種引流管由外科醫生自行決定。

OPEN VERSUS MINIMALLY INVASIVE APPROACH
開放式與微創方法 — 

Colonic resection for diverticulitis can be performed open or minimally invasively (laparoscopic or robotic). The minimally invasive approach is preferred when feasible because it affords superior short-term outcomes and comparable long-term outcomes to open resection [14,82-92].
憩室炎的結腸切除術可以進行開放式或微創（腹腔鏡或機器人）。在可行的情況下，首選微創方法，因為它提供與開放性切除術更好的短期結局和相當的長期結局[14,82-92]。

Whereas minimally invasive surgery has become the norm for elective colon resection for diverticular disease [93], its advantage in emergency surgery (ie, for complicated diverticulitis) is less certain [94-97].
雖然微創手術已成為憩室疾病擇期結腸切除術的常態[93]，但微創手術在急診手術（即複雜憩室炎）中的優勢不太確定[94-97]。

●In a meta-analysis of 19 nonrandomized studies comparing 1014 patients undergoing elective laparoscopic surgery with 1369 patients undergoing open surgery, open surgery was associated with significantly higher rates of wound infection (relative risk [RR] 1.85, 95% CI 1.25-2.78), blood transfusion (RR 4, 95% CI 1.67-10), postoperative ileus (RR 2.7, 95% CI 1.52-5), and incisional hernia (RR 3.7, 95% CI 1.56-8.33) [98]. The rates of serious complications (eg, anastomotic leak or stricture, inadvertent enterotomy, small bowel obstruction, intra-abdominal bleeding, or abscess formation) were comparable between the groups.
一項 meta 分析納入了 19 項非隨機研究，比較了 1014 例擇期腹腔鏡手術患者與 1369 例開放手術患者，結果顯示開放手術與傷口感染率顯著升高（相對風險（RR）為 1.85,95%CI 1.25-2.78）、輸血率（RR 4,95%CI 1.67-10）、術后腸梗阻（RR 2.7,95%CI 1.52-5）和切口疝（RR 3.7， 95% CI 1.56-8.33）[98]。兩組之間嚴重併發症（如吻合口漏或狹窄、意外腸切開術、小腸梗阻、腹腔內出血或膿腫形成）的發生率相當。

●A 2017 Cochrane review of three randomized trials (two for complicated diverticulitis, one for elective resection) found insufficient evidence to either support or refute the superiority of laparoscopic surgery over open surgery for diverticular disease [99]. Similarly, a 2018 meta-analysis of five trials comparing laparoscopic sigmoid resection versus open sigmoid resection for the treatment of acute complicated diverticulitis found no significant difference in short-term postoperative overall morbidity (RR 0.89, 95% CI 0.61-1.31) and long-term postoperative major morbidity (RR 0.78, 95% CI 0.46-1.31) [100].
2017 年的一項 Cochrane 評價納入了 3 項隨機試驗（2 項針對複雜性憩室炎，1 項針對擇期切除），發現沒有足夠的證據支援或反駁腹腔鏡手術優於開放手術治療憩室病[99]。同樣，2018 年一項 meta 分析納入了 5 項試驗，比較了腹腔鏡乙狀結腸切除術與開放性乙狀結腸切除術治療急性複雜性憩室炎的效果，發現術后短期總發病率（RR 0.89,95%CI 0.61-1.31）和術后長期主要發病率（RR 0.78,95%CI 0.46-1.31）無顯著差異[100]。

While minimally invasive surgery is now commonly used for elective sigmoid resection for diverticular disease, the optimal approach for complicated cases or acute indications remains unclear. In these situations, outcomes are likely influenced more by the patient's condition and the severity of the disease than by the choice of surgical technique itself.
雖然微創手術現在常用於憩室疾病的擇期乙狀結腸切除術，但複雜病例或急性適應症的最佳方法仍不清楚。在這些情況下，結果可能更多地受到患者病情和疾病嚴重程度的影響，而不是手術技術本身的選擇。

OUTCOMES  結果 — 

The mortality rates after colon surgery for diverticular disease range from 1.3 to 5 percent depending on the severity of illness and the presence of comorbidities [15,101].
憩室病結腸手術后的死亡率為 1.3%-5%，具體取決於疾病的嚴重程度和合併症的存在[15,101]。

●Emergency surgery for acute perforated diverticulitis is associated with the highest mortality rate of 15 to 25 percent and a morbidity rate of up to 50 percent [15-18,102,103].
急性穿孔性憩室炎急診手術的死亡率最高，為 15%-25%，發病率高達 50%[15-18,102,103]。

●The incidence of postoperative complications following elective surgery for diverticular disease varies widely from 5 to 38 percent [94]. Laparoscopic surgery conveys a lower risk of postoperative complications compared with open resection [98].
憩室病擇期手術術后併發症的發生率差異很大，從 5%到 38%不等[94]。與開腹切除術相比，腹腔鏡手術術后併發症的風險較低[98]。

Patients are typically cured of their diverticular disease after surgery. However, 15 percent will develop new diverticula in the remaining colon, and 2 to 11 percent will require repeat surgery [80,104,105]. Recurrences are more likely if the distal resection margin is not extended onto the rectum. (See 'Operative considerations' above.)
患者的憩室病通常在手術後治癒。然而，15%的患者在其餘結腸中會出現新的憩室，2%-11%的患者需要重複手術[80,104,105]。如果遠端切除邊緣沒有延伸到直腸，則更容易復發。（參見上文 '手術注意事項'）

However, after elective surgery, up to 40 percent of patients may complain of persistent abdominal pain in the same location as their prior diverticular disease [106]. Such patients require further evaluation by gastroenterologists as these symptoms are more attributable to coexisting functional intestinal disorders (eg, irritable bowel syndrome) rather than recurrent diverticulitis. (See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults" and "Treatment of irritable bowel syndrome in adults".)
然而，擇期手術后，高達 40%的患者可能會主訴持續性腹痛，其部位與既往憩室病相同[106]。此類患者需要胃腸病學家進一步評估，因為這些癥狀更多地歸因於並存的功能性腸道疾病（如腸易激綜合征），而不是復發性憩室炎。（參見 “成人腸易激綜合征的臨床表現和診斷” 和 “成人腸易激綜合征的治療”）

In a retrospective study of 17,368 patients from the National Surgical Quality Improvement Program data (2012 to 2018) who underwent colectomy for acute diverticulitis, cancer was found in 164 (0.94 percent) [107]. Eighty-four percent of patients had locally advanced tumors (T3-4), and 37 percent had positive lymph nodes. In multivariate analysis, cancer was associated with sepsis, weight loss, and low albumin. For this reason, colonoscopy should be performed prior to colon resection whenever possible. (See 'Perioperative considerations' above.)
一項回顧性研究納入了 17,368 例國家外科品質改進計劃（National Surgical Quality Improvement Program）數據（2012-2018 年）因急性憩室炎而接受結腸切除術的患者，發現 164 例（0.94%）患者發現癌症[107]。84%的患者為局部晚期腫瘤（T3-4），37%為淋巴結陽性。在多變數分析中，癌症與敗血症、體重減輕和低白蛋白有關。因此，應盡可能在結腸切除術之前進行結腸鏡檢查。（參見上文 '圍手術期注意事項'）

Specific complications of colon surgery are discussed elsewhere. (See "Management of anastomotic complications of colorectal surgery" and "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery".)
結腸手術的具體併發症詳見其他專題。（參見 “結直腸手術吻合口併發症的處理” 和 “結直腸手術的腹腔內、盆腔和泌尿生殖系統併發症的處理”）

SOCIETY GUIDELINE LINKS  學會指南連結 — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Colonic diverticular disease".)
全球選定國家和地區的學會和政府贊助的指南鏈接詳見其他專題。（參見 “學會指南鏈接：結腸憩室病”）

INFORMATION FOR PATIENTS
患者教育 — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
UpToDate 提供兩種類型的患者教育材料，即“基礎”和“超越基礎”。基礎患者教育文章以通俗易懂的語言編寫，適合 5 ^{至 6 年級的}閱讀水準，它們回答了患者可能對特定疾病提出的四五個關鍵問題。這些文章最適合想要一般概述和喜歡簡短、易於閱讀材料的患者。Beyond the Basics 患者教育文章更長、更複雜、更詳細。這些文章是在 10 ^至 12 ^年級閱讀水準上寫的，最適合想要深入資訊並熟悉一些醫學術語的患者。

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword(s) of interest.)
以下是與此主題相關的患者教育文章。我們鼓勵您將這些主題列印或通過電子郵件發送給您的患者。（您還可以透過搜索“患者教育”和感興趣的關鍵字來查找有關各種主題的患者教育文章。

●Basics topics (See "Patient education: Diverticulitis (The Basics)" and "Patient education: Diverticulitis – Discharge instructions (The Basics)".)
基礎篇（參見 “患者教育：憩室炎（基礎篇）” 和 “患者教育：憩室炎–出院指導（基礎篇）”）

SUMMARY AND RECOMMENDATIONS
總結與推薦

●Risk and indications of surgery for diverticulitis – Although most patients with acute diverticulitis can be treated medically, approximately 15 percent will require surgery for various indications (up to 32 percent among hospitalized patients). Surgery is required to treat severe complications, persistent symptoms, or recurrences of diverticulitis. (See 'Introduction' above.)
憩室炎手術的風險和指征 –儘管大多數急性憩室炎患者可以接受藥物治療，但大約 15%的患者需要針對各種適應症進行手術治療（住院患者中高達 32%）。需要手術來治療嚴重的併發症、持續癥狀或憩室炎的復發。（參見上文 '引言'）

●Surgery for complications
併發症手術

•Perforation – The majority of microperforations and localized perforations (abscesses) can be managed nonoperatively, while most generalized perforations require surgical intervention. (See 'Perforation' above.)
穿孔 – 大多數微穿孔和局部穿孔（膿腫）可以通過非手術治療，而大多數全身性穿孔需要手術干預。（參見上文 '穿孔'）

-For hemodynamically unstable patients with generalized perforation and septic shock, we suggest damage control surgery, rather than a conventional colonic resection (Grade 2C). Performed in two stages, damage control surgery permits rapid source control and time for resuscitation before reconstruction, which minimizes stoma rate. (See 'Unstable patients with generalized peritonitis' above.)
對於血流動力學不穩定的全身穿孔和感染性休克患者，我們建議進行損傷控制手術，而不是傳統的結腸切除術（2C 級 ）。損傷控制手術分兩個階段進行，可以在重建前快速控制源頭和復甦時間，從而最大限度地降低造口率。（參見上文 '不穩定的全身性腹膜炎患者'）

-For stable patients with generalized perforation, we suggest colon resection with primary anastomosis rather than a Hartmann procedure or a nonresectional drainage procedure such as laparoscopic lavage (Grade 2B). Compared with a Hartmann procedure, a primary anastomosis reduces the stoma rate without increasing the complication rate. It can be performed with or without proximal diversion. In fit patients with nonfeculent peritonitis, laparoscopic lavage is another option but may incur a higher reoperation or recurrence rate than resection. (See 'Stable patients with generalized peritonitis' above.)
對於全身穿孔的穩定患者，我們建議進行結腸切除術並進行初次吻合，而不是 Hartmann 手術或腹腔鏡灌洗等非切除引流手術（2B 級 ）。與 Hartmann 手術相比，初次吻合術可降低造口發生率而不增加併發症發生率。它可以在有或沒有近端分流的情況下進行。對於患有非糞便性腹膜炎的健康患者，腹腔鏡灌洗是另一種選擇，但可能比切除引起更高的再手術或復發率。（參見上文 '全身性腹膜炎穩定患者'）

-Patients with microperforation or localized perforation generally respond to antibiotic therapy or percutaneous drainage. For those who fail nonoperative management, we suggest a colonic resection with primary anastomosis rather than a Hartmann procedure or nonresection drainage (Grade 2C). Proximal diversion may be added for anatomic/patient factors. (See 'Perforation with localized peritonitis' above.)
微穿孔或局部穿孔患者通常對抗生素治療或經皮引流有反應。對於非手術治療失敗的患者，我們建議進行結腸切除術並進行初次吻合，而不是 Hartmann 手術或非切除引流（2C 級 ）。對於解剖/患者因素，可以增加近端分流。（參見上文 '穿孔伴局限性腹膜炎'）

•Other complications – Patients with obstruction/stricture or fistulization to another organ (eg, bladder, vagina) require surgical intervention. Diverticular bleeding rarely requires surgical treatment. (See "Large bowel obstruction" and "Diverticular fistulas" and "Colonic diverticular bleeding".)
其他併發症 –其他器官（如膀胱、陰道）梗阻/狹窄或瘺管化的患者需要手術干預。憩室出血很少需要手術治療。（參見 “大腸梗阻” 和 “憩室瘺” 和 “結腸憩室出血”）

●Surgery for persistent symptoms – Patients with persistent or chronic symptoms despite medical therapy warrant evaluation for either urgent or semielective surgery. Most can undergo colon resection with primary anastomosis. Surgery has been associated with a higher quality of life compared with continued medical therapy or observation. (See 'Surgery for persistent symptoms' above.)
持續癥狀的手術 – 儘管進行了藥物治療，但仍有持續或慢性癥狀的患者需要評估緊急或半擇期手術。大多數可以接受結腸切除術和初次吻合術。與持續的藥物治療或觀察相比，手術與更高的生活質量相關。（參見上文 '持續性癥狀的手術治療'）

●Surgery for recurrence prevention – For most asymptomatic patients with a prior episode of complicated diverticulitis, we suggest elective surgery to avoid the risk of future recurrence. An exception is asymptomatic patients with a healed diverticular abscess who are at lower risk for developing another complicated attack. (See 'Patients with prior complicated attack(s)' above.)
手術預防復發 –對於大多數既往有複雜性憩室炎發作的無癥狀患者，我們建議擇期手術以避免未來復發的風險。一個例外是憩室膿腫癒合的無癥狀患者，他們發生另一次複雜發作的風險較低。（參見上文 '既往有複雜發作的患者'）

Elective surgery is typically performed 10 to 12 weeks after an episode of acute diverticulitis when all infection and inflammation have resolved, and a primary anastomosis without protective ostomy (ie, a one-stage procedure) is standard. (See 'Surgery for recurrent diverticulitis' above.)
擇期手術通常在急性憩室炎發作后 10-12 周進行，此時所有感染和炎症均已消退，並且無需保護性造口的初次吻合術（即單期手術）是標準的。（參見上文 '復發性憩室炎的手術'）

●Open versus minimally invasive surgery – While minimally invasive surgery is now commonly used for elective sigmoid resection for diverticular disease, the optimal approach for complicated cases or acute indications remains unclear. (See 'Open versus minimally invasive approach' above.)
開放手術與微創手術 – 雖然微創手術現在常用於憩室病的擇期乙狀結腸切除術，但複雜病例或急性適應症的最佳方法仍不清楚。（參見上文 '開放式 vs 微創入路'）

ACKNOWLEDGMENT  確認 — 

The editorial staff at UpToDate acknowledges Tonia Young-Fadok, MD, and John H Pemberton, MD, who contributed to earlier versions of this topic review.
UpToDate 的編輯人員感謝 Tonia Young-Fadok， MD 和 John H Pemberton， MD，他們為本專題綜述的早期版本做出了貢獻。