Association between operative approach and complications in patients undergoing Hartmann's reversal

The use of self-expanding metallic stents in the management of benign colonic obstruction: a systematic review and meta-analysis

INTRODUCTION

Patients presenting with large bowel obstruction (LBO) frequently undergo emergency surgery that is associated with significant morbidity. In malignant LBO, endoscopic approaches with placement is a self-expanding metal stent (SEMS), have been proposed to prevent emergency surgery and act as a bridge to an elective procedure-with the intention of avoiding a stoma and reducing morbidity. This systematic review aims to assess the quality and outcomes of data available on the use of SEMS in benign causes of colonic obstruction.

METHODS

This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the protocol was registered on Prospero (ID: CRD42021239363). PUBMED, MEDLINE, HMIC, CINAHL, AMED, EMBASE, APA and Cochrane databases were searched. Studies were assessed for quality utilising the MINORS criteria. Pooled odds ratios with 95% confidence intervals (95% CI) were calculated using random effects models.

RESULTS

Sixteen studies were included for analysis. 300 patients were included with an average age of 68, and a male predominance of 57%. The quality of the papers included were at risk of bias. The pooled rate of technical success of procedure was 94.4% (95% CI 90.5-96.8%) The pooled rate of clinical success was 77.6% (95% CI: 66.6-85.7%). Adverse effects were low, with perforation 8.8% (4.5-16.6%), recurrence 26.5% (17.2-38.5%) and stent migration 22.5% (14.1-33.8%).

DISCUSSION

This systematic review demonstrated that SEMS for benign colonic obstruction can be a safe and successful procedure. The utilisation of SEMS in malignant disease as a bridge to surgery has been well documented. Whilst the limitations of the data interpreted are appreciated, we postulate that SEMS could be utilised to decompress patients acutely and allow pre-operative optimisation, leading to a more elective surgery with less subsequent morbidity.

Systematic review and meta-analysis of postoperative outcomes after combined stoma reversal and incisional hernia repair versus stoma reversal alone

BACKGROUND

The optimal management and timing of the abdominal wall reconstruction concomitantly performed with stoma closure are controversial. This study aims to compare short-term postoperative outcomes after concurrent stoma reversal (SR) with incisional hernia repair (IHR) and SR alone.

METHODS

PubMed/MEDLINE, Scopus and Web of Science databases were consulted to identify comparative studies. Random and common-effect models were used for the pooled analysis of the proportions and means.

RESULTS

Three studies met the inclusion criteria and a total of 504 patients who underwent simultaneous SR and IHR (N.=200) or SR alone (N.=304) were included in the meta-analysis. Postoperative morbidity increased after combined stoma and hernia surgery with a pooled OR for Surgical Site Occurrence (SSO) and severe postoperative complications (Clavien-Dindo ≥III) of 1.72 (95% CI 1.02-2.90) and 3.83 (95% CI 1.46-10.02), respectively. No significant difference was found between the two groups in terms of mortality (OR: 1.66; 95% CI 0.64-4.27), length of hospital stay (OR: 1.37; 95% CI 0.73-3.47). and readmission rate (OR: 1.17; 95% CI 0.67-2.06).

CONCLUSIONS

There is limited evidence suggesting that synchronous repair of SR and IH appears to be associated with a higher risk of SSO and severe postoperative complications. Therefore, a stepwise approach may be considered the best strategy in this setting.

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 Hartmann Procedure—A Surgery That Still Saves Lives

Background: A Hartmann operation, which is the intervention by which the lower part of the sigmoid and the upper part of the rectum are resected with the closing of the rectal stump and end colostomy, has as its indications: advanced or complicated rectosigmoid neoplasm, moderate biological condition of the patient, peritoneal sepsis, intestinal occlusion and fragile colonic wall, especially in the context of inflammatory changes. The Hartmann procedure can save lives even at the cost of a stoma reversal failure. Methods: The cases operated with the Hartmann procedure by an open approach or laparoscopic approach in our clinic, between 1 January 2016 and 31 December 2020, were admitted in this study and their medical records were reviewed, also making a comparison between the two types of approach. Univariate statistical comparisons but also a multivariate analysis was performed. Results: We performed 985 operations for intestinal and colonic occlusion (7.15% of the total operations in the clinic), 531 (54%) were non-tumor occlusions and 454 (46%) were occlusive tumors (88 Hartmann operations). Of these, 7.3% were laparoscopically performed (7 laparoscopic Hartmann operations and 23 diagnostic laparoscopies). A total of 11 cases (18%) also had colonic perforation. We compared laparoscopic Hartmann with open Hartmann and observed the benefits of laparoscopy for postoperative morbidity and mortality. The presence of pulmonary and cardiac morbidities is associated with the occurrence of general postoperative morbidities, while peritonitis is statistically significantly associated with the occurrence of local complications that are absent after the laparoscopic approach. Conclusions: The Hartmann procedure is still nowadays an operation widely used in emergency situations. Laparoscopy may become standard for the Hartmann procedure and reversal of the Hartmann procedure, but the percentage of laparoscopy remains low due to advanced or complicated colorectal cancer, poor general condition both at the first and second intervention, and the difficulties of reversal of the Hartmann procedure.

Open versus laparoscopic Hartmann's procedure: a systematic review and meta-analysis

PURPOSE

Hartmann's procedure is traditionally performed in emergency situations where single-step procedures with immediate anastomosis may be unsafe. However, it can be associated with significant morbidity and low colostomy reversal rate. Whilst randomised controlled trials and a Cochrane review have reported strong evidence of laparoscopic over open colectomies, no such reviews have been performed for Hartmann's procedure. Hence, this paper aims to summarise the existing evidence to determine the efficacy of laparoscopic Hartmann's procedure over its open counterpart.

METHODS

Embase, Medline and Cochrane databases were searched from inception to 15 November 2020 for keywords relating to 'laparoscopy' and 'Hartmann' using strict inclusion and exclusion criteria. Odds ratio was estimated for dichotomous outcomes and weighted mean difference was estimated for continuous outcomes.

RESULTS

From the 836 articles yielded from the search strategy, 12 articles were selected for meta-analysis. Pooled analysis revealed that laparoscopic Hartmann's procedure (LHP) allows for a shorter length of stay, and a lower risk of overall surgical site infections and superficial surgical site infections. There was no significant difference in other outcomes. Single-arm analysis of LHP also showed an unprecedented high colostomy reversal rate of over 80%.

CONCLUSION

In clinically suitable patients, laparoscopic Hartmann's procedure has benefits over open Hartmann's procedure. Despite the selection bias of single-arm studies, LHP has reported a high stoma reversal rate of over 80%. Future well-controlled studies should be done to affirm the findings.

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.

Laparoscopic Hartmann's reversal combined with interval lymphadenectomy after emergency surgery for perforated colon cancer: A case report

A 55-year-old man underwent Hartmann's procedure for generalized peritonitis caused by perforation of sigmoid colon cancer, which was histologically diagnosed as tubular adenocarcinoma penetrating the muscularis propria (T3). The extent of lymph node dissection was insufficient for the advanced cancer, according to the concept of complete mesocolic excision. Two months after surgery, he underwent laparoscopic Hartmann's reversal, combined with interval lymphadenectomy. En bloc resection of the colostomy, rectal stump and associated mesentery was performed with high ligation of the inferior mesenteric artery. Subsequently, the intestinal continuity was restored by end-to-end anastomosis. The postoperative course was uneventful except for infection at the stoma site. No lymph node metastasis was found by histological examination of the resected specimen, with no evidence of cancer recurrence 8 months after the initial 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.

Laparoscopic Hartmann Reversal: Experiences From a Developing Country

Purpose

Laparoscopic surgery is considered a promising approach for Hartmann reversal but is also a complicated major surgical procedure. We conducted a retrospective analysis at a city hospital in Vietnam to evaluate the treatment technique and outcomes of laparoscopic Hartmann reversal (LHR).

Methods

A colorectal surgery database in 5 years between 2015 and 2019 (1,175 cases in total) was retrieved to collect 35 consecutive patients undergoing LHR.

Results

The patients had a median age of 61 years old. The median operative time was 185 minutes. All the procedures were first attempted laparoscopically with a conversion rate of 20.0% (7 of 35 cases). There was no intraoperative complication. Postoperative mortality and morbidity were 0 and 11.4% (2 medical, 1 deep surgical site infection, and 1 anastomotic leak required reoperation) respectively. The median time to first bowel activity was 2.8 days and median length of hospital stay was 8 days.

Conclusion

When performed by skilled surgeons, LHR is a feasible and safe operation with acceptable morbidity rate.

Tissue content of metalloproteinase-9 and collagen in the colon with and without fecal stream after intervention with infliximab in rats subjected to Hartmann's surgery

PURPOSE

Quantify the tissue content of metalloproteinase-9 (MMP-9) and collagen in colic mucosa with and without intestinal transit after infliximab administration in rats subjected to Hartmann's surgery.

METHODS

Twenty-two rats underwent colon diversion by Hartmann's surgery. Animals were maintained with intestinal bypass for 12 weeks to induce development of diversion colitis (DC). Afterwards, animals were divided into three groups: first group received subcutaneous application of saline solution (SS) 0.9%, while the remaining two groups received infliximab subcutaneously at doses of 5 or 10 mg·kg-1·week-1 for five consecutive weeks. After the intervention, animals were sacrificed, removing the segments with and without intestinal transit. Diversion colitis was diagnosed by histological study, and its intensity was determined by a validated inflammatory scale. Tissue expression of MMP-9 was assessed byimmunohistochemistry, while total collagen was assessed by histochemistry. Tissue content of both was measuredby computerized morphometry.

RESULTS

Colon segments without intestinal transit had a higher degree of inflammation, which improved in animals treated with infliximab. Collagen content was always lower in those without intestinal transit. There was an increase in the collagen content in the colon without transit in animals treated with infliximab, primarily at a dose of 10 mg·kg-1·week-1. There was an increase in the content of MMP-9 in the colon without fecal transit, and a reduction was observed in animals treated with infliximab, regardless of the dose used.

CONCLUSIONS

Application of infliximab reduces inflammation, increases the total collagen content and decreases the content of MMP-9 in the colon without intestinal transit.

Laparoscopic Versus Open Hartmann Reversal: A Case-Control Study

Background

Laparoscopic reversal of Hartmann's procedure (LHR) offers reduced morbidity compared with open Hartmann's reversal (OHR). The aim of this study is to compare the outcome of laparoscopic versus open Hartmann reversal.

Materials and Methods

Thirty-four patients who underwent Hartmann reversal between January 2017 and July 2019 were evaluated. Patients underwent either LHR (n = 17) or OHR (n = 17). Variables such as numbers of patients, patient's age, sex, body mass index (BMI), comorbidities, ASA (American Society of Anesthesiology) score, indication for previous open sigmoid resection, mean operation time, rate of conversion to open surgery, length of hospital stay, mortality, and morbidity were retrospectively evaluated.

Results

The two groups of patients were homogeneous for gender, age, body mass index, cause of primary surgery, time to reversal, and comorbidities. In 97% of the cases, HP was done by open surgery. Our data revealed no difference in mean operation time (LHR: 180.5 ± 35.1 vs. OHR: 225.2 ± 48.4) and morbidity rate, although, in OHR group, there were more severe complications. Less intraoperative blood loss (LHR: 100 ± 40 mL vs. OHR: 450 ± 125 mL; p value <0.001), shorter time to flatus (LHR: 2.4 days vs. OHR: 3.6 days; p value <0.021), and shorter hospitalization (LHR: 4.4 vs. OHR: 11.2 days; p value <0.001) were observed in the LHR group. Mortality rate was null in both groups. Discussion. LHR is feasible and safe even for patients who received a primary open Hartmann's procedure. We suggest careful patient's selection allowing LHR procedures to highly skilled laparoscopy surgeons.

Frailty in older patients undergoing emergency colorectal surgery: USA National Surgical Quality Improvement Program analysis

Background

Frailty is associated with advancing age and may result in adverse postoperative outcomes. A suspected growing elderly population needing emergency colorectal surgery stimulated this study of the prevalence and impact of frailty.

Methods

Elderly patients (defined as aged at least 65 years by Medicare and the United States Census Bureau) who underwent emergency colorectal resection between 2012 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program population database. The five-item modified frailty index (mFI-5) score was calculated, and patients stratified into groups 0, 1 or 2 +. Main outcome measures were the prevalence of frailty, and its impact on 30-day postoperative morbidity, mortality, reoperation, duration of hospital stay (LOS), discharge destination and readmission.

Results

A total of 10 025 patients were identified with a median age 75 years, of whom 41·8 per cent were men. The majority (87·7 per cent) had an ASA fitness grade of III or greater and 3129 (31·2 per cent) were frail (mFI-5 group 2+). Major morbidity occurred in one-third of patients and the postoperative mortality rate was 15·9 per cent. Some 52·0 per cent of patients had a prolonged hospital stay and 11·0 per cent were readmitted. Although most patients (88·0 per cent) lived independently before surgery, only 45·4 per cent were discharged home directly. Frailty (mFI-5 2+) predicted mortality, overall and major morbidity, reoperation, prolonged LOS, discharge to an institution and readmission, but frailty was independent of sex.

Conclusion

Frailty is associated with morbidity, mortality and loss of independence in elderly patients needing emergency colorectal surgery.

Reversal of Hartmann's procedure in patients following failed colorectal or coloanal anastomosis: an analysis of 45 consecutive cases

AIM

This study aimed to assess outcomes of Hartmann's reversal (HR) after failure of previous colorectal anastomosis (CRA) or coloanal anastomosis (CAA).

METHODS

All patients planned for HR from 1997 to 2018 following the failure of previous CRA or CAA were included.

RESULTS

From 1997 to 2018, 45 HRs were planned following failed CRA or CAA performed for rectal cancer (n = 19, 42%), diverticulitis (n = 16, 36%), colon cancer (n = 4, 9%), inflammatory bowel disease (n = 2, 4%) or other aetiologies (n = 4, 9%). In two (4%) patients, HR could not be performed. HR was performed in 43/45 (96%) patients with stapled CRA (n = 24, 53%), delayed handsewn CAA with colonic pull-through (n = 11, 24%), standard handsewn CAA (n = 6, 14%) or stapled ileal pouch-anal anastomosis (n = 2, 4%). One (2%) patient died postoperatively. Overall postoperative morbidity rate was 44%, including 27% of patients with severe postoperative complication (Clavien-Dindo ≥ 3). After a mean follow-up of 38 ± 30 months (range 1-109), 35/45 (78%) patients presented without stoma. Multivariate analysis identified a remnant rectal stump < 7.5 cm in length as the only independent risk factor for long-term persistent stoma. Among stoma-free patients, low anterior resection syndrome (LARS) score was ≤ 20 (normal) in 43%, between 21 and 29 (minor LARS) in 33% and ≥ 30 (major LARS) in 24% of the patients.

CONCLUSION

HR can be recommended in patients following a failed CRA or CAA. It permits 78% of patients to be free of stoma. A short length of the remnant rectal stump is the only predictive factor of persistent stoma in these patients.

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.

Efficacy and Safety of Laparoscopic Hartmann Colostomy Reversal

Purpose

Hartmann operation is widely recognized as a useful procedure, especially in emergencies involving the rectosigmoid colon. One of the surgeon’s foremost concerns after Hartmann operation is future colostomy reversal, as colostomy reversal after a Hartmann procedure is associated with relatively high morbidity and mortality. Laparoscopic surgical techniques continue to prove useful for an ever-increasing variety of indications. We analyzed the outcomes of laparoscopic Hartmann colostomy reversals at our center.

Methods

We retrospectively analyzed the hospital records of 170 patients who had undergone Hartmann operation between January 2010 and June 2017 at Wonkwang University Hospital. Among 68 Hartmann colostomy reversals, we evaluated and compared the outcomes of 3 groups of patients: 29 patients in the open colostomy reversal group (OG) who had undergone laparotomies for Hartmann reversals, 19 patients in the conversion group (CG) whose laparoscopic procedures had required conversion to a laparotomy, and 20 patients in the laparoscopy group (LG).

Results

The overall reversal rate for Hartmann colostomies was 40.5% during this time period. The duration of hospital stay was significantly shorter among LG patients (10.15 ± 2.94 days) than among OG patients (16 ± 9.5 days). The overall complication rate among OG patients was higher than that among LG patients (adjusted odds ratio, 8.78; P = 0.01). The most common complication was postoperative ileus (19.1%).

Conclusion

If no contraindications to laparoscopy exist, surgeons should favor a laparoscopic reversal of Hartmann operation over an open reversal.

COLOSTOMY CLOSURE: RISK FACTORS FOR COMPLICATIONS

Background

: The restoration of intestinal continuity is an elective procedure that is not free of complications; on the contrary, many studies have proven a high level of morbidity and mortality. It is multifactorial, and has factors inherent to the patients and to the surgical technique.

Aim

: To identify epidemiological features of patients that underwent ostomy closure analyzing the information about the surgical procedure and its arising complications.

Method

: It was realized a retrospective analysis of medical records of patients who underwent ostomy closure over a period of seven years (2009-2015).

Results

: A total of 39 patients were included, 53.8% male and 46.2% female, with mean age of 52.4 years. Hartmann´s procedure and ileostomy were the mainly reasons for restoration of intestinal continuity, representing together 87%. Termino-terminal anastomosis was performed in 71.8% of cases, by using mainly the manual technique. 25.6% developed complications, highlighting anastomotic leakage; there were three deaths (7.6%). The surgical time, the necessity of ICU and blood transfusion significantly related to post-operative complications.

Conclusion

: It was found that the majority of the patients were male, with an average age of 52 years. It was observed that the surgical time, the necessity of blood transfusion and ICU were factors significantly associated with complications.

Comparison between laparoscopic and open Hartmann's reversal: results of a decade-long multicenter retrospective study

BACKGROUND

Hartmann's reversal is a challenging surgical procedure with significant postoperative morbidity rates. Various surgical methods have been suggested to lower the risk of postoperative complications. In this study, we aimed to compare the postoperative results between open and laparoscopic techniques for Hartmann's reversal.

METHODS

A retrospective study of all patients who underwent Hartmann's reversal in five centers in central Israel between January 2004 and June 2015 was conducted. Medical charts were reviewed, analyzing preoperative and operative parameters and short-term postoperative outcomes.

RESULTS

260 patients were included in the study. 76 patients were operated laparoscopically with a conversion rate of 26.3% (20 patients). No differences were found between patients operated laparoscopically and those operated in an open technique regarding gender (p = 0.785), age (61.34 vs. 62.64, p = 0.521), body mass index (26.6 vs. 26.2, p = 0.948), Charlson index score (1.79 vs. 1.95, p = 0.667), and cause for Hartmann's procedure (neoplastic vs. non-neoplastic, p = 0.644). No differences were seen in average time from the Hartmann's procedure to reversal (204.89 vs. 213.60 days, p = 0.688) and in overall complication rate (46.4 vs. 46.5%, p = 1). The Clavien-Dindo score for distinguishing between minor (0-2 score, p = 1) and major complications (3-5 score, p = 0.675) failed to demonstrate an advantage to laparoscopy, as well as to average length of stay (10.91 days in the laparoscopic group vs. 11.72 days in the open group, p = 0.529). An analysis based on the intention-to-treat with laparoscopy, including converted cases in the laparoscopic group, showed similar results, including overall complication rate (48.6 vs. 45.6%, p = 0.68) and Clavien-Dindo score in both minor (p = 0.24) and major complications (p = 0.44). Length of stay (10.92 vs. 11.81 days, p = 0.45) was also similar between the two groups.

CONCLUSION

In this series, a laparoscopic approach to Hartmann's reversal did not offer any short-term advantage when compared to an open surgical approach.

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.

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.

Assessing trends in laparoscopic colostomy reversal and evaluating outcomes when compared to open procedures

BACKGROUND

Laparoscopic colostomy reversal has emerged as a viable option for Hartmann's reversal but the trends in national adoption and postoperative complications are unknown. This study evaluates the practice trends for laparoscopic colostomy and compares complications, length of stay, and operative times between laparoscopic and open colostomy reversal.

METHODS

All patients who had open or laparoscopic colostomy reversal surgery (current procedure codes: 44227 and 44626) between 2005 and 2014 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Data collected included patient demographics, comorbid conditions, postsurgical diagnosis, and estimated probabilities of morbidity and mortality. Univariate and multivariate unconditional logistic regression models and linear regression models were employed to evaluate the associations between various outcomes and surgical specialties.

RESULTS

The reported volume of both open and laparoscopic colostomy reversal surgeries increased over time, but the percentage of open reversal surgery decreased from 100% in 2005 to 74.2% in 2014. The average annual increase in percentage of laparoscopic colostomy reversal surgery was 2.87%. The complication rates of open colostomy reversal surgery were significantly higher than the rates of laparoscopic colostomy reversal surgery (P < 0.0001). Although there were fluctuations, the complication rates remained constant over the 9-year study period for both open and laparoscopic colostomy reversal surgeries. The total hospital length of stay among patients who had laparoscopic colostomy reversal surgery was shorter compared to patients who had open colostomy reversal surgery [mean change (MC) = -1.77 days, P < 0.0001]. Similarly, a shorter operation time was also observed for patients who had laparoscopic colostomy reversal surgery (MC = -26.48 min, P < 0.0001).

CONCLUSION

Based on the NSQIP database, laparoscopic colostomy reversal is increasing steadily year over year from 2005 to 2014 in NSQIP participating hospitals. Overall complication rates and length of stay are significantly lower and sustained throughout the study period for laparoscopic reversal.

[Emergency endoscopic surgery of colon cancer]

AIM

To assess the role of endoscopic technologies in treatment of complicated forms of colorectal cancer.

MATERIAL AND METHODS

Our trial included patients after endoscopic intervention (n=18) and open surgery (n=11).

RESULTS

Mean time of surgery in this group was 158.8±10.7 minutes. In elective surgery group this value was 161.3 minutes (p>0.05). Mean blood loss was not great (near 122.5±17.9 ml). Overall and postoperative hospital-stay was 23.1±2.4 and 8.6±0.5 days, respectively. There were no intraoperative and postoperative complications.

CONCLUSION

Endoscopic interventions may be performed for colon cancer for emergency indications including patients with severe complications.

Surgeon specialization impacts the management but not outcomes of acute complicated diverticulitis

BACKGROUND

The management and outcomes of patients receiving nonelective surgical treatment of acute complicated diverticulitis by surgeon specialization have received little attention.

METHODS

A retrospective review was performed of consecutive patients with acute complicated diverticulitis who underwent surgery from 2006 to 2013. Patients were analyzed based on surgeon specialty: general surgery (GS) or colorectal surgery (CRS).

RESULTS

One hundred fifteen patients met criteria for study; 62 patients in the CRS and 53 in the GS group. GS were more likely to perform Hartmann's procedures or primary anastomosis and less likely to perform primary anastomosis with diverting ileostomy than CRS. There were no differences between groups for any outcome measures on univariate analysis. CRS patients had shorter operative time (P = .001) and length of stay (P ≤ .001) for stoma reversal procedures. Surgeon specialization was not associated with morbidity, readmission, or length of stay on multivariate analysis.

CONCLUSIONS

Although surgical management differed significantly between CRS and GS, comparable outcomes were observed at the index hospital admission.

The rise of big clinical databases

BACKGROUND

The routine collection of large amounts of clinical data, 'big data', is becoming more common, as are research studies that make use of these data source. The aim of this paper is to provide an overview of the uses of data from large multi-institution clinical databases for research.

METHODS

This article considers the potential benefits, the types of data source, and the use to which the data is put. Additionally, the main challenges associated with using these data sources for research purposes are considered.

RESULTS

Common uses of the data include: providing population characteristics; identifying risk factors and developing prediction (diagnostic or prognostic) models; observational studies comparing different interventions; exploring variation between healthcare providers; and as a supplementary source of data for another study. The main advantages of using such big data sources are their comprehensive nature, the relatively large number of patients they comprise, and the ability to compare healthcare providers. The main challenges are demonstrating data quality and confidently applying a causal interpretation to the study findings.

CONCLUSION

Large clinical database research studies are becoming ubiquitous and offer a number of potential benefits. However, the limitations of such data sources must not be overlooked; each research study needs to be considered carefully in its own right, together with the justification for using the data for that specific purpose.

Surgical outcome in patients undergoing reversal of Hartmann's procedures: a multicentre study

AIM

Recent evidence has suggested that a laparoscopic rather than an open approach to reversal of Hartmann's procedure (ROH) may be associated with fewer complications. Much of the data for comparison are historical or based on small case series. The aims of this study were to determine the morbidity and mortality of ROH in 10 hospitals in the modern era and to identify risk factors for complications.

METHOD

A multicentre study of patients undergoing ROH (2007-2013) was performed. Data were collected retrospectively from perioperative health databases and casenotes where appropriate on patient demographics, laboratory investigations and operative details. Complications were classified as minor (I-II) or major (III-IV) based on the Clavien-Dindo criteria. Risk factors for complications were assessed by multivariate analysis with calculation of OR with 95% CI.

RESULTS

Ten hospitals in Scotland provided data on 252 patients undergoing ROH. Most operations were open (85%) with 15% started laparoscopically (conversion rate 64%). In the postoperative period, 35 (14%) patients had a major complication, including anastomotic leakage in 10 (4%) and postoperative death in one (0.4%). Patients with a complication stayed significantly longer in hospital (12 days vs 7 days, P < 0.001). On multivariate analysis, a wound complication after the original Hartmann's procedure (OR = 3.85, 95% CI: 1.08-13.75, P = 0.038) was associated with any complication after ROH, but only American Society of Anesthesiologists (ASA) grade (OR = 3.35, 95% CI: 1.38-8.09, P = 0.007) was independently associated with the development of a major complication.

CONCLUSION

ROH has a low postoperative mortality but significant morbidity. Most operations are still performed by open surgery, and in those attempted laparoscopically, the conversion rate is high.

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.

A retrospective case note review of laparoscopic versus open reversal of Hartmann's procedure

INTRODUCTION

First described in 1921, Hartmann's procedure is the gold standard treatment for complicated sigmoid diverticular disease. It is also used commonly for other causes of perforation of the large bowel. However, the reversal rate in the UK is much lower than in comparable countries, at only 18-22%. Furthermore, laparoscopic reversal (LRH) is used far less frequently than open reversal (ORH) despite evidence that a laparoscopic technique reduces patient morbidity and decreases patient recovery time.

METHODS

This retrospective case note review undertook an analysis of all the patients who had undergone Hartmann's procedure at two centres in Leeds Teaching Hospitals NHS Trust between February 2007 and February 2012. Out of 305 patients, 235 were identified and included in the analysis. Comparisons were then drawn between LRH and ORH groups.

RESULTS

The reversal rate was 21%. Three-quarters (76%) were performed using an open technique, 20% were laparoscopic and 5% were converted to an open procedure. The mean hospital stay was longer for the ORH group (9.82 days, standard deviation [SD]: 5.85 days, 95% confidence interval [CI]: 2.99 days) than for the LRH group (7.29 days, SD: 4.65 days, 95% CI: 11.58 days) p=0.006). Seven ORH patients (21%) were reoperated but only one LRH patient (13%) had a reoperation at six months. Five factors were found to have a significant effect on the likelihood of reversal of Hartmann's procedure.

CONCLUSIONS

The overall reversal rate for Hartmann's procedure remains low. Shorter hospital stays, lower 6-month reoperation rates and reduced 30-day complication rates are associated with LRH when compared with ORH.

Efficacy of laparoscopic-assisted approach for reversal of Hartmann's procedure: results from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database

INTRODUCTION

Morbidity after reversal of Hartmann's procedure remains high. The laparoscopic approach (LAP) may be associated with lower morbidity versus open Hartmann's closure. This study's aim is to compare results after LAP and OPEN colostomy takedown and Hartmann's reversal.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2012 for CPT procedure codes 44227 (LAP) and 44626 (OPEN). Exclusion criteria included: ventilator dependence, ASA class 4 or 5, SIRS, sepsis, emergency case, and advanced malignancy. Demographic parameters were assessed as well as comorbidities and short-term outcomes. Statistical methods used include Fisher's exact test for categorical variables and Student's t test for continuous variables.

RESULTS

In total, 4,148 patients underwent stoma closure and Hartmann's reversal (LAP 732 [17.6 %], OPEN 3,416 [82.3 %]). The mean BMI was lower in the LAP (mean ± SD 27.6 ± 6.6) versus OPEN group (28.3 ± 6.8, p = 0.012). The groups were similar as regards comorbidities except for dyspnea (LAP 5.6 %, OPEN 7.8 %, p = 0.043). The mean surgery times were similar and the median LOS shorter in the LAP versus OPEN groups (5 vs 6 days, p < 0.0001). A lower overall morbidity rate was noted for the LAP group (18.4 % vs OPEN 27 %, p < 0.0001) but mortality was statistically similar. Lower rates were noted in the LAP group for the following complications: incisional SSI (10.4 vs 14.1 %, p = 0.033), organ space SSI (3.1 vs 5.0 %, p = 0.033), UTI (1.6 vs 3.3 %, p = 0.005), sepsis (3.4 vs 6.0 %, p = 0.038), and reoperation (3.1 vs 5.4 %, p = 0.011).

CONCLUSION

Only 18 % of Hartmann's reversal's were done using LAP methods. The LAP and OPEN groups were similar except for gender, BMI, and dyspnea history. LAP methods were associated with a 1 day LOS benefit and significantly lower overall morbidity and lower rates of incisional and deep SSI, UTI, sepsis, and reoperations. Operative length was similar. The short-term results of the LAP approach are superior to the OPEN results.

Laparoscopic reversal of Hartmann's procedure

Reestablishing continuity after a Hartmann's procedure is considered a major surgical procedure with high morbidity/mortality. The aim of this study was to assess the short-/long-term outcome of laparoscopic restoration of bowel continuity after HP. A prospectively collected database of colorectal laparoscopic procedures (>800) performed between June 2005 and June 2013 was used to identify 20 consecutive patients who had undergone laparoscopic reversal of Hartmann's procedure (LHR). Median age was 65.4. Ten patients (50 %) had undergone surgery for perforated diverticulitis, 3 (15 %) for cancer, and 7 (35 %) for other reasons (volvulus, posttraumatic perforation, and sigmoid perforation from foreign body). Previous HP had been performed laparoscopically in only 3 patients. Median operative time was 162.5 min. All the procedures were completed laparoscopically. Intraoperative complication rate was nil. Post-operative mortality and morbidity were respectively 0 and 10 % (1 pneumonia, 1 bowel obstruction from post-anastomotic stenosis which required resection and redo of the anastomosis). Median time to first flatus was 3 days, to normal diet 5 days. Median hospital stay was 9 days without readmissions. We followed up the patients for a median of 44 months: when asked, all 20 (100 %) said they would undergo the operation (LHR) again; 3 (15 %) had been re-operated of laparoscopic mesh repair for incisional hernia. When performed by experienced surgeons, LHR is a feasible, safe, reproducible operation, which allows early return of bowel function, early discharge and fast return to work for the patient. It has a low morbidity rate.

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

BACKGROUND

Restoration of bowel continuity following Hartmann's procedure may be performed using a laparoscopic or open technique. This study is the first of its kind comparing laparoscopic with open reversal of Hartmann's procedure in Australasia.

METHODS

This is a retrospective review of 107 patients who underwent either a laparoscopic (n = 43) or open (n = 64) reversal of Hartmann's procedure between 2001 and 2012. Outcome measures were perioperative clinical outcomes and post-operative complications.

RESULTS

Patients in the two groups were comparable in age, body mass index, American Society of Anesthesiologists score and number of previous operations. The most common indication for the original Hartmann's operation in both groups was diverticular disease. Total theatre time was longer for the laparoscopic group (276.4 versus 242.0 min; P = 0.02). Three patients in the laparoscopic group required conversion to laparotomy (7%). Laparoscopic reversal of Hartmann's procedure was associated with shorter time to passage of flatus (2.8 versus 4.0 days; P < 0.001) and faeces (4.2 versus 5.6 days; P = 0.002), and shorter overall length of hospital stay (6.7 versus 10.8 days; P < 0.001). There were fewer patients in the laparoscopic group who had post-operative complications (14% versus 31%; P = 0.04), including fewer cases of post-operative ileus (2% versus 17%; P = 0.02). There were no cases of anastomotic leak or in-hospital mortality in either group.

CONCLUSION

Laparoscopic reversal of Hartmann's procedure is a safe and feasible alternative to open Hartmann's reversal and may be associated with significantly faster recovery time and fewer post-operative complications.