Perforated diverticulitis in a Hartmann rectal pouch

Hartmann procedure: place in surgery and what after?

The results of 65 consecutive cases of Hartmann's procedure carried out between 1982/1993 inclusive, were reviewed. There were 41 emergency procedures including 27 cases with complicated carcinoma and 24 elective procedures including 20 with carcinoma, 3 with diverticular disease and one with perirectal haemangioma. Postoperative complications occurred in 25 (38.5%) patients, including 13 (19%) with wound infection. Seven patients had to be reoperated because of intraperitoneal abscess (3 cases) or wound dehiscence (4 cases). There were five (7.7%) postoperative deaths. The mean hospital stay of operation survivors was 16 days (range 8-54). Intestinal continuity has been reestablished in 13 (81.2%) of 16 survivors in the benign disease group and in 4.5% of patients of the malignant group. The mean time to of restoration of continuity was 240 days (range 40-630) after the primary procedure. No one died after these procedures. In five (31.2%) patients postoperative complications were observed: anastomotic leak (2 cases) and wound infection (3 cases). All complications were treated conservatively.

Subtotal colectomy for ulcerative colitis: complications related to the rectal remnant

Complications related to the retained rectal remnant were reviewed in 136 patients undergoing subtotal colectomy for acute ulcerative colitis. Fifty-five patients (Group 1) had a closed rectal stump brought up into the subcutaneous tissue, and 30 (Group 2) had an open mucous fistula. These were compared with an intrapelvic Hartmann's pouch performed in 51 patients (Group 3). All patients eventually had a pelvic pouch procedure. Age, duration and activity of disease, and preoperative steroid use were similar in all groups. There was no mortality. The rectal stump in 19 Group 1 patients (35 percent) spontaneously opened, and seven (13 percent) developed local left lower quadrant wound infections. Two Group 1 patients (4 percent) developed pelvic septic complications, as compared with two Group 2 patients (7 percent) and six Group 3 patients (12 percent). Subsequent pelvic dissection was difficult in 20 percent of Group 3 patients, vs. 4 percent and 0 percent of Group 1 and Group 2 patients, respectively (P less than 0.05). Persistent rectal disease activity was present in 41 percent of Group 3, vs. 27 percent of Groups 1 and 2. Our study suggests that exteriorization of the closed rectal stump following subtotal colectomy is associated with fewer pelvic septic complications and minimal local morbidity, facilitates subsequent pelvic dissection, and is not associated with increased disease activity in the retained rectum.

Case report: rectal mucocele following Hartmann's procedure

A post-surgical rectal stump normally secretes a small amount of mucus which is passed per rectum. An example of an unusually large collection of mucus (mucocele) in a rectal stump is presented and the difficulties in diagnosis discussed.

The fate of the forgotten rectal pouch after Hartmann's procedure without reconstruction

The rectal pouches of 45 patients who underwent Hartmann's procedure and were not scheduled to have a colostomy closure were examined with an endoscope at least 1 year after operation. Twenty-five patients had no symptoms related to the rectal pouch. The rest had pain, mucous discharge, moderate-to-severe bleeding, or discharge of small bowel contents. Endoscopic findings included moderate-to-severe proctitis in 20 patients, 10 of whom had no symptoms. Polyps were found in four patients (two asymptomatic) and carcinoma in seven (one asymptomatic). Of 24 patients operated upon for diverticulitis, 12 had proctitis and 2 had polyps. Of 14 patients with carcinoma, 4 had proctitis, 1 polyps, and 5 carcinoma. Of two patients with benign polyps, one had polyps and one, carcinoma and of five patients with inflammatory bowel disease, four had proctitis and one, carcinoma. The treatment of polyps and carcinoma is the same as for other patients with these conditions. Proctitis should be treated with reanastomosis. The frequent presence of abnormality in the rectal pouch indicates the need for regular follow-up examinations of these patients.