Hartmann's procedure for obstructive carcinoma of the left colon and rectum: a comparative study with one-stage surgery

Hartmann's procedure, reversal and rate of stoma-free survival

Background Hartmann's procedure is a commonly performed operation for complicated left colon diverticulitis or malignancy. The timing for reversal of Hartmann's is not well defined as it is technically challenging and carries a high complication rate. Methods This study is a retrospective audit of all patients who underwent Hartmann's procedure between 2008 and 2014. Reversal of Hartmann's rate, timing, American Society of Anesthesiologists grade, length of stay and complications (Clavien-Dindo) including 30-day mortality were recorded. Results Hartmann's procedure (n = 228) indications were complicated diverticular disease 44% (n = 100), malignancy 32% (n = 74) and other causes 24%, (n = 56). Reversal of Hartmann's rate was 47% (n = 108). Median age of patients was 58 years (range 21-84 years), American Society of Anesthesiologists grade 2 (range 1-4), length of stay was eight days (range 2-42 days). Median time to reversal of Hartmann's was 11 months (range 4-96 months). The overall complication rate from reversal of Hartmann's was 21%; 3.7% had a major complication of IIIa or above including three anastomotic leaks and one deep wound dehiscence. Failure of reversal and permanent stoma was less than 1% (n = 2). Thirty-day mortality following Hartmann's procedure was 7% (n = 15). Where Hartmann's procedure wass not reversed, for 30% (n = 31) this was the patient's choice and 70% (n = 74) were either high risk or unfit. Conclusions Hartmann's procedure is reversed less frequently than thought and consented for. Only 46% of Hartmann's procedures were stoma free at the end of the audit period. The anastomotic complication rate of 1% is also low for reversal of Hartmann's procedure in this study.

Colon cancer surgery in patients operated on an emergency basis

OBJECTIVE

to study the epidemiological profile of patients with colorectal cancer operated on an emergency basis at the Bonsucesso Federal Hospital.

METHODS

this is a retrospective study of patients operated between January 1999 and December 2012. We analyzed the following variables: age, gender, clinical data, TMN staging, tumor location, survival and types of surgery.

RESULTS

we evaluated 130 patients in the study period. The most frequent clinical picture was intestinal obstruction, in 78% of cases. Intestinal perforation was the surgical indication in 15%. The majority (39%) of the patients had advanced TNM staging, compared with 27% in the initial stage. There were 39 deaths (30%) documented in the period. The most common tumor site was the sigmoid colon (51%), followed by the ascending colon (16%). The curative intent was performed in most cases, with adjuvant treatment being performed in 40% of the patients. Distant metastases were found in 42% of the patients and 10% had documented disease recurrence. Disease-free survival at two and five years was 69% and 41%, respectively.

CONCLUSION

there was a high mortality rate and a low survival rate in colorectal cancer patients operated on urgently.

Reviewing the Management of Obstructive Left Colon Cancer: Assessing the Feasibility of the One-stage Resection and Anastomosis After Intraoperative Colonic Irrigation

BACKGROUND

The management of obstructive left colon cancer (OLCC) remains debatable with the single-stage procedure of primary colonic anastomosis after cancer resection and on-table intracolonic lavage now being supported.

PATIENTS AND METHODS

Patients with acute OLCC who were admitted between January 2008 and January 2015 were distributed into 5 different groups. Group ICI underwent emergency laparotomy for primary anastomosis following colonic resection and intraoperative colonic lavage; Group HP underwent emergency Hartmann's Procedure; Group CON consisted of patients treated by conservative management with subsequent elective open cancer resection; Group COL were colostomy patients; and Group INT consisted of patients who had interventional radiology followed by open elective colon cancer resection. The demographics of the patients and comorbidity, intraoperative data, and postoperative data were collected, with P < .05 as significant.

RESULTS

There were 4 deaths in 138 cases (2.90%). There was only 1 patient who had anastomotic leakage (5.56%) in Group ICI, compared with none in Group HP and Group COL, 1 case in Group INT (7.69%), and 2 cases in Group CON (6.06%) (P > .05). Group INT and Group CON, when compared to the three surgical groups, Groups ICI, Group COL, and Group HP, individually, were statistically significant for the duration of surgery (P < .05).

CONCLUSIONS

Primary anastomosis following colonic resection after irrigation can be safely performed in selected patients, with the necessary surgical expertise, with no increased risk in mortality, anastomotic leakage, and other postoperative complications.

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.

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.

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.