Analysis of the factors related to the decision of restoring intestinal continuity after Hartmann's procedure

Factors influencing postoperative adverse events after Hartmann's reversal

AIM

The study was performed to evaluate factors influencing postoperative adverse events after Hartmann's reversal (HR).

METHOD

This was a retrospective study of unselected patients who underwent HR after the Hartmann's procedure (HP) for left colonic perforation with peritonitis at a single institution. Data were retrieved from an Institutional Review Board-approved database. The study end-point was postoperative adverse events, which included mortality, complications, reoperations and 30-day readmission. Lag time was defined as the time from HP to HR. The results are expressed as mean±SD.

RESULTS

From 1997 to 2007, 204 (39.1%) of all patients who underwent the HP [60±16 years of age; 58% men; body mass index (BMI) 27.6±5.7; 2% were American Society of Anesthesiology (ASA) 1, 50.2% were ASA 2, 39.9% were ASA 3 and 7.9% were ASA 4) underwent HR at an interval of 158±107 days. There were 24 laparoscopic and 180 open HRs, with no deaths. The operating time was 167±64 min, estimated blood loss was 245±283 ml and the 30-day readmission rate was 4.9%. Eleven (5.4%) patients developed 14 (6.8%) complications and five (2.4%) of these patients required a new stoma at the time of HR or later. On multivariate analysis controlling for confounders, chronic renal failure requiring dialysis (OR=21.0; 95% CI: 1.5-284; P=0.02) was significantly associated with increased adverse events.

CONCLUSION

The study showed that chronic renal failure requiring dialysis was the only independent predictor of postoperative adverse event rates following HR.

Hartmann's operation: how often is it reversed and at what cost? A multicentre study

AIM

The study evaluated the rate of reversal of Hartmann's operation after the initial surgery and its morbidity.

METHOD

A multicentre retrospective study was carried out in seven hospitals in the Valencia area of patients who underwent Hartmann's operation from 2004 to 2008. The incidence of reversal was determined.

RESULTS

Four hundred and fifty-two patients of mean age 67.5 ± 15.4 years were included, of whom 78.8% had an emergency operation. The most common diagnosis was cancer (58.6%), although diverticulitis predominated in the emergency setting. At a median follow up of 44 months, 159 (35.2%) patients had undergone reversal, including 16.6% after elective surgery and 40.4% after an emergency Hartmann's procedure (P < 0.001). The most frequent reason why reversal was not done was death (74 [25%] patients). Patients undergoing reversal were younger and had a low ASA risk. Trauma was associated with a higher rate of reversal, followed by diverticular disease. Surgery was performed at a median of 10 months. An open approach with stapled anastomosis was used in most cases. The mortality was 3.5%. Complications occurred in 45.2%, with a 6.2% rate of anastomotic leakage. Complications were associated with age, diabetes mellitus, arteriosclerosis, obesity, smoking, chemotherapy and COPD.

CONCLUSION

Hartmann's reversal was performed in a small percentage of patients, mostly including those with benign disease. It had a significant morbidity.

Technical aspects and outcome of a standardized full laparoscopic approach to the reversal of Hartmann's procedure in a teaching centre

AIM

Laparoscopic reversal of Hartmann's procedure is technically demanding. We evaluated the technical aspects and outcome of a standardized approach in a single centre and examined the feasibility of including this into training curricula.

METHOD

The procedure entails a laparoscopy for adhesiolysis and identification and mobilization of the rectal stump. Mobilization of the splenic flexure is performed if necessary, and a colorectal anastomosis is fashioned after introduction of the stapler anvil via the colostomy with intra-abdominal positioning and delivery into the proximal colonic segment to be anastomosed. The stoma is excised as the last step in the operation.

RESULTS

Forty-two patients underwent the procedure over an 8-year period with either an expert (n=21) or trainee under expert mentorship (n=21) as first operator. Intra-operative data and postoperative outcomes were evaluated by retrospective review of clinical charts and theatre records. There was a 9.5% conversion rate and 0% mortality. One patient suffered a ureteric injury, while postoperative surgical complications occurred in 7 patients (including one clinical anastomotic leakage). The mean operative time was 117 min. There was no significant difference in intra operative technical parameters or postoperative clinical consequences between procedures performed by a trained surgeon or by a trainee under mentorship.

CONCLUSION

Adherence to a standardized operative protocol and expert mentorship allows this technically demanding operation to be associated with low conversion and complication rates. The absence of any difference between procedures performed by a trainee or trained surgeon suggests that the operation can be included in training programmes for laparoscopic surgery.

Application of a Tertiary Referral Scoring System to Predict Nonreversal of Hartmann's Procedure for Diverticulitis in a Community Hospital

Riansuwan et al. at Cleveland Clinic developed a scoring system to quantify the risk of Hartmann's nonreversal based on age, preoperative transfusion, pulmonary comorbidity, American Society of Anesthesiologists score, perforation, and anticoagulation. Our study validates the scoring system in a community hospital setting. Patients undergoing Hartmann's procedure for diverticulitis (2006 to June 2009) were identified from our hospital's database. Two groups were formed based on Hartmann's reversal within 1 year and those with nonreversal. An independent-sample t test and logistic regression using score and nine other variables as predictors of Hartmann's non-reversal were run. Sixty-three of 93 patients (67.7%) had a Hartmann's reversal. Higher scores and higher mean age were seen in the nonreversal group (15.5 ± 3.0 vs 12.1 ± 2.5 and 73 ± 15 vs 63 ± 14 years, respectively). Patients with scores 18 or above were not reversed; 43 of 49 patients (88%) with scores of 13 or less were reversed. Logistic regression confirmed that the only predictive variable for nonreversal is a higher score. The scoring system is predictive of nonreversibility of Hartmann's procedure for acute diverticulitis. This will be useful in allowing surgeons to strategize accurately and to counsel patients realistically. Higher scores may allow both the surgeon and patient to have a low threshold for exploring alternatives to Hartmann's procedure.

Restoration of intestinal continuity after Hartmann's procedure--not a benign operation. Are there predictors for morbidity?

BACKGROUND

Restoration of intestinal continuity is usually the second step after Hartmann's procedure and an established procedure in abdominal surgery, particularly for complicated diverticular disease. This descriptive study aimed to examine the morbidity and mortality associated with the procedure and to define potential risk factors.

PATIENTS AND METHODS

Data from 161 consecutive patients (median age 62 years, median BMI 25.2) undergoing elective surgery with restoration of bowel continuity between October 2001 and November 2008 at the Department of Surgery, University of Heidelberg, were included in this study. The association of potential prognostic variables with postoperative morbidity and mortality were examined by univariate and multivariate analyses.

RESULTS

The median time between the initial operation and the restoration of bowel continuity was 7 months. The median operation time was 185 min with a blood loss of 150 ml and median postoperative hospital stay of 9 days. Fifty-one percent of the patients had an uneventful recovery, whereas 49% had a postoperative complication. Surgical infections occurred in 18% of patients, 3.8% suffered from anastomotic leakage, and surgical re-exploration was necessary in 11.2%. Medical complications occurred in 21.1% of the patients, with pneumonia in 2.5% and urinary tract infections in 1.3%. One patient died 17 days after surgery. Univariate analysis showed that patients taking immunosuppressant drugs had significantly more wound infections and, interestingly, protective ileostomy was associated with postoperative anastomotic stenosis in our cohort. The administration of PRBC and a prolonged hospital were significantly associated with increased postoperative morbidity in the multivariate analysis.

CONCLUSIONS

Restoration of bowel continuity is a surgical procedure with high overall morbidity. The high morbidity confirmed in our study and various other papers justify a randomized clinical study to investigate the one-stage concept with primary anastomosis against the Hartmann's procedure and its reversal.

Factors affecting reversal following Hartmann's procedure: experience from two district general hospitals in the UK

PURPOSE

Restoration of gastrointestinal continuity following Hartmann's procedure is a challenging task associated with significant morbidity and mortality. New strategies to avoid a stoma are not readily available in general hospitals. Knowledge of the factors related to reversal is required to develop treatment strategies and counsel patients realistically. The present study was conducted to determine the reversal rate and factors affecting Hartmann's reversal in our practice.

METHODS

This study retrospectively reviewed the medical records of patients who underwent Hartmann's procedure and its reversal in two United Kingdom District Hospitals between January 1996 and December 2005.

RESULTS

Case notes from 184 patients were reviewed. Hartmann's procedure was reversed in 51 (34.7%) of the surviving patients, with a complication rate of 37.3% and no mortality. Reversal of Hartmann's procedure was significantly related to patient age (P < 0.001), mode of admission (P = 0.003), American Society of Anesthesiologists grading (P = 0.003), Dukes' staging (P = 0.003), benign pathology (P = 0.001), and extracolonic cancer (P = 0.023).

CONCLUSIONS

Despite the challenging nature of Hartmann's reversal, colostomy closure can be achieved without mortality in a district general hospital. Familiarity with the factors associated with reversal should enable a genuine discussion with patients regarding reversal.

Conventional and laparoscopic reversal of the Hartmann procedure: a review of literature

PURPOSE

The aim of this study was to provide a systematic overview on both laparoscopic and conventional Hartmann reversal. Furthermore, the Hartmann procedure is reevaluated in the light of new emerging alternatives.

METHODS

Medline, Ovid, EMBASE, and Cochrane database were searched for studies reporting on outcomes after Hartmann reversal.

RESULTS

Thirty-five studies were included in this review of which 30 were retrospective. A total of 6,249 patients with a mean age of 60 years underwent Hartmann reversal. Two thirds of patients were classified as American Society of Anesthesiologists (ASA) I-II. The mean reversal rate after a Hartmann procedure was 44%, and mean time interval between Hartmann procedure and Hartmann reversal was 7.5 months. The most frequent reported reasons for renouncing Hartmann reversal were high ASA classification and patients' refusal. The overall morbidity rate ranged from 3% to 50% (mean 16.3%) and mortality rate from 0% to 7.1% (mean 1%). Patients treated laparoscopically had a shorter hospital stay (6.9 vs. 10.7 days) and appeared to have lower mean morbidity rates compared to conventional surgery (12.2% vs. 20.3%).

CONCLUSION

Hartmann reversal carries a high risk on perioperative morbidity and mortality. The mean reversal rate is considerably low (44%). Laparoscopic reversal compares favorably to conventional; however, high level evidence is needed to determine whether it is superior.

Reversal of Hartmann's procedure following acute diverticulitis: is timing everything?

BACKGROUND

Patients who undergo a Hartmann's procedure may not be offered a reversal due to concerns over the morbidity of the second procedure. The aims of this study were to examine the morbidity post reversal of Hartmann's procedure.

METHODS

Patients who underwent a Hartmann's procedure for acute diverticulitis (Hinchey 3 or 4) between 1995 and 2006 were studied. Clinical factors including patient comorbidities were analysed to elucidate what preoperative factors were associated with complications following reversal of Hartmann's procedure.

RESULTS

One hundred and ten patients were included. Median age was 70 years and 56% of the cohort were male (n = 61). The mortality and morbidity rate for the acute presentation was 7.3% (n = 8) and 34% (n = 37) respectively. Seventy six patients (69%) underwent a reversal at a median of 7 months (range 3-22 months) post-Hartmann's procedure. The complication rate in the reversal group was 25% (n = 18). A history of current smoking (p = 0.004), increasing time to reversal (p = 0.04) and low preoperative albumin (p = 0.003) were all associated with complications following reversal.

CONCLUSIONS

Reversal of Hartmann's procedure can be offered to appropriately selected patients though with a significant (25%) morbidity rate. The identification of potential modifiable factors such as current smoking, prolonged time to reversal and low preoperative albumin may allow optimisation of such patients preoperatively.

Surgical practices for malignant left colonic obstruction in Germany

AIM

Data from the multicentric observation study Kolon/Rektum-Karzinome (Primärtumor) (primary colorectal carcinoma) are adduced to assess the status of surgical treatment of this condition in Germany and to compare different operative approaches in the emergency treatment of obstructive left-sided colon cancer, especially diversion (Hartmann's procedure) and primary anastomosis.

PATIENTS AND METHODS

Out of 15,911 patients with cancer of the left colon, recorded between 01.01.2000 and 31.12.2004, a total of 743 patients underwent emergency surgery for an obstructive tumour, performed as a radical resection. These patients were compared in respect of their risk profile and postoperative result.

RESULTS

In 57.9% (n=430) a one-stage operation (Group I), in 11.7% (n=87) a primary anastomosis with protective stoma (Group II), and in 30.4% (n=226), Hartmann's procedure (Group III) was performed. In Group III more patients were male, overweight and multimorbid, and more had advanced-stage tumours. The morbidity and hospital mortality (overall hospital mortality, 7.7%; n=57) did not differ significantly between the groups. The insertion of a protective stoma did not affect the rate of anastomotic insufficiency (Group I, 7%; Group II, 8.0%).

CONCLUSIONS

Primary anastomosis for emergency left colon carcinoma obstruction should only be regarded as indicated in cases where the risk profile is favourable. Our results suggest that in advanced obstruction and in high-risk cases Hartmann's procedure should be used. A protective stoma did not appear to confer any advantage.

Use of Hartmann's procedure in England

INTRODUCTION

Hartmann's procedure is widely used in the management of complicated diverticular disease and for colorectal cancer. Very little national data are available about the reasons for performing this procedure and the reversal rate.

METHOD

Hospital episode statistics data were obtained from The Department of Health and exported to an Access database for analysis. A cohort of patients who underwent a Hartmann's procedure between April 2001 and March 2002 were identified and followed until April 2006 to identify patients undergoing reversal of Hartmann's.

RESULTS

Approximately 3950 Hartmann's procedures were performed between April 2001 and March 2002, 2853 as an emergency and 1097 as an elective procedure. Most emergency Hartmann's were performed for benign disease (2067, 72.5%) whereas a majority of the elective Hartmann's were performed for cancer (756, 68.9%). Seven hundred and thirty six (23.3%) of these patients underwent reversal during the study period. The median time interval between a Hartmann's procedure and reversal was 284.5 days (interquartile range 181-468.25).

CONCLUSION

This study represents the single largest cohort in whom outcome after Hartmann's procedure has been studied. A majority of Hartmann's are performed as an emergency for benign diseases and most of them are not reversed.

Results of emergency Hartmann's operation for obstructive or perforated left-sided colorectal cancer

Background

Up to 15% of colorectal cancer (CRC) patients present with obstructive or perforated tumours, and require emergency surgery. The Hartmann's procedure (HP) provides the opportunity to achieve a potentially curative (R0) resection, while minimizing surgical trauma in poor-risk patients. The aim of this study was to assess the surgical (operative mortality), and oncological (long-term survival after curative resection) results of emergency HP for obstructive or perforated left-sided CRC.

Methods

A retrospective review of 50 patients who underwent emergency HP for perforated/obstructive CRC in our institution between 1995 and 2006.

Results

Median age of patients was 75 (range 22–95) years and the indications for HP were obstruction (32) and perforation (18 patients). Operative mortality and morbidity were 8% and 26% respectively. 35 patients (70%) were operated with a curative intent; in this group, overall 1-, 3- and 5-year survival rates were 80%, 54% and 40%. In univariate analysis, the presence of lymph node metastases was associated with poor 5-year survival (62% [Stage II] vs. 27% [Stage III], log-rank test, p = 0.02). Eleven patients (22%) had their operation reversed with a median delay of 225 (range 94–390) days. In this subgroup, two patients died from distant metastases, but there were no instances of loco-regional recurrence.

Conclusion

Hartmann's operation remains a good option to palliate symptoms in 30% of patients with left-sided CRC who are not candidates to a curative resection. For those who have a curative resection, the oncological outcome is acceptable, especially stage II patients, who appear to benefit the most from this surgical strategy.

Reversal of Hartmann's procedure through the stomal side: a new even more minimal invasive technique

BACKGROUND

Several minimal invasive, mainly laparoscopic-assisted, techniques for reversal of Hartmann's procedure (HP) have been published. The purpose of this pilot study was to assess a minimal invasive procedure through the stomal site that may compare favorably with open or laparoscopic-assisted procedures in terms of operative time, hospital stay and postoperative complications.

METHODS

HP reversal through the stomal side was attempted in 13 consecutive patients. Lysis of intra-abdominal adhesions was done manually through an incision at the formal stoma side, without direct vision between thumb and index finger. The rectal stump was identified intra-abdominally using a transanal rigid club. A manually controlled stapled end-to-end colorectal anastomosis was created.

RESULTS

Mean duration of operation was 81 min (range 58-109 min); mean hospital stay was 4.2 days (range 2-7 days). In two patients the procedure was converted because of strong adhesions in the lower pelvic cavity around the rectal stump that could not be lysed manually safely. No complications occurred in the patients in whom reversal was completely done through the stomal site.

CONCLUSIONS

In our opinion, restoration of intestinal continuity through the stomal side after HP is a feasible operation, without need for additional incisions. In the hands of a specialist gastrointestinal surgeon this technique can be attempted in all patients, as conversion to a laparoscopic-assisted or an open procedure can be performed when necessary.