Laparoscopic versus open reversal of Hartmann's procedure: a retrospective review

A proactive technique for reversal of Hartmann's procedure: lifting the rectal stump to the abdominal wall

BACKGROUND

Reversing Hartmann's procedure is complicated owing to dense adhesions resulting from inflammation in the pelvic region. These adhesions pose challenges in identifying the rectum and increase the risk of pelvic organ injuries.

METHODS

We propose a technique to lift and fix the rectal stump to the abdominal wall to diminish adhesions to the rectum and facilitate identification of the rectal stump.

RESULTS

The patient underwent Hartmann's procedure for generalized peritonitis resulting from perforation of the sigmoid colon. The abdominal cavity was significantly contaminated with fecal ascites, and postoperative pelvic adhesions were anticipated. Therefore, the rectal stump was lifted. The outcomes demonstrated that despite the presence of dense adhesions in the abdominal cavity, the rectal segment was promptly identified during the reversal of Hartmann's procedure. The procedure proceeded smoothly and was deemed satisfactory.

CONCLUSIONS

The technique of lifting and fixing the rectal stump to the abdominal wall is useful in cases where dense pelvic adhesions are anticipated during the subsequent reversal of Hartmann's procedure.

Single-port laparoscopic reversal of Hartmann's procedure through the colostomy site: technical aspects and early postoperative outcomes

BACKGROUND

Single-port laparoscopic surgical approaches offer improved cosmetic outcomes and enhance recovery following surgery. The purpose of the study was to assess the reliability and efficacy of a single-port laparoscopic Hartmann's reversal(SPL-HR) through the colostomy site.

METHODS

Prospective data from consecutive patients who underwent SPL-HR between 2020 and 2024 was analysed. Once the colostomy was detached from abdominal wall, a single-port device was introduced through the colostomy site. After mobilizing the rectal stump and afferent colon, colorectal anastomosis was carried out using a circular stapler transanally under laparoscopic vision. Postoperative care and discharge decisions were made following the ERAS protocol. Patient demographics, details of Hartmann's procedure, intraoperative outcomes, and early postoperative outcomes were evaluated.

RESULTS

SPL-HR was successfully performed in 23 of 27 patients (85.1%), with a median operation time of 92 (50-172) min and a median blood loss of 100 (10-360) mL. Five patients (21.7%) experienced a postoperative complication. Two of them experienced grade 3a complications according to Clavien-Dindo classification: one with an intraabdominal abscess and one with a hematoma at the colostomy site, both requiring drainage under local anaesthesia. Anastomotic leak or mortality wasn't observed in patients. Functional recovery measures such as first flatus time and time to resuming a soft diet were favourable, with a median length of hospital stay of 4 (2-9) days.

CONCLUSION

The SPL-HR technique is a reliable and efficient method that is easy to perform. It has acceptable complication rates while improving postoperative recovery and reducing the length of hospital stay.

The Effect of Bowel Anastomosis on Outcomes in Complex Abdominal Wall Reconstruction: A 10-Year Retrospective Cohort Study

BACKGROUND

In patients who require complex abdominal wall reconstruction (CAWR), the need for a bowel anastomosis could impact procedure choice and outcome. In this retrospective cohort study, we examine the effect of bowel anastomosis on complications and hernia recurrence.

METHODS

All patients who underwent CAWR between 2011 and 2021 by the senior author were reviewed in a retrospective cohort analysis. Patients were included if they met the above criteria. Patients were excluded if they did not undergo the above procedure or if they underwent a different procedure simultaneously. Univariate analysis was performed for patients who underwent bowel anastomosis, and multiple variable logistic regression analysis was performed with respect to overall complications.

RESULTS

A total of 264 patients underwent CAWR over a 10-year interval. A total of 41 patients underwent bowel anastomosis (16%), and 223 patients (84%) underwent CAWR without bowel anastomosis. Mean patient age was 55.50 ± 11.55 years. Mean patient body mass index was 32.36 ± 7.31 kg/m 2 . Mean follow-up time was 10.20 months. There was a significant difference in hernia repair etiology, with higher rates of recurrent hernia repair among patients receiving bowel anastomosis (odds ratio, 2.98; 95% confidence interval, 1.49-5.95; P = 0.0018). Acellular dermal matrix was used more frequently in patients who required a bowel anastomosis (odds ratio, 3.74; 95% confidence interval, 1.75-8.00; P = 0.0018). Major and minor complications were also significantly higher in this cohort. Regression analysis for overall complications revealed the presence of bowel anastomosis, fascial repair technique, and follow-up time as independent predictors of overall complications.

CONCLUSION

Bowel anastomosis performed at the time of CAWR significantly increased the rate of overall and major complications but did not predict hernia recurrence. Plastic surgeons should utilize this information in counseling patients and in deciding the most appropriate hernia repair technique.

Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies

BACKGROUND

The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence.

OBJECTIVE

To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction.

DATA SOURCES

A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023.

STUDY SELECTION

Randomized controlled trials and propensity score-matched studies.

INTERVENTIONS

Emergency colonic resection, self-expanding metallic stent, and decompressing stoma.

MAIN OUTCOME MEASURES

Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates.

RESULTS

Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively.

LIMITATIONS

There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction.

CONCLUSIONS

This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Postoperative effects of laparoscopic Hartmann reversal: A multicenter propensity score matched study

BACKGROUND

Although the advantages of laparoscopic Hartmann reversal (LHR) compared to open Hartmann reversal (OHR) have been reported in the literature, the number of multicenter studies with good matching investigating this topic is rare. In the present study, we aimed to confirm the advantages of LHR in terms of short-term outcomes through propensity score matching of LHR and OHR groups, using data collected from multiple institutions.

METHODS

Patients who underwent Hartmann reversal at six institutions under the Catholic Medical Center of the Catholic University of Korea between January 1, 2005, and December 31, 2021, were included. The patients were divided into the LHR and OHR groups based on the technique used. The two groups were matched using propensity score matching (1:1 ratio, logistic regression with the nearest-neighbor method). The primary outcome was postoperative ileus (POI) frequency, and secondary outcomes were time to solid diet (days) and length of stay (days).

RESULTS

Among 337 patients, propensity score matching was performed on 322, after excluding 15 who had undergone open conversion. Of these, 63 patients were assigned to each group through propensity score matching. There was no difference in the frequency of adhesiolysis (77.8% vs. 82.5%, p = 0.503) or the operation time. (210 (IQR 159-290) vs. 233 (IQR 160-280), p = 0.718) between the two groups. As the primary outcome, the LHR group showed significantly lower POI frequency than the OHR group. (4.8% vs. 22.2%, p = 0.0041) Regarding the secondary outcomes, the LHR group showed a shorter period to solid diet than the OHR group. The length of hospital stay was also significantly shorter in the LHR group (4 vs. 6, p < 0.0001; 9 vs. 12, p<0.0001).

CONCLUSION

LHR is an effective method to ensure faster recovery of patients after surgery compared to OHR.

Laparoscopic versus open Hartmann reversal: a propensity score matching analysis

PURPOSE

The purpose of this study was to compare the short-term outcomes between laparoscopic Hartmann reversal (LHR) and open Hartmann reversal (OHR) in patients who had undergone Hartmann surgery for colorectal cancer (CRC).

METHODS

The patients who underwent Hartmann reversal (HR) at the First Affiliated Hospital of Chongqing Medical University from Jun 2013 to Jun 2022 were retrospectively enrolled. The LHR group and the OHR group were compared using propensity score matching (PSM) analysis.

RESULTS

A total of 89 patients who underwent Hartmann reversal (HR) were enrolled in this study. There were 48 (53.9%) patients in the LHR group and 41 (46.1%) patients in the OHR group. After 1:1 ratio PSM, no difference in baseline information remained (p > 0.05). There was no significant difference in operation time, blood loss, postoperative hospital stay, and postoperative complications (p > 0.05) before and after PSM. In the multivariable logistic regression analysis, pre-operative albumin < 42.0 g/L was an independent risk factor (p = 0.013 < 0.05, OR = 0.248, 95% CI = 0.083-0.741) for the HR-related complications; however, LHR/OHR was not a predictive risk factor (p = 0.663, OR = 1.250, 95% CI = 0.500-3.122).

CONCLUSION

Based on the current evidence, although there was no difference in short-term prognosis, LHR still had some advantages considering that it was less invasive to the patient.

Reversal of Hartmann's procedure: timelines, preoperative investigations and early outcomes. A single Australian institution's ten-year experience

BACKGROUND

Real-world data on outcomes following Hartmann's reversal is necessary to help optimize the patient experience. We have explored the timing between the index operation and its reversal; what investigations were carried out prior to this, and the associated short-term outcomes.

METHODS

A retrospective study of all patients who underwent Hartmann's reversal from 2010 to 2020 within a tertiary referral centre in Melbourne, Australia. One hundred from a total of 406 (25%) who underwent an emergency Hartmann's procedure had a subsequent reversal. Complete patient data was available for 83 of these patients.

RESULTS

The average patient age was 60 years, and the median time for reversal was 14.0 (IQR 10-23) months. Seventy-nine of 83 (95%) reversals had a preoperative endoscopic evaluation of both their rectal stump and a complete colonoscopy. Stoma stenosis (n = 2), patient refusal (n = 1) and emergency reversal (n = 1) were cited reasons for not undergoing preoperative endoscopic evaluation. A third (n = 28, 34%) had a computed tomography prior to reversal; the majority was due to their underlying cancer surveillance (n = 21, 75%). Reversal was associated with a morbidity rate of 47% (n = 39). Surgical site infections (SSIs) (n = 21, 25%) were the most common type of complications encountered, with the majority being superficial (n = 15, 71%). SSIs were associated with steroid use (5/21 versus 4/62, p = 0.03) and greater hospital length of stay (6 versus 10 days, p = 0.03).

CONCLUSION

Only a quarter of emergency Hartmann's procedures within our institution were reversed. A significant proportion developed postoperative complications. Surgical site infection was the most common morbidity.

Hartmann's Reversal: A Single-Centre Experience

A proctosigmoidectomy, commonly called Hartmann's procedure (HP), is the surgical resection of the rectosigmoid colon with the closure of the anorectal stump and creation of an artificial stomal opening (ostomy) on the abdomen (colostomy). It is generally performed with the intention of reversal once the underlying cause is treated. The aim of this study is to assess the predictive factors and intra-operative difficulties that might influence the decision to indicate or contra-indicate stomal reversal after HP. Patients who underwent HP between January 2010 and December 2017 were retrospectively evaluated in a single institution. Preoperative, intraoperative, and postoperative data were analysed for patients who underwent HP for benign as well as malignant conditions. The reversal rate was comparable with the proportion of benign cases, consistent with published evidence that reversal rates for diverticular disease are higher as compared to colorectal cancer. Disease progression/metastasis, advanced age, multiple co-morbidities, and procedure abandonment (frozen pelvis /leak) were the most common contra-indications for reversal.

Laparoscopic Hartmann's reversal has better clinical outcomes compared to open surgery: An international multicenter cohort study involving 502 patients

BACKGROUND

Hartmann's procedure (HP) is used in surgical emergencies such as colonic perforation and colonic obstruction. "Temporary" colostomy performed during HP is not always reversed in part due to potential morbidity and mortality associated with reversal. There are several contributing factors for patients requiring a permanent colostomy following HP. Therefore, there is still some discussion about which technique to use. The aim of this study was to evaluate perioperative variables of patients undergoing Hartmann's reversal using a laparoscopic and open approach.

METHODS

The multicenter retrospective cohort study was done between January 2009 and December 2019 at 14 institutions globally. Patients who underwent Hartmann's reversal laparoscopic (LS) and open (OS) approaches were evaluated and compared. Sociodemographic, preoperative, intraoperative variables, and surgical outcomes were analyzed. The main outcomes evaluated were 30-day mortality, length of stay, complications, and postoperative outcomes.

RESULTS

Five hundred and two patients (264 in the LS and 238 in the OS group) were included. The most prevalent sex was male in 53.7%, the most common indication was complicated diverticular disease in 69.9%, and 85% were American Society of Anesthesiologist (ASA) II-III. Intraoperative complications were noted in 5.3% and 3.4% in the LS and OS groups, respectively. Small bowel injuries were the most common intraoperative injury in 8.3%, with a higher incidence in the OS group compared with the LS group (12.2% vs. 4.9%, p < 0.5). Inadvertent injuries were more common in the small bowel (3%) in the LS group. A total of 17.2% in the OS versus 13.3% in the LS group required intensive care unit (ICU) admission (p = 0.2). The most frequent postoperative complication was ileus (12.6% in OS vs. 9.8% in LS group, p = 0.4)). Reintervention was required mainly in the OS group (15.5% vs. 5.3% in LS group, p < 0.5); mortality rate was 1%.

CONCLUSIONS

Laparoscopic Hartmann's reversal is safe and feasible, associated with superior clinical outcomes compared with open surgery.

Is laparoscopy a reliable alternative to laparotomy in Hartmann's reversal? An updated meta-analysis

BACKGROUND

The aim of this study was to perform a systematic review of the literature on and updated meta-analysis of surgical postoperative complications after laparoscopic Hartmann's reversal (LHR) and open Hartmann's reversal (OHR).

METHODS

Studies comparing LHR versus OHR published from inception until June 2020 were selected and submitted to a systematic review and meta-analysis. Articles were searched in the MEDLINE and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0.

RESULTS

Twenty-three retrospective comparative studies (including 5 case-controlled studies) with a total of 3139 patients with LHR and a total of 10,325 patients with OHR were included. Meta-analysis showed that LHR was significantly associated with a decreased rate of revision surgery (OR = 0.73, 95% CI = 0.60-0.89, p < 0.001), anastomotic leakage (OR = 0.61, 95% CI = 0.49-0.75, p < 0.00001), postoperative morbidity (OR = 0.53, 95% CI = 0.47-0.58, p < 0.00001), intra-abdominal abscess (OR = 0.67 [0.52-0.87], 95% CI = , p = 0.003), wound abscess (OR = 0.53 [0.46-0.61], 95% CI = , p < 0.00001), and postoperative ileus (OR = 0.46, 95% CI = 0.29-0.72, p = 0.0008), respectively. Conversely, mortality was comparable between LHR and OHR.

CONCLUSIONS

These results suggest that LHR significantly improved surgical postoperative outcomes. However, considering the low level of evidence, further randomized trials are required to validate these findings.

[Results of reconstructive surgery with formation of low colorectal anastomoses after previous Hartmann's procedure]

OBJECTIVE

To evaluate the efficacy and safety of original access to short rectal stump compared to traditional direct one.

MATERIAL AND METHODS

A retrospective-prospective cohort comparative study was conducted between 2012 and 2018. Inclusion criterion was previous Hartmann's procedure with formation of a short rectal stump. Short stump was determined by its length from anal-skin line to the cupola <7 cm. There were 93 patients who were divided into 2 groups: the main group - new approach (n=38), the control group - traditional direct approach (n=55). We analyzed surgery time, blood loss, intraoperative, early and late postoperative morbidity.

RESULTS

Surgery time and blood loss were similar in both groups (299.9 vs. 288.3 min, p=0.82; 204.5 vs. 112.4 ml, p=0.94, respectively). Intraoperative complications occurred in 7 patients of the control group (0 vs. 12.7% (7/55), p=0.02). Incidence of early postoperative complications was similar (28.9% (11/38) vs. 25.5% (14/55), p=0.71). Adverse events Clavien-Dindo grade I and IIIa were more common in the main group, grade IIIb and IVa - in the control group. Incidence of delayed postoperative complications were similar (10.5% (4/38) vs. 7.3% (4/55), p=0.58). Colorectal anastomosis stricture prevailed in the control group, ureteral stricture - in the main group. Neurophysiological and complex urodynamic examinations revealed no between-group differences.

CONCLUSION

The new method ensures access to the rectal stump and formation of colorectal anastomosis under direct visual control. Postoperative outcomes demonstrated safety and effectiveness of this technique.

Outcomes of Laparoscopic vs. Open Reversal of Hartmann's Procedure: A Single Centre Experience

Introduction

Hartmann’s procedure is widely performed to fix colonic obstruction and perforation. It should ideally be followed by a reversal to restore bowel continuity. Reversal of Hartmann’s procedure was traditionally performed using an open technique. However, in recent days, the use of a laparoscopic approach has become increasingly popular. In our retrospective observational study, we aim to investigate the outcomes of laparoscopic versus open reversal of Hartmann’s procedure in a UK tertiary centre.

Methods

All patients who underwent reversal of their Hartmann’s procedure between January 2017 and December 2019 were included in the study. Data including demographics, days between primary operation and reversal, laparoscopic or open reversal, length of hospital stay following reversal procedure, 30-day readmission, mortality, and complication rate were collected. Statistical analysis was performed using t-test and chi-squared test.

Results

Forty-nine patients underwent reversal of Hartmann’s procedure from January 2017 to December 2019. The mean age of our cohort was 59.6 ± 13.2 years. There was no significant difference in baseline demographics of both groups, apart from the number of days between the primary operation and reversal procedure. There was also no statistical difference in length of stay, 30-day readmission, and mortality between laparoscopic and open reversal techniques. However, there was a higher incidence of wound complications in patients who underwent open reversal of Hartmann’s procedure.

Conclusion

The reversal of Hartmann’s procedure is a challenging operation. We found no significant difference between both open and laparoscopic approaches, but our study might be confounded by various factors including small sample size and selection bias. A larger, randomised study with greater statistical power is needed to confirm our findings.

Conventional Versus Minimally Invasive Hartmann Takedown: A Meta-analysis of the Literature

Although end colostomy closure following Hartmann's procedure is a major surgery that is traditionally performed by conventional celiotomy, over the last decade there has been a growing interest toward the application of different minimally invasive techniques. We aimed at evaluating the relative outcomes of conventional surgery versus minimally invasive surgery by meta-analyzing the available data from the medical literature. The PubMed/MEDLINE, Cochrane Library and EMBASE electronic databases were searched through August 2018. Inclusion criteria considered eligible all comparative studies evaluating open versus minimally invasive procedures. Conventional laparoscopy, robotic and single-port laparoscopy were considered as minimally invasive techniques. Overall morbidity, rate of anastomotic failure, rate of wound complications and mortality were evaluated as primary outcomes. Perioperative details and surgical outcomes were also assessed. The data of a total of 13,740 patients from 26 studies were eventually included in the analysis. There were no significant differences on baseline characteristics such as age, BMI and proportion of high-risk patients between the two groups of patients. As compared to the conventional technique, minimally invasive surgery proved significantly superior in terms of postoperative morbidity, length of hospital stay and rate of incisional hernia. The current literature suggests that minimally invasive surgery should be considered in performing Hartmann's reversal, if technically viable. However, due to the low level of the available evidence it is impossible to draw definitive conclusions.

Case Selection for Laparoscopic Reversal of Hartmann's Procedure

BACKGROUND

Laparoscopic reversal of Hartmann's procedure offers reduced morbidity compared with open surgery while improving reversal rates. However, it is one of the most technically challenging operations in minimally invasive colorectal surgery, with further < 20% of the reversal procedures being attempted laparoscopically. Complications related to late conversion to open surgery may suggest a selective use of the laparoscopic approach for Hartmann's reversal in a subgroup of patients: The aim of this study is to systematically investigate the literature to identify the ideal case for a laparoscopic approach.

MATERIALS AND METHODS

Data were extracted from a systematic review of the literature of Medline, Scopus, Web of Science, Embase, and the Cochrane Central Register of controlled trials. Subgroup analysis to identify suitable patients for laparoscopic surgery included age at surgery, body mass index, American Society of Anesthesiologists status, indication for the index Hartmann's procedure (HP), interval time to reversal from the index HP, conversion to open surgery, and temporary ileostomy rate.

RESULTS

A total of 862 patients were included, with 403 cases performed laparoscopically. Conversion to open surgery occurred in 65 patients (mean 16.1%). The indication for the HP showed a trend toward more benign patients included in the laparoscopic group, and the interval time between the index Hartmann's procedure and its reversal was significantly shorter in the laparoscopic group with a trend toward a higher rate of temporary ileostomy in patients undergoing an open procedure.

CONCLUSIONS

Patients' selection can explain these differences, with more complex disease operated via an open approach. Nevertheless, future studies are needed to demonstrate an increasing number of reversals attempted laparoscopically in high-volume centers.

Hartmann's reversal: a comparative study between laparoscopic and open approaches

BACKGROUND

A reversal of Hartmann's procedure can be performed using either a laparoscopic or open approach. However, laparoscopic reversal (LR) of Hartmann's procedure is challenging. This study was designed to compare the results between open and laparoscopic approaches.

METHODS

This was a retrospective study of prospectively collected data. We analysed 29 patients who received Hartmann's reversal at Korea University Anam Hospital between April 2007 and September 2014. All patients underwent either LR (n = 17) or open reversal (OR, n = 12).

RESULTS

Patient characteristics were similar between the LR and OR groups. There was also no difference in mean operation time (212.5 versus 251.8 min), diversion ileostomy, length of hospital stay, postoperative analgesic days, time to diet resumption (3.9 versus 6.2 days) or complication rate. Although the time to resuming a solid diet was not different between the two groups (P = 0.053), bowel movement occurred faster in LR patients (LR versus OR, 1.8 versus 2.8 days, P = 0.020). Patients in the LR group also had less blood loss during surgery (114.1 versus 594.2 mL, P = 0.026). There were no mortalities in this study.

CONCLUSION

LR of Hartmann's procedure resulted in faster bowel function recovery than the open method. Laparoscopic approaches are feasible even for patients who received an open Hartmann's procedure.

Transanal Hartmann's colostomy reversal assisted by laparoscopy: outcomes of the first 10 patients

INTRODUCTION

Restoration of intestinal continuity after Hartmann's procedure is a technically difficult surgery associated with significant morbidity and mortality. This study presents the short-term results of a new approach: a transanal Hartmann's colostomy reversal assisted by laparoscopy.

METHOD

This is a retrospective analysis of data collected in one tertiary hospital, from October 2013 to November 2015.

RESULTS

During the study period, there were ten cases of transanal Hartmann's reversal. Reasons for Hartmann's procedure were: complicated diverticulitis (4), anastomotic leak (3), and recto-sigmoid cancer (3). Rectal stump length was 10.4 ± 4.5 cm. Reconstruction was achieved in all patients. One low colorectal anastomosis was hand-sewn, the other 9 were stapled. Mean operative time was 204 ± 65 min. Diverting loop ileostomies were created in five patients and all were closed during the following year. One case required hand-assistance but there was no conversion to open surgery. Iatrogenic laparoscopic enterotomies occurred in four patients and all were repaired primarily without consequences. Three patients had a total of four post-operative complications: ileus (2), abdominal abscess and wound infection (1). None required reoperation. Mean length of stay was 7.2 ± 4.3 days. One required readmission.

CONCLUSION

A transanal Hartmann's reversal assisted by laparoscopy is a new approach for a difficult surgery. It has the potential to be an additional tool in the case of hostile pelvises or with a rectal stump difficult to identify. The surgery remains challenging and indications need to be clarified.

Considerations in Stoma Reversal

Temporary stomas are frequently used in the management of diverticulitis, colorectal cancer, and inflammatory bowel disease. These temporary stomas are used to try to mitigate septic complications from anastomotic leaks and to avoid the need for reoperation. Once acute medical conditions have improved and after the anastomosis has been proven to be healed, stomas can be reversed. Contrast enemas, digital rectal examination, and endoscopic evaluation are used to evaluate the anastomosis prior to reversal. Stoma reversal is associated with complications including anastomotic leak, postoperative ileus, bowel obstruction, enterocutaneous fistula, and, most commonly, surgical site infection. Furthermore, many stomas, which were intended to be temporary, may not be reversed due to postoperative complications, adjuvant therapy, or prohibitive comorbidities.

Reversal of the Hartmann's procedure: A comparative study of laparoscopic versus open surgery

BACKGROUND:

The Hartmann's operation, although less frequently performed today, is still used when initial colonic anastomosis is too risky in the short term. However, the subsequent procedure to restore gastrointestinal continuity is associated with significant morbidity and mortality.

PATIENTS AND METHODS:

The review of an institutional review board (IRB)-approved prospectively maintained database provided data on the Hartmann's reversal procedure performed by either laparoscopic or open technique at our institution. The data collected included: demographic data, operative approach, conversion for laparoscopic cases and perioperative morbidity and mortality.

RESULTS:

Over a 14-year period from January 1997 to August 2011, 74 Hartmann's reversal procedures were performed (laparoscopic surgery—49, open surgery—25). The average age was 55 years for the laparoscopic and 57 years for the open surgery group, respectively. Male patients represent 61% of both groups. There was no significant difference in operative time between the two groups (149 min vs 151 min; P = 0.95), and there was a tendency to lower morbidity (3/49—7.3% vs 4/25—16%; P = 0.24) in the laparoscopic surgery group. In the laparoscopic group, eight patients (16.3%) were converted to open surgery, mostly due to severe adhesions. The length of hospital stay was significantly shorter for the laparoscopic group (5 days vs 7 days; P = 0.44).

CONCLUSIONS:

The Hartmann's reversal procedure can be safely performed in the majority of the cases using a laparoscopic approach with a low morbidity rate and achieving a shorter hospital stay.

Retrospective Evaluation of Laparoscopic Versus Open Hartmann's Reversal: A Single-Institution Experience

PURPOSE

Restoration of intestinal continuity after Hartmann's procedure has significant associated morbidity. There has been a trend toward increasing utilization of laparoscopy in colorectal surgery, with improvements in short-term outcomes. This study evaluates our experience with laparoscopic Hartmann's procedure reversal.

METHODS

All patients who underwent laparoscopic and open reversal of Hartmann's procedure between 2007 and 2010 were reviewed. Demographics, length of stay, postoperative morbidity, and mortality were compared between the 2 groups.

RESULTS

Nineteen patients underwent laparoscopic Hartmann's reversal and 62 underwent open reversal. There were no statistically significant differences in demographics, comorbidities, mean operative times, blood loss, reoperation, and readmission rates between the groups. The laparoscopic group had a shorter length of hospitalization (5.7 vs. 7.9 d, P<0.01).

CONCLUSIONS

Laparoscopic reversal of Hartmann's pouch is a safe and feasible alternative to the open reversal technique. Patients who undergo the laparoscopic technique have a shorter length of hospital stay.

Laparoscopic versus open Hartmann's reversal: a systematic review and meta-analysis

BACKGROUND

Hartmann's reversal is a major surgical procedure with consistent morbidity and mortality rates. Laparoscopy has been extensively applied to colorectal surgery providing significant benefits on short- and long-term outcomes. We performed a meta-analysis of the current evidence comparing the short-term outcomes of laparoscopic Hartmann's reversal (LHR) to open Hartmann's reversal (OHR).

METHODS

A systematic search of Medline, Scopus, Web of Science, Embase, and the Cochrane database was performed. Comparative studies reporting short-term outcomes of LHR versus OHR with an intention-to-treat analysis were considered for eligibility. Primary outcome was 30-day morbidity. Secondary outcomes were 30-day mortality, 30-day reoperations, length of hospital stay (LOS), operating time, and estimated blood loss.

RESULTS

Thirteen studies comparing 862 patients (403 LHR vs 459 OHR) were included. There was no difference in mortality, while LHR was associated with a reduced overall postoperative 30-day morbidity (OR, 0.24; 95 % CI, 0.16 to 0.34). Wound infections (OR, 0.54; 95 % CI, 0.35 to 0.85) and ileus (OR, 0.47; 95 % CI, 0.25 to 0.87) were more common after OHR. LOS was shorter in the laparoscopic group as it was the time to flatus. Meta-regression analysis showed that the results were independent from potential effect modifiers.

CONCLUSIONS

LHR has less short-term complications than OHR in terms of overall morbidity, wound infection, and postoperative ileus. LOS is shorter in the LHR group, while no significant difference exists in the operating time. Randomized controlled trials are needed to confirm these findings on unbiased populations.

Who gets Hartmann's reversed in a regional centre?

BACKGROUND

Many patients who undergo a Hartmann's procedure do not have their stoma reversed. We analysed parameters and co-morbidity scales to assess their accuracy in predicting likelihood of undergoing reversal.

MATERIAL AND METHODS

Retrospective analysis of 165 patients from a prospective colorectal database who were discharged home following a Hartmann's procedure at Barwon Health (Geelong, Australia), a regional centre, between 2002 and 2010. Parameters measured included age, sex, time to reversal, ICU admission and pathology results were recorded. Patients' ASA, POSSUM and Elixhauser co-morbidity scales were retrospectively analysed.

RESULTS

Reversal of Hartmann's was performed in 74/165 (45%) patients after a median of 294 days (range 70-902). Age (mean 58.5 vs 72.9 years, p < 0.001), ICU stay (34/74 vs 66/91, p < 0.001), ASA (p < 0.002), Elixhauser co-morbidity count (mean 1.14 vs 1.92, p < 0.002) and a malignant diagnosis (9/74 vs 31/91, p < 0.002) were all associated with a decreased reversal rate on univariate analysis. Age was the only parameter found to be significant on multivariate analysis. The complication rate was 23/74, with 7/74 noted to have major complications (Clavian-Dindo III-IV). Reasons for not reversing patients included age and co-morbidities, patient refusal, and malignant disease progression.

CONCLUSIONS

More than half the patients undergoing a Hartmann's procedure did not proceed to a closure of their stoma. Age was the only parameter significant in predicting those patients undergoing reversal.