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Shauly O, Marxen T, Menon A, Rumbika S, Ash M, Jean-Baptiste O, Losken A. The Effect of Bowel Anastomosis on Outcomes in Complex Abdominal Wall Reconstruction: A 10-Year Retrospective Cohort Study. Ann Plast Surg 2024; 93:235-238. [PMID: 38980917 DOI: 10.1097/sap.0000000000004017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
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.
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Affiliation(s)
- Orr Shauly
- From the Division of Plastic and Reconstructive Surgery
| | - Troy Marxen
- From the Division of Plastic and Reconstructive Surgery
| | - Ambika Menon
- School of Medicine, Emory University, Atlanta, GA
| | | | - Makenna Ash
- School of Medicine, Emory University, Atlanta, GA
| | | | - Albert Losken
- From the Division of Plastic and Reconstructive Surgery
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2
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Horesh N, Emile SH, Khan SM, Freund MR, Garoufalia Z, Silva-Alvarenga E, Gefen R, Wexner SD. Meta-analysis of Randomized Clinical Trials on Long-term Outcomes of Surgical Treatment of Perforated Diverticulitis. Ann Surg 2023; 278:e966-e972. [PMID: 37249187 DOI: 10.1097/sla.0000000000005909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To assess long-term outcomes of patients with perforated diverticulitis treated with resection or laparoscopic lavage (LL). BACKGROUND Surgical treatment of perforated diverticulitis has changed in the last few decades. LL and increasing evidence that primary anastomosis (PRA) is feasible in certain patients have broadened surgical options. However, debate about the optimal surgical strategy lingers. METHODS PubMed, Scopus, and Web of Science were searched for randomized clinical trials (RCT) on surgical treatment of perforated diverticulitis from inception to October 2022. Long-term reports of RCT comparing surgical interventions for the treatment of perforated diverticulitis were selected. The main outcome measures were long-term ostomy, long-term complications, recurrence, and reintervention rates. RESULTS After screening 2431 studies, 5 long-term follow-up studies of RCT comprising 499 patients were included. Three studies, excluding patients with fecal peritonitis, compared LL and colonic resection, and 2 compared PRA and Hartmann procedures. LL had lower odds of long-term ostomy [odds ratio (OR) = 0.133, 95% CI: 0.278-0.579; P < 0.001] and reoperation (OR = 0.585, 95% CI: 0.365-0.937; P = 0.02) compared with colonic resection but higher odds of diverticular disease recurrence (OR = 5.8, 95% CI: 2.33-14.42; P < 0.001). Colonic resection with PRA had lower odds of long-term ostomy (OR = 0.02, 95% CI: 0.003-0.195; P < 0.001), long-term complications (OR = 0.195, 95% CI: 0.113-0.335; P < 0.001), reoperation (OR = 0.2, 95% CI: 0.108-0.384; P < 0.001), and incisional hernia (OR = 0.184, 95% CI: 0.102-0.333; P < 0.001). There was no significant difference in odds of mortality among the procedures. CONCLUSIONS Long-term follow-up of patients who underwent emergency surgery for perforated diverticulitis showed that LL had lower odds of long-term ostomy and reoperation, but more risk for disease recurrence when compared with resection in purulent peritonitis. Colonic resection with PRA had better long-term outcomes than the Hartmann procedure for fecal peritonitis.
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Affiliation(s)
- Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
- Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Tel Aviv University, Israel
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
- General Surgery Department, Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura, Egypt
| | - Sualeh Muslim Khan
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
- Department of General Surgery Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
| | | | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
- Department of General Surgery, Hadassah Medical Organization, Hebrew University of Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
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3
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Kim DH, Lee KH. Safety of early Hartmann reversal during adjuvant chemotherapy in colorectal cancer: a pilot study. Front Surg 2023; 10:1243125. [PMID: 37829597 PMCID: PMC10566360 DOI: 10.3389/fsurg.2023.1243125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
Introduction Most patients undergoing the Hartmann procedure for complicated colorectal cancer require chemotherapy because of their advanced status. Stoma created during the procedure is typically closed after the completion of postoperative chemotherapy. However, stomas can induce medical or surgical complications and disturb quality of life. This study aimed to evaluate the safety of Hartmann's reversal during postoperative chemotherapy. Methods We conducted a retrospective review of electronic medical records. Between 2017 and 2021, 96 patients underwent Hartmann reversal for after colorectal cancer surgery. Among them, the number of patients who underwent Hartmann procedure with radical resection of complicated colorectal cancer and Hartmann reversal during adjuvant chemotherapy was 13. The clinical, surgical, and pathological characteristics of the patients were evaluated. Results Eight and five patients had obstructions and perforations, respectively. Two patients with synchronous liver metastases underwent simultaneous liver resection and reversal simultaneously. Five and eight patients received adjuvant chemotherapy with capecitabine and FOLFOX, respectively. The median interval between the Hartmann procedure and reversal was 3.31 months (2.69-5.59). The median operative time for Hartmann's reversal was 190 min (100-335). The median hospital stay was 10 days (7-21). Four patients (30.8%) developed postoperative complications, and the rate of 3 or higher grade according to the Clavien-Dindo classification within 90 days postoperatively was 0%. Except for 1 patient who refused continuation of chemotherapy, 12 patients completed the planned chemotherapy. Median total duration of adjuvant chemotherapy was 6.78 months (5.98-8.48). There was no mortality. Conclusion Early Hartmann reversal during adjuvant chemotherapy is tolerable and safe in carefully selected patients. In particular, it can be used as a therapeutic option for patients with complicated colorectal cancer with synchronous resectable metastases.
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Affiliation(s)
| | - Kyung-Ha Lee
- Department of Colorectal Surgery, Chungnam National University College of Medicine and Hospital, Daejeon, Republic of Korea
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4
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Lynch CA. Are Patients Requiring Hartmann's Procedure Being Adequately Optimised for Surgery: An Audit Cycle. Cureus 2023; 15:e41589. [PMID: 37559850 PMCID: PMC10407682 DOI: 10.7759/cureus.41589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2023] [Indexed: 08/11/2023] Open
Abstract
Introduction Hartmann's procedures are common surgical operations indicated in a wide variety of presentations including colon malignancy, diverticular disease, volvulus, and colovesical and colovaginal fistulas. The procedure is a major undertaking for the patient and those presenting in the emergency setting are often clinically unwell with deranged laboratory investigations. Numerous studies have demonstrated that pre-operative anaemia contributes to increased morbidity and mortality. Applying the conclusions of one study recommending a minimum haemoglobin >12 g/dL level pre-operatively, this audit assessed patient optimisation prior to Hartmann's procedure. Materials and methods Patients undergoing Hartmann's procedures between May 2016 and February 2020 were identified. Data was collected retrospectively to analyse American Society of Anesthesiology (ASA) grade and pre-operative haemoglobin level. Pre-operative haemoglobin and group and save blood test values were identified pre-and post-intervention. Results Pre-intervention, 15 (21%) of 70 patients had a haemoglobin level <12 g/dL and 63 patients (90%) had a group and save blood test completed on admission. Post-intervention data was collected from 45 patients, with figures improving to five (11%) and 44 (97%) patients, respectively. Conclusion Our flowchart poster distribution and addition to the surgical proforma led to increased patient optimisation prior to Hartmann's procedure.
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Affiliation(s)
- Cameron A Lynch
- General Surgery, Tameside and Glossop Integrated Care National Health Service (NHS) Foundation Trust, Manchester, GBR
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5
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The suspended ileal loop for difficult Hartmann's reversal. Tech Coloproctol 2023; 27:243-246. [PMID: 36316535 DOI: 10.1007/s10151-022-02715-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/10/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hartmann's reversal can be complicated by the presence of dense adhesions in the upper part of the abdominal cavity, difficulties in freeing the splenic flexure with the risk of splenic tears, a lack of sufficient colonic length, the risk of ureteral lesion, or the risk of lesions of the vascular arcade. METHODS We propose a technique which consists of interposing an adapted segment of ileal loop between the end of the proximal colon and the rectum to restore intestinal continuity. RESULTS Two patients had Hartmann procedure, the first for a Hinchey stage 4 perforated diverticulitis and the second for a colorectal fistula due to ischemia of the proximal colonic segment. Hartmann's reversal was expected to be difficult, so a suspended ileal loop was used. The outcomes were uneventful, and functional results were satisfactory. CONCLUSIONS A suspended ileal loop could be used as a salvage procedure in some cases of potentially difficult Hartmann's reversal.
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6
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Van Hoof S, Sels T, Patteet E, Hendrickx T, Van den Broeck S, Hubens G, Komen N. Functional outcome after Hartmann's reversal surgery using LARS, COREFO & QoL scores. Am J Surg 2023; 225:341-346. [PMID: 36116971 DOI: 10.1016/j.amjsurg.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/31/2022] [Accepted: 09/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Functional complaints after colorectal surgery have a profound effect on quality of life (QoL). Our goal was to investigate the prevalence of functional complaints and quality of life after Hartmann's reversal surgery. METHOD A cross-sectional study was performed where one hundred nineteen patients were included. All patients underwent Hartmann's reversal procedure between 2007 and 2019. All patients were asked to complete 3 validated questionnaires related to bowel function in benign and colorectal cancer surgery as well as general QoL. RESULTS The response rate was 67%. Among responders, 32.8% reported LARS-like symptoms whereas 25% had significant COREFO Scores (>15). Higher LARS and COREFO scores were significantly associated with worse global QoL and several QoL domain scores (p < 0.05). CONCLUSION This study highlights the prevalence of bowel dysfunction after Hartmann's reversal surgery. Patients undergoing this procedure show similar functional complaints compared to those in literature who had a resection without colostomy.
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Affiliation(s)
- Sander Van Hoof
- Department of Abdominal Surgery, Antwerp University Hospital Wilrijkstraat 10, 2610, Edegem, Belgium.
| | - Toon Sels
- Department of Abdominal Surgery, Antwerp University Hospital Wilrijkstraat 10, 2610, Edegem, Belgium; Department of General & Abdominal Surgery, AZ Turnhout Rubensstraat 166, 2300, Turnhout, Belgium
| | - Eveline Patteet
- Department of Abdominal Surgery, Antwerp University Hospital Wilrijkstraat 10, 2610, Edegem, Belgium; Department of General & Abdominal Surgery, AZ Turnhout Rubensstraat 166, 2300, Turnhout, Belgium
| | - Tom Hendrickx
- Department of General & Abdominal Surgery, AZ Turnhout Rubensstraat 166, 2300, Turnhout, Belgium
| | - Sylvie Van den Broeck
- Department of Abdominal Surgery, Antwerp University Hospital Wilrijkstraat 10, 2610, Edegem, Belgium
| | - Guy Hubens
- Department of Abdominal Surgery, Antwerp University Hospital Wilrijkstraat 10, 2610, Edegem, Belgium; Antwerp ReSURG, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Niels Komen
- Department of Abdominal Surgery, Antwerp University Hospital Wilrijkstraat 10, 2610, Edegem, Belgium; Antwerp ReSURG, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
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7
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Katsura M, Fukuma S, Chida K, Saegusa Y, Kanda S, Kawasaki K, Tsuzuki Y, Ie M. Which factors influence the decision to perform Hartmann's reversal in various causative disease situations? A retrospective cohort study between 2006 and 2021. Colorectal Dis 2023; 25:305-314. [PMID: 36222174 DOI: 10.1111/codi.16364] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/18/2022] [Accepted: 09/29/2022] [Indexed: 02/08/2023]
Abstract
AIM Our aim was to investigate the predictive factors for Hartmann's reversal and to describe the differences in the rates and timings of Hartmann's reversal for various causative diseases. METHOD In this multicentre retrospective cohort study patients who underwent Hartmann's procedure (HP) between 2006 and 2018 were enrolled. To describe the demographic patterns of Hartmann's reversal through to 2021, we analysed the cumulative incidence rate of Hartmann's reversal over time based on the Kaplan-Meier failure estimate. Multivariable Cox proportional hazard analysis was performed with cluster-adjusted robust standard errors to calculate hazard ratios (HRs) for the assessment of variables associated with colostomy reversal. RESULTS Of 250 patients who underwent the index HP and survived to discharge, 112 (45%) underwent subsequent Hartmann's reversal (36% for malignant and 51% for benign disease). The causative diseases with the highest probability of colostomy reversal were trauma (85%) and diverticular disease (73%). Conversely, colostomy reversal was performed in only 16% for colonic volvulus and 17% for bowel ischaemia. Home discharge after index HP (HR 5.22, 95% CI 3.31-8.23) and a higher body mass index (HR 1.03, 95% CI 1.01-1.04) were associated with a higher probability of Hartmann's reversal, whereas older age, malignant disease and a history of cardiovascular and psychoneurological diseases were independently associated with a lower probability of colostomy reversal. CONCLUSION The probability and timing of Hartmann's reversal varied considerably with the surgical indications for colostomy creation. Our results could help surgeons counsel patients and their families regarding stoma closure surgery to set realistic expectations.
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Affiliation(s)
- Morihiro Katsura
- Department of Surgery, Okinawa Chubu Hospital, Uruma, Japan.,Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kohei Chida
- Department of Surgery, Okinawa Chubu Hospital, Uruma, Japan
| | | | - Shuhei Kanda
- Department of Surgery, Okinawa Miyako Hospital, Miyakojima, Japan
| | - Kyohei Kawasaki
- Department of Surgery, Okinawa Yaeyama Hospital, Ishigaki, Japan
| | - Yukihiro Tsuzuki
- Department of Surgery, Okinawa Nanbu Medical Center & Children's Medical Center, Haebaru, Japan
| | - Masafumi Ie
- Department of Surgery, Okinawa Chubu Hospital, Uruma, Japan
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8
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Nasseri Y, Liu A, Kasheri E, Oka K, Cohen J, Ellenhorn J, Bergamaschi R, Barnajian M. Hartmann's Reversal is More Complex Than Elective Left Colectomy. Am Surg 2023; 89:224-229. [PMID: 36321223 DOI: 10.1177/00031348221135777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hartmann's reversal (HR) is associated with significant technical complexity and morbidity. The decision to perform HR is difficult and up to 50% of patients with colostomies do not undergo a reversal. To better guide surgeons and patients with this decision, we sought to assess the surgical risks and outcomes of HR as compared to elective left colectomy (LC). METHODS We conducted a retrospective analysis of a prospective database at a tertiary medical center. Patients undergoing elective Hartmann's reversal and left colectomy between January 2014 and November 2021 were identified. We compared preoperative variables, intraoperative events, and short-term postoperative outcomes. RESULTS 135 patients were identified: 30 HR and 105 LC. There were no significant differences in demographics or preoperative comorbidities between HR and LC. There were more open and fewer robotic cases in HR (23.3% vs 2.9%, P < .0001; 46.6% vs 76.0%, P < .01). Total operative time was significantly longer in HR than LC (261.8 vs 211.7 minutes, P = .02). There was a significantly higher percentage of intraoperative complications in HR (13.3% vs 1.9%, P < .01). There was a significantly higher rate of minor postoperative complications in HR than LC (46.7% vs 26.7%, P = .04), but not major (6.7% vs 5.8%, P = .85). Time to first flatus/bowel movement was significantly longer in HR than LC (3.6 vs 2.5 days, P < .001). CONCLUSION Hartmann's reversal is a more technically challenging operation than elective left colectomy and is associated with significantly higher rates of intraoperative and minor postoperative complications. Future studies should focus on mitigating these risk factors to optimize patient outcomes.
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Affiliation(s)
- Yosef Nasseri
- Surgery Group Los Angeles, Los Angeles, CA, USA.,22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andy Liu
- Surgery Group Los Angeles, Los Angeles, CA, USA
| | - Eli Kasheri
- Surgery Group Los Angeles, Los Angeles, CA, USA
| | | | - Jason Cohen
- Surgery Group Los Angeles, Los Angeles, CA, USA.,22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joshua Ellenhorn
- Surgery Group Los Angeles, Los Angeles, CA, USA.,22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Moshe Barnajian
- Surgery Group Los Angeles, Los Angeles, CA, USA.,22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
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McChesney SL, Hawkins AT. Anastomotic Considerations in Diverticulitis. Clin Colon Rectal Surg 2023; 36:57-62. [PMID: 36619284 PMCID: PMC9815908 DOI: 10.1055/s-0042-1756511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Diverticulitis is a common indication for colorectal surgery, both in the acute and the elective setting. The anastomosis between the colon and rectum is a critical component of colectomy for diverticular disease and should be approached thoughtfully. This article reviews important surgical considerations when creating a colorectal anastomosis in the setting of diverticular disease, whether following the reversal of an end colostomy, during an acute episode of diverticulitis, or electively for chronic or complicated disease. Timing of surgery and preoperative assessment, minimally invasive approaches, and intraoperative maneuvers and considerations are discussed.
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Affiliation(s)
- Shannon L. McChesney
- Section of Colon and Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenessee
| | - Alexander T. Hawkins
- Section of Colon and Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenessee
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10
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Hartmann's reversal is associated with worse outcomes compared to elective left colectomy: A NSQIP analysis of 36,794 cases. Am J Surg 2022; 224:1351-1355. [PMID: 36272826 DOI: 10.1016/j.amjsurg.2022.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/21/2022] [Accepted: 10/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hartmann's reversal (HR) is associated with significant technical difficulty and morbidity. Using the ACS-NSQIP database, we assessed the outcomes of HR as compared to elective left colectomy (LC). METHODS The 2016-2019 ACS-NSQIP datasets were queried to identify patients undergoing HR and elective LC. Patients' demographics, comorbidities, and short-term surgical outcomes were evaluated using both univariable and multivariable methods. RESULTS The study included 7,632 HR cases and 29,162 LC cases. The HR group had more patients with ASA grade III (50% vs. 42.4%). HR had more open-operative cases (69.4 vs. 18.5%) and longer mean operative times (213 vs. 191 min) than LC. Postoperatively, the HR group had a longer mean hospital stay (5.5 vs. 4.1 days) and higher complication rate (18.3% vs. 10.3%). HR was associated with increased odds of having a concurrent ileostomy (OR 2.11), deep space/organ infection (OR 1.55), and at least one complication (OR 1.56). CONCLUSION HR is a more challenging operation with patients who fared worse than their LC counterparts. Consideration should be given to alternatives of the index Hartmann's procedure.
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11
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Muacevic A, Adler JR. Hartmann's Reversal: A Single-Centre Experience. Cureus 2022; 14:e31654. [PMID: 36545156 PMCID: PMC9760391 DOI: 10.7759/cureus.31654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 11/20/2022] Open
Abstract
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.
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12
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Arnott SM, Zollinger B, Haviland S, Ng M, Obias V. A nutritional screening threshold for optimal outcomes after Hartmann's reversal. Int J Colorectal Dis 2022; 37:2041-2048. [PMID: 36002747 DOI: 10.1007/s00384-022-04236-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Determining is nutritionally replete enough for Hartmann's reversal (HR) can be controversial and multifactorial. While there are many preoperative nutritional screening tools, the impact of malnourishment on HR has not been evaluated. The study aims to clarify how often patients undergoing HR are high risk for malnourishment at the time of surgery and how this impacts postoperative outcomes. METHODS From 2012-2019, all elective HRs were identified in ACS-NSQIP. Patients were categorized in a malnourished group if they met one of the following criteria: (1) BMI < 18.5 kg/m2, (2) albumin < 3.5 g/dL, or (3) > 10% body weight loss in the last 6 months. Bivariate associations of preoperative demographics and postoperative outcomes were analyzed. Multivariable logistic regression was performed to identify independent predictors for 30-day mortality and organ space wound infection. RESULTS 8878 procedures were evaluated (well-nourished = 7116 and malnourished = 1762). The malnourished group had higher mortality (p < 0.001), shorter operating time (p < .001), longer length of stay (p = 0.016), and higher rates of infection (p = 0.011), reintubation (p = 0.002), bleeding (p < 0.001), sepsis (p = 0.001), and reoperation (p = 0.018). In multivariate regression models, malnourishment was an independent predictor for mortality (OR = 2.72, p < 0.001) and wound infection (OR = 1.19, p = 0.028). CONCLUSION A large percentage of patients undergoing HR were classified as being high-risk for malnutrition. Malnourishment was associated with some worse postoperative compilations including death and wound infection. Surgeons should routinely use preoperative screening for malnutrition to identify and attempt to optimize nutritional status prior to undergoing Hartmann's Reversal.
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Affiliation(s)
- Suzanne M Arnott
- Department of Colorectal Surgery, George Washington University, Washington, D.C, USA. .,Department of Surgery, George Washington University, Washington, D.C, USA.
| | - Benjamin Zollinger
- School of Medicine and Health Sciences, George Washington University, Washington, D.C, USA
| | - Sarah Haviland
- Department of Colorectal Surgery, George Washington University, Washington, D.C, USA.,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Matthew Ng
- Department of Colorectal Surgery, George Washington University, Washington, D.C, USA
| | - Vincent Obias
- Department of Colorectal Surgery, George Washington University, Washington, D.C, USA
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13
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Clementi M, Pietroletti R, Carletti F, Sista F, Grasso A, Fiasca F, Cappelli S, Balla A, Rizza V, Ciarrocchi A, Guadagni S. Colostomy Reversal following Hartmann’s Procedure: The Importance of Timing in Short- and Long-Term Complications: A Retrospective Multicentric Study. J Clin Med 2022; 11:jcm11154388. [PMID: 35956003 PMCID: PMC9369122 DOI: 10.3390/jcm11154388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/23/2022] [Accepted: 07/23/2022] [Indexed: 01/19/2023] Open
Abstract
The restoration of bowel continuity following Hartmann’s Procedure (HP) has been reported hitherto with high morbidity and mortality rates. No clear guidelines exist about timing in Hartmann’s Reversal (HR), the literature data being conflicting. We have sought to investigate the effect of the interval time between HP and HR in short- and long-term HR outcomes through a retrospective study based on consecutive patients undergoing HR between 2009 and 2017 in two regional hospitals in Italy. Demographic characteristics, comorbidities, intra- and post-operative data, as well as early complications, were recorded. Long-term data were collected on the surgical site occurrences of Incisional Ventral Hernia (IVH). One hundred and five patients were recruited for the study. Late HR, female gender, and long operating time were related to the highest incidence of peri-operative complications. Patients who developed IVH had undergone HR at significantly shorter times and had a higher Body Mass Index (BMI). The timing of HR seems to be an important variable linked to the onset of early and late post-operative complications. The patients submitted to early HR show a significantly lower complication rate but, at the same time, a higher rate of IVH incidence after restorative surgery. These data, in our opinion, reflect the need for planning, where possible, an early restoration of bowel continuity after HP.
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Affiliation(s)
- Marco Clementi
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
- Correspondence: ; Tel.: +39-33-5538-6225
| | - Renato Pietroletti
- Unit of Proctology and Colorectal Surgery, Val Vibrata-Sant’Omero Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (R.P.); (V.R.)
| | - Filippo Carletti
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
| | - Federico Sista
- Hepatic Pancreatic and Biliary Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy;
| | - Antonella Grasso
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
| | - Fabiana Fiasca
- Public Health Unit, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy;
| | - Sonia Cappelli
- Department of Surgery, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy;
| | - Andrea Balla
- General and Minimally Invasive Surgical Unit, San Paolo Hospital, 00053 Civitavecchia, Italy;
| | - Vinicio Rizza
- Unit of Proctology and Colorectal Surgery, Val Vibrata-Sant’Omero Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (R.P.); (V.R.)
| | - Andrea Ciarrocchi
- General Surgical Unit, Maria ss. dello Splendore Hospital, 67021 Giulianova, Italy;
| | - Stefano Guadagni
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
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14
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de Paula Freitas BZ, Campos FG, Kanno DT, Delben AG, Pereira JA, Dos Santos Mendonça RL, Martinez CAR. Infliximab Increases the Tissue Contents of Type-I and Type-III Collagen in Colorectal Segments Without Fecal Stream After Hartmann's Procedure. J Gastrointest Surg 2022; 26:662-664. [PMID: 34561770 DOI: 10.1007/s11605-021-05138-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/17/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Bruna Zini de Paula Freitas
- Postgraduate Program in Health Sciences, São Francisco University Medical School, Av. São Francisco de Assis, 218, Bragança Paulista, São Paulo, CEP 12916-900, Brazil
| | - Fábio Guilherme Campos
- Department of Gastroenterology, Faculty of Medicine of University of São Paulo, Av. Dr Arnaldo, 455, São Paulo, CEP 01246-903, Brazil
| | - Danilo Toshio Kanno
- Postgraduate Program in Health Sciences, São Francisco University Medical School, Av. São Francisco de Assis, 218, Bragança Paulista, São Paulo, CEP 12916-900, Brazil
| | - Andress Godoy Delben
- Department of Surgery, Campinas State University, Av. Tessália Vieira de Camargo, 126, Campinas, São Paulo, CEP 13083-887, Brazil.
| | - José Aires Pereira
- Department of Pathology, São Francisco University Medical School, Av. São Francisco de Assis, 218, Bragança Paulista, São Paulo, CEP 12916-900, Brazil
| | - Roberta Laís Dos Santos Mendonça
- Postgraduate Program in Health Sciences, São Francisco University Medical School, Av. São Francisco de Assis, 218, Bragança Paulista, São Paulo, CEP 12916-900, Brazil
| | - Carlos Augusto Real Martinez
- Postgraduate Program in Health Sciences, São Francisco University Medical School, Av. São Francisco de Assis, 218, Bragança Paulista, São Paulo, CEP 12916-900, Brazil.,Department of Surgery, Campinas State University, Av. Tessália Vieira de Camargo, 126, Campinas, São Paulo, CEP 13083-887, Brazil
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15
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Polovinkin VV, Igolkin AN, Pryn PS, Khalafyan AA. [Results of reconstructive surgery with formation of low colorectal anastomoses after previous Hartmann's procedure]. Khirurgiia (Mosk) 2022:39-49. [PMID: 35080825 DOI: 10.17116/hirurgia202201139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- V V Polovinkin
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - A N Igolkin
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
| | - P S Pryn
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russia
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16
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Hartmann's Reversal Through Transanal Hand-Sewn Anastomosis With Rectal Mucosectomy for a Challenging Case: Case Report. Int Surg 2022. [DOI: 10.9738/intsurg-d-21-00020.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction
Despite the advances in surgical techniques, Hartmann's reversal is often considered a difficult procedure, and the stoma cannot be restored in up to 40% of the cases. We report a patient with a challenging case of severe dense adhesions and a short rectal stump who recovered successfully after undergoing Hartmann's reversal through rectal mucosectomy and transanal hand-sewn anastomosis.
Case presentation
A 39-year-old man had multiple bowel injuries, including rectum, bladder, and ureter laceration, due to a stab wound. He underwent Hartmann's procedure with a short rectal stump. One year and 9 months later, Hartmann's reversal was performed. In the operative field, severe dense adhesions were observed in the pelvic cavity. Therefore, complications, including fistula, were likely to occur. Thus, we minimized the dissection around the rectal stump and avoided stapled anastomosis. Proctotomy was performed behind the rectal stump, and the proximal colon was inserted into the rectum. Rectal mucosectomy was performed for the rectum above the expected anastomosis site. Colorectal hand-sewn anastomosis was performed on the rectum, 3 cm from the anal verge. The patient recovered well after the surgery, and has remained healthy, without any discomfort, except for frequent defecation.
Conclusion
Rectal mucosectomy and transanal hand-sewn anastomosis were performed in a complex case of Hartmann's reversal, resulting in the patient's successful recovery without complications. This study recommends the preceding surgical technique for similar cases.
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Abstract
Management of the acute anastomotic leak is complex and patient-specific. Clinically stable patients often benefit from a nonoperative approach utilizing antibiotics with or without percutaneous drainage. Clinically unstable patients or nonresponders to conservative management require operative intervention. Surgical management is dictated by the degree of contamination and inflammation but includes drainage with proximal diversion, anastomotic resection with end-stoma creation, or reanastomosis with proximal diversion. Newer therapies, including colorectal stenting, vacuum-assisted rectal drainage, and endoscopic clipping, have also been described.
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Affiliation(s)
- Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - William Kane
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
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18
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Cho HJ, Kim WR, Kim JW. A comparative study between open versus laparoscopic Hartmann reversal: A single-center experience and analysis. Medicine (Baltimore) 2021; 100:e27976. [PMID: 34964789 PMCID: PMC8615443 DOI: 10.1097/md.0000000000027976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 11/10/2021] [Indexed: 01/05/2023] Open
Abstract
As one of the most challenging procedures in colorectal surgery, Hartmann reversal (HR) carries a burden of morbidity and mortality. We report our experience and compare open and laparoscopic HR.Between December 2012 and January 2020, 30 patients who underwent Hartmann reversal were reviewed. All patients either received laparoscopic or open reversal.Of the 87 patients who underwent Hartmann operation (HO), 30 patients received HR (Laparoscopic Hartmann Reversal, [LHR], n = 20; Open Hartmann Reversal, Open Hartmann Reversal [OHR], n = 10). There were 15 males and 15 female patients. The mean operation time was 223.8 minutes (range 115-350 minutes) with mean blood loss of 252.5 mL (range 0-700 mL). There was no conversion from LHR to OHR, and there was no ileostomy formation. Mean time to flatus was 5.0 days (range 2-13 days). There were 15 early postoperative complications and 5 late postoperative complications, but only 1 case of grade 3A. No anastomosis leakage was reported.HR is an operation that can be performed safely in well-selected patients. Minimally invasive techniques, such as LHR, is an attractive option resulting in shorter operation time, less blood loss, less pain, and shorter hospital stay.
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19
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Lee DB, Shin S, Yang CS. Patient outcomes and prognostic factors associated with colonic perforation surgery: a retrospective study. Yeungnam Univ J Med 2021; 39:133-140. [PMID: 34710320 PMCID: PMC8913914 DOI: 10.12701/yujm.2021.01445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background Despite advances in surgery and intensive perioperative care, fecal peritonitis secondary to colonic perforation is associated with high rates of morbidity and mortality. This study was performed to review the outcomes of patients who underwent colonic perforation surgery and to evaluate the prognostic factors associated with mortality. Methods A retrospective analysis was performed on 224 consecutive patients who underwent emergency colonic perforation surgery between January 2008 and May 2019. We divided the patients into survivor and non-survivor groups and compared their surgical outcomes. Results The most common cause of colon perforation was malignancy in 54 patients (24.1%), followed by iatrogenic perforation in 41 (18.3%), stercoral perforation in 39 (17.4%), and diverticulitis in 37 (16.5%). The sigmoid colon (n=124, 55.4%) was the most common location of perforation, followed by the ascending colon, rectum, and cecum. Forty-five patients (20.1%) died within 1 month after surgery. Comparing the 179 survivors with the 45 non-survivors, the patient characteristics associated with mortality were advanced age, low systolic blood pressure, tachycardia, organ failure, high C-reactive protein, high creatinine, prolonged prothrombin time, and high lactate level. The presence of free or feculent fluid, diffuse peritonitis, and right-sided perforation were associated with mortality. In multivariate analysis, advanced age, organ failure, right-sided perforation, and diffuse peritonitis independently predicted mortality within 1 month after surgery. Conclusion Age and organ failure were prognostic factors for mortality associated with colon perforation. Furthermore, right-sided perforation and diffuse peritonitis demonstrated a significant association with patient mortality.
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Affiliation(s)
- Do-Bin Lee
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Seonhui Shin
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Chun-Seok Yang
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
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20
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Alves Junior AJT, Pereira JA, Ávila MGD, Domingues FA, Sato DT, Martinez CAR. 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. Acta Cir Bras 2021; 36:e360401. [PMID: 34008743 PMCID: PMC8128352 DOI: 10.1590/acb360401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 12/29/2022] Open
Abstract
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.
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21
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Shahait A, Qadeer AF, Hasnain MR, Baldawi M, Gruber SA, Weaver D, Mostafa G. Hartmann's Reversal Outcomes: a VASQIP Study. J Gastrointest Surg 2021; 25:539-541. [PMID: 32968932 DOI: 10.1007/s11605-020-04807-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/15/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Awni Shahait
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, MI, USA.,Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI, USA
| | - Afreen Fatma Qadeer
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | | | - Mohanad Baldawi
- Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI, USA
| | - Scott A Gruber
- Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI, USA
| | - Donald Weaver
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Gamal Mostafa
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, MI, USA. .,Department of Surgery, John D. Dingell VA Medical Center, Detroit, MI, USA.
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22
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Konopke R, Schubert J, Stöltzing O, Thomas T, Kersting S, Denz A. [Palliative Surgery in Colorectal Cancer - Which Factors Should Influence the Choice of the Surgical Procedure?]. Zentralbl Chir 2020; 146:44-57. [PMID: 33296936 DOI: 10.1055/a-1291-8293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The surgical procedure for patients with colorectal cancer (CRC) in the palliative situation cannot be adequately standardised. The present study was initiated to identify criteria for the decision for resection of the malignancy with or without anastomosis. PATIENTS/MATERIAL AND METHODS In a unicentric retrospective analysis, 103 patients after palliative resection with or without anastomosis due to CRC were examined. Using univariate and logistic regression analysis, the influence of a total of 40 factors on postoperative morbidity and mortality was assessed. RESULTS In 46 cases, resection with primary anastomosis and in 57 cases a discontinuity resection was performed. Postoperative morbidity was 44.7% and mortality 17.5%. After one-stage resection with anastomosis, nicotine abuse (OR 4.2; p = 0.044), hypalbuminaemia (OR 4.0; p = 0.012), ASA score > 2 (OR 3.7; p = 0.030) and liver remodelling/cirrhosis (OR 3.6; p = 0.031) increased the risk for postoperative complications. Hypalbuminaemia (OR 1.8; p = 0.036), cachexia (OR 1.8; p = 0.043), anaemia (OR 1.5; p = 0.038) and known alcohol abuse (OR 1.9; p = 0.023) were identified as independent risk factors for early postoperative mortality. After discontinuity resection, renal failure (OR 2.1; p = 0.042) and cachexia (OR 1.5; p = 0.045) led to a significant increase in the risk of postoperative morbidity, alcohol abuse (OR 1.8; p = 0.041) in mortality. Hypalbuminaemia (OR 2.8; p = 0.019) and an ASA score > 2 (OR 2.6; p = 0.004) after resection and reconstruction increased the risk of major complications according to Clavien-Dindo, while pre-existing renal failure (OR 1.6; p = 0.023) increased the risk after discontinuity resection. In univariate analysis, an ASA score > 2 (p = 0.038) after simultaneous tumour resection and reconstruction, and urgent surgery in both groups with or without primary anastomosis were additionally identified as significant parameters with a negative influence on mortality (p = 0.010 and p = 0.017). CONCLUSION Palliative resections of colorectal carcinomas have high morbidity and mortality. Especially in cases of pre-existing alcohol abuse and/or urgent indication for surgery, more intensive monitoring should be performed. In the case of anaemia, cachexia, hypalbuminemia and an ASA score > 2, discontinuity resection may be the more appropriate procedure.
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Affiliation(s)
- Ralf Konopke
- Zentrum für Allgemein- und Viszeralchirurgie, Elblandklinikum Riesa, Deutschland
| | - Jörg Schubert
- Klinik für Innere Medizin 2, Elblandklinikum Riesa, Deutschland
| | - Oliver Stöltzing
- Zentrum für Allgemein- und Viszeralchirurgie, Elblandklinikum Riesa, Deutschland
| | - Tina Thomas
- Medizinische Klinik I, Universitätsklinikum Dresden, Deutschland
| | - Stephan Kersting
- Klinik und Poliklinik für Allgemeine, Viszeral-, Thorax- und Gefäßchirurgie, Greifswald, Deutschland
| | - Axel Denz
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Deutschland
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23
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Arnold AA, May V, Nanthakumaran S, Pagad S, Somagutta MR, Sridharan S, Malik BH. Reversal of Hartmann's Procedure: Evaluating Outcomes of Single-Port Laparoscopic Approach Versus Conventional Approach. Cureus 2020; 12:e11916. [PMID: 33425502 PMCID: PMC7785510 DOI: 10.7759/cureus.11916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Bowel restoration following Hartmann's procedure (HP) remains a topic of discussion and innovation. This article seeks to highlight and analyze the outcomes of conventional reversal approaches such as open surgery (OS) and conventional laparoscopic (CL) to single-port laparoscopic reversal (SPLR) approach to evaluate whether SPLR is a feasible alternative to the OS or CL approach. A PubMed search using keywords yielded 5,750 articles. After applying the inclusion/exclusion criteria, 40 articles of relevance were reviewed, and endpoints considered. These included 13 systematic reviews and 27 observational reviews, three of which identified themselves as retrospective or comparative studies. The analysis showed overwhelming support for CL over OS as a choice for HP reversal. Studies comparing SPLR to CL showed SPLR to be a safe and feasible alternative, given its significantly shorter operating times, hospitalization times, and complication rates.
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Affiliation(s)
- Ashley A Arnold
- Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Vanessa May
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Saruja Nanthakumaran
- Psychiatry, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Sukrut Pagad
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Manoj R Somagutta
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Saijanakan Sridharan
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Krogsgaard M, Gögenur I, Helgstrand F, Andersen RM, Danielsen AK, Vinther A, Klausen TW, Hillingsø J, Christensen BM, Thomsen T. Surgical repair of parastomal bulging: a retrospective register-based study on prospectively collected data. Colorectal Dis 2020; 22:1704-1713. [PMID: 32548884 DOI: 10.1111/codi.15197] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022]
Abstract
AIM The aim of this work was to examine (1) the incidence of primary repair, (2) the incidence of recurrent repair and (3) the types of repair performed in patients with parastomal bulging. METHOD Prospectively collected data on parastomal bulging from the Danish Stoma Database were linked to surgical data on repair of parastomal bulging from the Danish National Patient Register. Survival statistics provided cumulative incidences and time until primary and recurrent repair. RESULTS In the study sample of 1016 patients with a permanent stoma and a parastomal bulge, 180 (18%) underwent surgical repair. The cumulative incidence of a primary repair was 9% [95% CI (8%; 11%)] within 1 year and 19% [95% CI (17%; 22%)] within 5 years after the occurrence of a parastomal bulge. We found a similar probability of undergoing primary repair in patients with ileostomy and colostomy. For recurrent repair, the 5-year cumulative incidence was 5% [95% CI (3%; 7%)]. In patients undergoing repair, the probability was 33% [95% CI (21%; 46%)] of having a recurrence requiring repair within 5 years. The main primary repair was open or laparoscopic repair with mesh (43%) followed by stoma revision (39%). Stoma revision and repair with mesh could precede or follow one another as primary and recurrent repair. Stoma reversal was performed in 17% of patients. CONCLUSION Five years after the occurrence of a parastomal bulge the estimated probability of undergoing a repair was 19%. Having undergone a primary repair, the probability of recurrent repair was high. Stoma reversal was more common than expected.
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Affiliation(s)
- M Krogsgaard
- Department of Surgical Gastroenterology, Clinic C Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Gastroenterology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - I Gögenur
- Department of Surgery, Centre for Surgical Sciences, Zealand University Hospital, Koege, Denmark
| | - F Helgstrand
- Department of Surgery, Centre for Surgical Sciences, Zealand University Hospital, Koege, Denmark
| | - R M Andersen
- Department of Surgical Gastroenterology, Clinic C Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Gastroenterology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - A K Danielsen
- Department of Gastroenterology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A Vinther
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital in Herlev and Gentofte, Copenhagen, Denmark.,QD-Research Unit, Copenhagen University Hospital in Herlev and Gentofte, Denmark
| | - T W Klausen
- Department of Haematology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - J Hillingsø
- Department of Surgical Gastroenterology, Clinic C Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - B M Christensen
- Department of Surgical Gastroenterology, Clinic C Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - T Thomsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Herlev Acute, Critical and Emergency Care Science Group, Department of Anaesthesiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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25
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Yilmaz Y, Cengiz F, Kamer E, Acar T, Gür EÖ, Bag H, Peker Y, Atahan K. The factors that affect the mortality of emergency operated ASA 3 colon cancer patients. Pan Afr Med J 2020; 36:290. [PMID: 33117484 PMCID: PMC7572692 DOI: 10.11604/pamj.2020.36.290.24385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/30/2020] [Indexed: 01/13/2023] Open
Abstract
Introduction colorectal cancers take third place among cancer-related deaths and 10-28% of these patients are admitted with the necessity of emergency surgical intervention. The main propose of this study was to investigate the factors affecting mortality in ASA 3 colorectal cancer patients who undergo emergency surgery. Methods between 2010 and 2017 ASA 3 patients who underwent emergency colon cancer surgery were included in the study. All of the study group was evaluated within the first 30-day time-frame. The results were obtained by a statistical comparison of the data of patients with and without mortality. Results one hundred and twenty eight patients included in the study. There was no statistical difference in the demographic data of the groups and the indications of the operation. The differences and durations of surgery also did not make any statistical difference. The complication rate was the same according to the Clavien-Dindo classification. Conclusion despite the screening programs applied in colorectal cancers, applications to emergency services and procedures performed under emergency conditions are still at high levels. Surgical operations, which have to be performed in patients with impaired metabolic status, carry major risks for patients, but their outcomes are also satisfactory for them.
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Affiliation(s)
- Yeliz Yilmaz
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Fevzi Cengiz
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Erdinç Kamer
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Turan Acar
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Emine Özlem Gür
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Halis Bag
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Yasin Peker
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Kemal Atahan
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
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Joo Y, Lee Y, Yoo T, Kim J, Park I, Gwak G, Cho H, Yang K, Kim K, Bae BN. Prognostic Factors and Management for Left Colonic Perforation: Can Hartmann's Procedure Be Preventable? Ann Coloproctol 2020; 36:178-185. [PMID: 32674547 PMCID: PMC7392568 DOI: 10.3393/ac.2019.11.14.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/14/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To identify factors significantly associated with the mortality of patients with left colonic perforation, and to compare the outcome of Hartmann's procedure (HP) and primary repair (PR) or primary anastomosis (PA) in patients with left colonic perforation without factors associated with mortality. METHODS This retrospective study included patients who underwent surgery for left colonic perforation from January 2009 to February 2018. Preoperative factors related to postoperative mortality, including vital signs, laboratory findings, and intraoperative findings, were analyzed by type of operation. The chi-square, Fisher exact, and Mann-Whitney U-tests were used to analyze the data. RESULTS Ninety-one patients were included (36 men, 55 women), and 15 (16.5%) died postoperatively. Prognostic factors were age, leukopenia, thrombocytopenia, bleeding tendency, acute kidney injury, hemodynamic instability, and the existence of feculent ascites. Leukopenia and longer operative time were independent risk factors for mortality. Seventy-nine patients did not have leukopenia and 30 of these patients who underwent PR without diversion were excluded from the subanalysis. HP was performed in 30 patients, and PR with diversion and PA with or without diversion were performed in 19. Compared to the other operative methods, HP had no advantage in reducing hospital mortality (P=0.458) and morbidity. CONCLUSION Leukopenia could be an objective prognostic factor for left colonic perforation. Although HP is the gold standard for septic left colonic perforation, it did not improve the hospital mortality of the patients without leukopenia. For such patients, PR or PA may be suggested as an alternative option for left colonic perforation.
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Affiliation(s)
- Yilseok Joo
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Yujin Lee
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Taeyoung Yoo
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Jungbin Kim
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Inseok Park
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Geumhee Gwak
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Hyunjin Cho
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Keunho Yang
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Kiwhan Kim
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Byung-Noe Bae
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
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Christou N, Rivaille T, Maulat C, Taibi A, Fredon F, Bouvier S, Fabre A, Derbal S, Durand-Fontanier S, Valleix D, Robert-Yap J, Muscari F, Mathonnet M. Identification of risk factors for morbidity and mortality after Hartmann's reversal surgery - a retrospective study from two French centers. Sci Rep 2020; 10:3643. [PMID: 32107426 PMCID: PMC7046632 DOI: 10.1038/s41598-020-60481-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/27/2020] [Indexed: 11/25/2022] Open
Abstract
Hartmann’s reversal procedures are often fraught with complications or failure to recover. This being a fact, it is often difficult to select patients with the optimal indications for a reversal. The post-recovery morbidity and mortality rates in the literature are heterogeneous between 0.8 and 44%. The identification of predictive risk factors of failure of such interventions would therefore be very useful to help the practitioner in his approach. Given these elements, it was important to us to analyze the practice of two French university hospitals in order to highlight such risk factors and to allow surgeons to select the best therapeutic strategy. We performed a bicentric observational retrospective study between 2010 and 2015 that studied the characteristics of patients who had undergone Hartmann surgery and were subsequently reestablished. The aim of the study was to identify factors influencing morbidity and postoperative mortality of Hartmann’s reversal. Primary outcome was complications within the first 90 postoperative days. 240 patients were studied of which 60.4% were men. The mean age was 69.48 years. The median time to reversal was 8 months. 79.17% of patients were operated as emergency cases where the indication was a diverticular complication (39.17%). Seventy patients (29.2%) underwent a reversal and approximately 43% of these had complications within the first 90 postoperative days. The mean age of these seventy patients was 61.3 years old and 65.7% were males. None of them benefited from a reversal in the first three months. We identified some risk factors for morbidity such as pre-operative low albuminemia (p = 0.005) and moderate renal impairment (p = 0.019). However, chronic corticosteroid use (p = 0.004), moderate renal insufficiency (p = 0.014) and coronary artery disease (p = 0.014) seem to favour the development of anastomotic fistula, which is itself, a risk factor for mortality (p = 0.007). Our study highlights an important rate of complications including significant anastomotic fistula after Hartmann’s reversal. Precarious nutritional status and cardiovascular comorbidities should clearly lead us to reconsider the surgical indication for continuity restoration.
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Affiliation(s)
- Niki Christou
- Service de chirurgie digestive, endocrinienne et générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, 87042, France. .,Department of Visceral Surgery, Geneva University Hospitals and Medical School, Geneva, Rue Gabrielle Perret-Gentil 4, 1205, Geneva, Switzerland.
| | - Thibaud Rivaille
- Service de chirurgie digestive, endocrinienne et générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, 87042, France
| | - Charlotte Maulat
- Chirurgie digestive et transplantation d'organes (département), Pôle digestif, Hôpital Rangueil, 1, avenue du Professeur Jean Poulhès - TSA 50032, 31059, Toulouse, cedex 9, France
| | - Abdelkader Taibi
- Service de chirurgie digestive, endocrinienne et générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, 87042, France
| | - Fabien Fredon
- Service de chirurgie digestive, endocrinienne et générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, 87042, France
| | - Stephane Bouvier
- Service de chirurgie digestive, endocrinienne et générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, 87042, France
| | - Anne Fabre
- Service de chirurgie digestive, endocrinienne et générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, 87042, France
| | - Sophiane Derbal
- Service de chirurgie digestive, endocrinienne et générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, 87042, France
| | - Sylvaine Durand-Fontanier
- Service de chirurgie digestive, endocrinienne et générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, 87042, France
| | - Denis Valleix
- Service de chirurgie digestive, endocrinienne et générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, 87042, France
| | - Joan Robert-Yap
- Department of Visceral Surgery, Geneva University Hospitals and Medical School, Geneva, Rue Gabrielle Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Fabrice Muscari
- Chirurgie digestive et transplantation d'organes (département), Pôle digestif, Hôpital Rangueil, 1, avenue du Professeur Jean Poulhès - TSA 50032, 31059, Toulouse, cedex 9, France
| | - Muriel Mathonnet
- Service de chirurgie digestive, endocrinienne et générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, 87042, France
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Caille C, Collard M, Moszkowicz D, Prost À la Denise J, Maggiori L, Panis Y. Reversal of Hartmann's procedure in patients following failed colorectal or coloanal anastomosis: an analysis of 45 consecutive cases. Colorectal Dis 2020; 22:203-211. [PMID: 31536670 DOI: 10.1111/codi.14854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/15/2019] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- C Caille
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
| | - M Collard
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
| | - D Moszkowicz
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
| | - J Prost À la Denise
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
| | - L Maggiori
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
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Horesh N, Lessing Y, Rudnicki Y, Kent I, Kammar H, Ben-Yaacov A, Dreznik Y, Zbar AP, Tulchinsky H, Avital S, Mavor E, Kashtan H, Klausner JM, Gutman M, Zmora O, Wasserberg N. Timing of colostomy reversal following Hartmann's procedure for perforated diverticulitis. J Visc Surg 2020; 157:395-400. [PMID: 31954631 DOI: 10.1016/j.jviscsurg.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
AIM Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome. PATIENTS AND METHODS A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. RESULTS One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P=0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P=0.16), Major (Clavien-Dindo score of 3 or more) complications (P=0.19), Minor (Clavien Dindo 1-2) and no complications (P=0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P=0.4). CONCLUSION Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.
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Affiliation(s)
- N Horesh
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel.
| | - Y Lessing
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, 6423906 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - Y Rudnicki
- Department of Surgery B, Meir Medical Center, Kfar Saba, 4428164 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - I Kent
- Department of Surgery B, Meir Medical Center, Kfar Saba, 4428164 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - H Kammar
- Department of Surgery, Kaplan Medical Center, Rehovot, 7661041 Israel; The Hebrew University-Hadassah Medical School, Jerusalem 9112001 Israel
| | - A Ben-Yaacov
- Department of Surgery B, Rabin Medical Center-Beilinson Hospital, Petach Tikva 4941492 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - Y Dreznik
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - A P Zbar
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - H Tulchinsky
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, 6423906 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - S Avital
- Department of Surgery B, Meir Medical Center, Kfar Saba, 4428164 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - E Mavor
- Department of Surgery, Kaplan Medical Center, Rehovot, 7661041 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - H Kashtan
- Department of Surgery B, Rabin Medical Center-Beilinson Hospital, Petach Tikva 4941492 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - J M Klausner
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, 6423906 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - M Gutman
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - O Zmora
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - N Wasserberg
- Department of Surgery B, Rabin Medical Center-Beilinson Hospital, Petach Tikva 4941492 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
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30
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Hartmann’s reversal as a safe procedure for selected patients: analysis of 199 patients at a high-volume center in Sao Paulo. Surg Today 2020; 50:855-862. [DOI: 10.1007/s00595-020-01957-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 12/20/2019] [Indexed: 12/11/2022]
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Resio BJ, Jean R, Chiu AS, Pei KY. Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis. JAMA Surg 2019; 154:218-224. [PMID: 30476948 DOI: 10.1001/jamasurg.2018.4359] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance The Hartmann procedure (end colostomy) remains a common operation for diverticulitis requiring surgery. However, the timing of subsequent colostomy reversal remains widely varied, and the optimal timing remains unknown. Objective To investigate the association of the timing of colostomy reversal with operative outcomes. Design, Setting, and Participants This retrospective analysis of the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida and Maryland included patients with colostomy for diverticulitis linked to their colostomy reversal. Patients with readmissions between the index surgery and reversal were excluded, leaving a final cohort of 1660 patients. Data were collected from January 1, 2010, to December 31, 2016, and analyzed from December 1, 2017, through May 31, 2018. Exposures Patients were divided based on timing of colostomy reversal following the index surgery into early (45-110 days), middle (111-169 days), and late (≥170 days) reversal timing. Main Outcomes and Measures Primary outcomes of interest after reversal included mortality, morbidity, and readmissions and were compared among all groups using logistic regression adjusted for comorbidities and age. Results In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. Of patients who underwent reversal within 1 year, 1660 had no readmissions before reversal (860 men [51.8%]; median age, 61 years [interquartile range {IQR}, 51-70 years]). The median time to reversal was 129 days (IQR, 99-182 days). On multivariable analysis, patient characteristics associated with early reversal included being 60 years or younger (odds ratio [OR], 1.31; 95% CI, 1.00-1.70; P = .0497), white race (OR, 1.32; 95% CI, 1.05-1.67; P = .02), and private insurance vs Medicaid (OR, 2.45; 95% CI, 1.67-3.60; P < .001). Mortality, transfusion, ileus, and major complications were not significantly different among the reversal timing groups. However, prolonged length of stay (OR, 1.62; 95% CI, 1.19-2.21; P = .002) and 90-day readmissions (OR, 1.61; 95% CI, 1.18-2.22; P = .003) were significantly more likely in the late vs early timing groups. Conclusions and Relevance Less than one-third of patients undergo colostomy reversal within 1 year after end colostomy for diverticulitis, and reversal timing is associated with socioeconomic disparities. In selected patients with an uncomplicated course, improved outcomes are associated with earlier reversal, and colostomy reversal is safe as early as 45 to 110 days after the initial procedure.
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Affiliation(s)
- Benjamin J Resio
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Raymond Jean
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Y Pei
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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