直腸から下行結腸は図１４の1から数字順に展開する．図２〜図４で少量だが腹壁直下に遊離ガス（▲）を認める．腹壁直下の遊離ガスはその近辺の腸管の穿孔を示す特異性は低いが，図４〜図８の腸間膜間の，液貯留を伴う腸管外ガス（△）は近辺の腸管穿孔を意味すると思っていい．図８〜図１４の強く造影される大きな腫瘤性病変（↑）は辺縁不整で，造影効果も不整で明らかな進行癌である．従って，診断はＳ状結腸癌の穿孔となる．手術でＳ状結腸癌の口側穿孔を認め，腹腔内の汚染は軽度であったがHartmann手術が施行された．図Aの↑が癌病変で，白矢印が穿孔部．徳洲会グループでの，Ｓ状結腸穿孔に対する手術法はHartmann手術（病変部を切除，肛門側を閉鎖し口側を人工肛門とする）がほとんどで，一期的吻合が行われたのはほんの数例だけである．筆者は半数以上に一期的吻合が可能と考える（下記文献参照）．

文献考察１）：15の文献（963例）のreviewから，切除・一期的吻合は57％に行われ，Hartmann手術（43％）より安全．
Dis Colon Rectum. 2006 Jul;49(7):966-81.
Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: a systematic review.
Constantinides VA, Tekkis PP, Athanasiou T, Aziz O, Purkayastha S, Remzi FH, Fazio VW, Aydin N, Darzi A, Senapati A.
PURPOSE: This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. METHODS: Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. RESULTS: Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. CONCLUSIONS: Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.PMID: 16752192

文献考察２）：98の文献考察から，腹膜炎があっても切除・一期的吻合はHartmann手術より安全
Dis Colon Rectum. 2004 Nov;47(11):1953-64.
Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review.
Salem L, Flum DR.
PURPOSE: This systematic literature review was designed to summarize and compare the reported outcomes of one-stage and two-stage operations for the treatment of perforated diverticulitis with peritonitis. METHODS: This review identified 98 published studies (1957-2003) dealing with the surgical management of perforated diverticulitis with peritonitis, either with primary resection and anastomosis or with the Hartmann's procedure. Aggregated results of adverse outcomes were calculated but statistical comparisons were not appropriate because of data and design heterogeneity. RESULTS: Operative mortality data from patients with diverticular peritonitis undergoing Hartmann's procedure (n = 1,051) were derived from 54 studies. Considering the Hartmann's procedure and its reversal procedures together, the mortality rate was 19.6 percent (18.8 percent for the Hartmann's procedure and 0.8 percent for its reversal), the wound infection rate was 29.1 percent (24.2 percent for the Hartmann's procedure and 4.9 percent for its reversal), and stoma complications and anastomotic leaks (in the reversal operation) occurred in 10.3 and 4.3 percent, respectively. Of 569 reported cases of primary anastomosis from 50 studies, the aggregated mortality rate was 9.9 (range, 0-75) percent with an anastomotic leak rate of 13.9 (range, 0-60) percent and a wound infection rate of 9.6 (range, 0-26) percent. CONCLUSIONS: Reported mortality and morbidity in patients with diverticular peritonitis who underwent primary anastomosis were not higher than those in patients undergoing Hartmann's procedure were. This suggests that primary anastomosis is a safe operative alternative in certain patients with peritonitis. Despite inclusion of only patients with peritonitis in this analysis, selection bias may have been a limitation and a prospective, randomized trial is recommended.PMID: 15622591

文献考察３）：Hinchey分類とは
Adv Surg. 1978;12:85-109.
Treatment of perforated diverticular disease of the colon.
Hinchey EJ, Schaal PG, Richards GK.
憩室炎合併症のHinchey分類．Stage1:Confined pericolic abscess. Stage 2:Distant abscess(retroperitoneal or pelvic). Stage 3:Generalized peritonitis caused by rupture of a pericolic or pelvic abscess,"noncommunicating" with bowel lumen because of obliteration of diverticular neck by inflammation. Stage 4:Fecal peritonitis caused by free perforation of a diverticulum("communicating"). 治療方針は，Stage１：5cm以下の小さい膿瘍は保存的に試みる．5cm以上のはドレナージ（可能なら経皮的に）が必要となる場合が多い．Stage２：ドレナージが必要（経直腸的，経腟的，開腹）．Stage３とStage４は緊急手術の適応である．