O papel da cirurgia electiva na diverticulite aguda do cólon

Catarina Tavares Machado, Luís Sá Malheiro

Resumo


O tratamento cirúrgico de doentes com antecedentes de diverticulite (DV) aguda tem sido alvo de debate ao longo dos últimos anos. Na primeira metade do século XX, apenas os casos de DV aguda complicada eram submetidos a intervenção cirúrgica. Na segunda metade, alguns estudos sugeriram que doentes com episódios de DV aguda não complicada teriam um risco acrescido de desenvolver doença complicada, com morbilidade e mortalidade significativas, estando assim o tratamento cirúrgico indicado. Em 1995 a ASCRS recomendou a sigmoidectomia eletiva após dois episódios de DV não complicada (ou um episódio se o doente tivesse menos de 50 anos) ou após um episódio de DV complicada. Estudos recentes colocaram em causa estas recomendações. Em primeiro lugar, apesar de a DV aguda ser uma doença particularmente agressiva aquando do primeiro episódio, os episódios subsequentes tendem a ser significativamente mais benignos e passíveis de tratamento conservador eficaz. Nestes casos, a cirurgia eletiva não reduz o risco de cirurgia urgente nem a mortalidade global devido a complicações da DV. Aliás, a cirurgia eletiva não é desprovida de riscos e alguns doentes poderão ainda desenvolver episódios de DV aguda após a intervenção. Em segundo lugar, nos doentes com menos de 50 anos, a doença não aparenta ser tão agressiva como previamente sugerido. Por último, relativamente aos episódios de DV complicada, é questionável se a sigmoidectomia eletiva será sempre necessária após uma drenagem percutânea eficaz de um abcesso. As guidelines internacionais são no entanto consensuais ao recomendarem a cirurgia eletiva precoce em doentes cronicamente imunodeprimidos, com doença do colagénio ou doença renal crónica. Enquanto aguardamos pelos resultados dos primeiros ensaios clínicos randomizados que comparam abordagens de tratamento distintas em doentes com episódios de DV aguda, o presente artigo visa resumir o debate relativo às indicações para realizar cirurgia eletiva.


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Referências


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