Pelvic sepsis after extended Hartmann's procedure

Oncological outcome following Hartmann's procedure compared with anterior resection and abdominoperineal resection for rectal cancer-The type of procedure does not influence local recurrence or distant metastasis: A population-based study

AIM

The type of surgical procedure used in rectal cancer treatment may affect cancer recurrence. The aim of this study was to determine whether the type of procedure influences oncological outcomes in rectal cancer surgery.

METHOD

We gathered data from the Swedish Colorectal Cancer Registry regarding patients with TNM Stage I-III rectal cancer who underwent R0/R1 surgery from 2013 to 2017. The outcomes after Hartmann's procedure (HP), anterior resection (AR) and abdominoperineal resection (APR) were compared, and a multivariable Cox regression analysis was performed. The primary outcome of the study was the local recurrence rate. The secondary outcomes were distant metastasis, disease-free survival and overall survival at 5 years as well as risk factors for local recurrence.

RESULTS

A total of 4741 patients were included in the study: 614 underwent HP, 3075 underwent AR and 1052 underwent APR. Multivariable Cox regression revealed no difference in local recurrence, distant metastasis or disease-free survival. Overall survival was higher following AR (OR 0.62, CI 0.54-0.72). Risk factors for local recurrence were intraoperative bowel perforation (OR 2.41, CI 1.33-4.40), a pT4 tumour (OR 1.93, CI 1.11-3.4) and a positive circumferential resection margin (OR 5.62, CI 3.28-9.61).

CONCLUSIONS

This nationwide study showed that the type of procedure did not affect the local recurrence rate or distant metastasis. In patients who are unfit for restorative surgery, HP is a viable alternative with oncological outcomes similar to those of APR.

Hartmann's Procedure Versus Intersphincteric Abdominoperineal Excision in Patients with Rectal Cancer: Report from the Swedish Colorectal Cancer Registry (SCRCR)

Objective

The primary outcome was to compare overall postoperative surgical complications within 30 days after Hartmann's procedure (HP) compared with intersphincteric abdominoperineal excision (iAPE). The secondary outcome was major surgical complications (Clavien-Dindo ≥ III).

Background

There is uncertainty regarding the optimal surgical method in patients with rectal cancer when an anastomosis is unsuitable.

Methods

Rectal cancer patients with a tumor height >5 cm, registered in the Swedish Colorectal Cancer Registry who received HP or iAPE electively in 2017-2020 were included, (HP, n = 696; iAPE, n = 314). Logistic regression analysis adjusting for body mass index, American Society of Anesthesiologists classification, sex, age, preoperative radiotherapy, tumor height, cancer stage, operating hospital, and type of operation was performed.

Results

Patients in the HP group were older and had higher American Society of Anesthesiologists scores. The mean operating time was less for HP (290 vs 377 min). Intraoperative bowel perforations were less frequent in the HP group, 3.6% versus 10.2%. Overall surgical complication rates were 20.3% after HP and 15.9% after iAPE (P = 0.118). Major surgical complications were 7.5% after HP and 5.7% and after iAPE (P = 0.351). Multiple regression analysis indicated a higher risk of overall surgical complications after HP (odds ratio: 1.63; 95% confidence interval = 1.09-2.45).

Conclusions

HP was associated with a higher risk of surgical complications compared with iAPE. In patients unfit for anastomosis, iAPE may be preferable. However, the lack of statistical power regarding major surgical complications, prolonged operating time, increased risk of bowel perforation, and lack of long-term outcomes, raises uncertainty regarding recommending intersphincteric abdominoperineal excision as the preferred surgical approach.

Postoperative morbidity following Hartmann's procedure in comparison to anterior resection and abdominoperineal resection for rectal cancer-a population-based study

AIM

There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry.

METHODS

All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry.

RESULTS

A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality.

CONCLUSIONS

For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.

Management of acute and chronic pelvic sepsis after total mesorectal excision for rectal cancer-a 10-year experience of a national referral centre

AIM

Uncontrolled pelvic sepsis following rectal cancer surgery may lead to dramatic consequences with significant impact on patients' quality of life. The aim of this retrospective observational study is to evaluate management of pelvic sepsis after total mesorectal excision for rectal cancer at a national referral centre.

METHOD

Referred patients with acute or chronic pelvic sepsis after sphincter preserving rectal cancer resection, with the year of referral between 2010 and 2014 (A) or between 2015 and 2020 (B), were included. The main outcome was control of pelvic sepsis at the end of follow-up, with healed anastomosis with restored faecal stream (RFS) as co-primary outcome.

RESULTS

In total 136 patients were included: 49 in group A and 87 in group B. After a median follow-up of 82 months (interquartile range 35-100) in group A and 42 months (interquartile range 22-60) in group B, control of pelvic sepsis was achieved in all patients who received endoscopic vacuum assisted surgical closure (7/7 and 2/2), in 91% (19/21) and 89% (31/35) of patients who received redo anastomosis (P = 1.000) and in 100% (18/18) and 95% (41/43) of patients who received intersphincteric resection (P = 1.000), respectively. Restorative procedures resulted in a healed anastomosis with RFS in 61% (17/28) of patients in group A and 68% (25/37) of patients in group B (P = 0.567).

CONCLUSION

High rates of success can be achieved with surgical salvage of pelvic sepsis in a dedicated tertiary referral centre, without significant differences over time. In well selected and motivated patients a healed anastomosis with RFS can be achieved in the majority.

Hartmann's procedure in rectal cancer surgery is often an intraoperative decision: a retrospective multicenter study

PURPOSE

This study aimed to investigate patient-related factors predicting the selection of rectal cancer patients to Hartmann's procedure as well as to investigate how often, and on what grounds, anterior resection is intraoperatively changed to Hartmann's procedure.

METHODS

Prospectively collected data from the Swedish Colorectal Cancer Registry regarding patients with rectal cancer operated upon from January 1 2007 to June 30 2017 in the county of Skåne were retrospectively reviewed. Data were expanded with further details from medical charts. A univariable analysis was performed to investigate variables associated with unplanned HP and significant variables included in a multivariable logistic regression analysis.

RESULTS

Altogether, 1141 patients who underwent Hartmann's procedure (275 patients, 24%), anterior resection (491 patients, 43%), or abdominoperineal resection (375 patients, 33%) were included. Patients undergoing Hartmann's procedure were significantly older and had more frequently comorbidity. The decision to perform Hartmann's procedure was made preoperatively in 209 (76%) patients, most commonly because of a comorbidity (27%) or oncological reasons (25%). Patient preference was noted in 8% of cases. In 64 cases (23%), the decision was made intraoperatively, most often due to anastomotic difficulties (60%) and oncological reasons (22%). Anastomotic difficulties were most often reported due to technical difficulties, a low tumor or neoadjuvant radiotherapy. Male gender was a significant risk factor for undergoing unplanned Hartmann's procedure.

CONCLUSIONS

The decision to perform Hartmann's procedure was frequently made intraoperatively. Hartmann's procedure should be considered and discussed preoperatively in old and frail patients, especially in the presence of mid-rectal cancer and/or male gender, since these factors increase the risk of intraoperative anastomotic difficulties.

Risk Factors for Rectal Stump Leakage After Discontinuity Resection: Stump Length Matters Most

BACKGROUND

Discontinuity resection is commonly conducted to avoid anastomotic leakage in high-risk patients but potentially results in rectal stump leakage. Although risk factors for anastomotic leakage have been widely studied, data on rectal stump leakage rates and underlying risk factors are scarce.

OBJECTIVE

To determine rectal stump leakage rates following Hartmann's procedure and to identify patient-and surgery-associated risk factors.

DESIGN

A retrospective study with univariate and multivariate analyses was performed to identify risk factors of rectal stump leakage. A subgroup analysis of scheduled operations was performed.

SETTINGS

The study was conducted at Heidelberg University Hospital, Germany.

PATIENTS

Patients were included who underwent discontinuity resection with rectal stump formation between 2010 and 2020.

MAIN OUTCOME MEASURES

The main outcome measures included rectal stump leakage rates, 30-day mortality, length of hospitalization, and necessity for further invasive treatment.

RESULTS

Rectal stump leakage occurred in 11.78% of patients. Rectal stump leakage rates varied considerably depending on the surgical procedure performed and were highest following subtotal pelvic exenteration (34%). Diagnosis of rectal stump leakage peaked on postoperative day 7. A short rectal stump ( p = 0.001), previous pelvic radiotherapy ( p = 0.04), chemotherapy ( p = 0.004), and previous laparotomy ( p = 0.03) were independent risk factors for rectal stump leakage in the entire patient collective. In patients undergoing scheduled surgery, a short rectal stump was the only independent risk factor ( p = 0.003). Rectal stump leakage was not associated with increased 30-day mortality but prolonged length of hospitalization and frequently necessitated further invasive treatment.

LIMITATIONS

Study results are limited by the retrospective design, a high number of emergency operations, and the mere inclusion of symptomatic leakages.

CONCLUSIONS

Rectal stump leakage is a relevant complication after discontinuity resection. Risk factors should be considered during surgical decision-making when both discontinuity resection and abdominoperineal resection are feasible. See Video Abstract.

FACTORES DE RIESGO PARA LA FUGA DEL MUN RECTAL DESPUS DE UNA RESECCIN POR DISCONTINUIDAD LA LONGITUD DEL MUN ES LO MS IMPORTANTE

ANTECEDENTES:La resección de discontinuidad se realiza comúnmente para evitar la fuga anastomótica en pacientes de alto riesgo, pero potencialmente da como resultado una fuga del muñón rectal. Si bien los factores de riesgo de fuga anastomótica se han estudiado ampliamente, los datos sobre las tasas de fuga del muñón rectal y los factores de riesgo subyacentes son escasos.OBJETIVO:Determinar las tasas de fuga del muñón rectal después del procedimiento de Hartmann e identificar los factores de riesgo asociados con el paciente y la cirugía.DISEÑO:Se realizó un estudio retrospectivo con análisis univariado y multivariado para identificar los factores de riesgo de fuga del muñón rectal. Se llevó a cabo un análisis de subgrupos de las operaciones programadas.AJUSTES:El estudio se realizó en el Hospital Universitario de Heidelberg, Alemania.PACIENTES:Se incluyeron pacientes que se sometieron a resección de discontinuidad con formación de muñón rectal entre 2010 y 2020.MEDIDAS DE RESULTADO PRINCIPALES:Las principales medidas de resultado incluyeron las tasas de fuga del muñón rectal, la mortalidad a los 30 días, la duración de la hospitalización y la necesidad de un tratamiento invasivo adicional.RESULTADOS:La fuga del muñón rectal ocurrió en el 11,78% de los pacientes. Las tasas de fuga del muñón rectal variaron considerablemente según el procedimiento quirúrgico realizado y fueron más altas después de la exenteración pélvica subtotal (34%). El diagnóstico de fuga del muñón rectal alcanzó su punto máximo en el día 7 del postoperatorio. Un muñón rectal corto (p = 0,001), radioterapia pélvica previa (p = 0,04), quimioterapia (p = 0,004) y laparotomía previa (p = 0,03) fueron factores de riesgo independientes de fuga rectal. Fuga del muñón en todo el colectivo de pacientes. En los pacientes sometidos a cirugía programada, el muñón rectal corto fue el único factor de riesgo independiente (p = 0,003). La fuga del muñón rectal no se asoció con un aumento de la mortalidad a los 30 días, pero con una duración prolongada de la hospitalización y con frecuencia requirió un tratamiento invasivo adicional.LIMITACIONES:Los resultados del estudio están limitados por el diseño retrospectivo, un alto número de operaciones de emergencia y la mera inclusión de fugas sintomáticas.CONCLUSIONES:La fuga del muñón rectal es una complicación relevante tras la resección por discontinuidad. Se deben considerar los factores de riesgo durante la toma de decisiones quirúrgicas cuando son factibles tanto la resección por discontinuidad como la resección abdominoperineal. (Traducción-Yesenia Rojas-Khalil ).

Incidence and risk factors of blowout within 90 days after a primary Hartmann's procedure: a retrospective cohort study

PURPOSE

The literature reports a varying occurrence (3-33%) of blowout of the rectal remnant after Hartmann's procedure, and there is a lack of multivariate analyses on potential risk factors for blowout following Hartmann's procedure. We aimed to estimate the incidence of blowout within 90 days after a primary Hartmann's procedure and to identify potential risk factors for blowout through multivariate analysis.

METHODS

A retrospective cohort study was conducted at the Department of Surgery, Aarhus University Hospital, a Danish primary and tertiary hospital. Patients who underwent primary surgery with Hartmann's procedure irrespective of surgical setting and indications between September 2016 and August 2021 were included. Blowout was defined as a defective closure line of the rectal stump or a pelvic abscess.

RESULTS

A total of 178 patients were included, and blowout occurred in 30 patients (16.9%) within 90 days after a primary Hartmann's procedure. Multivariate analysis showed increased risk of blowout among patients with Hinchey IV diverticulitis (relative risk 6.32 (95% CI 4.09-9.75)), previous radiotherapy (relative risk 3.35 (95% CI 1.67-6.74)), and alcohol overconsumption (relative risk 1.69 (95% CI 1.05-2.72)). Intraoperative insertion of a Foley catheter in the rectal remnant significantly reduced the risk of blowout within 90 days after a primary Hartmann's procedure (relative risk 0.18 (95% CI 0.05-0.65)).

CONCLUSION

Blowout remains a severe and common complication within 90 days after a primary Hartmann's procedure. Hinchey IV diverticulitis, pelvic radiotherapy, and alcohol overconsumption are risk factors. An intraoperatively inserted rectal Foley catheter is a protective factor and can be considered used in all patients undergoing Hartmann's procedure.

Low incidence of pelvic sepsis following Hartmann's procedure for rectal cancer: a retrospective multicentre study

BACKGROUND

Results of previous studies regarding pelvic sepsis after Hartmann's procedure (HP) for rectal cancer have been inconsistent and few studies report the risk factors. This study aimed to investigate the incidence of pelvic sepsis after HP, identify risk factors and describe when as well as how pelvic sepsis was diagnosed and treated.

METHODS

Data were collected from the Swedish Colorectal Cancer Registry on all patients undergoing HP for rectal cancer in the county of Skåne from 2007-2017. Patients diagnosed with pelvic sepsis were compared with patients without pelvic sepsis and risk factors for developing pelvic sepsis were analysed in a multivariable model.

RESULTS

A total of 252 patients were included in the study, with 149 (59%) males, and a median age of 75 years (range 20-92). Altogether, 27 patients (11%) were diagnosed with pelvic sepsis. Risk factors for developing pelvic sepsis were neoadjuvant radiotherapy (OR 7.96, 95% CI 2.54-35.36) and BMI over 25 kg/m² (OR 5.26, 95% CI 1.80-19.50). Median time from operation to diagnosis was 21 days (range 5-355) with 11 (40%) patients diagnosed beyond 30 days postoperatively. The majority of cases 19 (70%) were treated conservatively and none needed major surgery.

CONCLUSION

Pelvic sepsis occurred in 11% of patients. Neoadjuvant radiotherapy and higher BMI were significant risk factors for developing pelvic sepsis. Forty percent of patients were diagnosed later than 30 days postoperatively and most patients were successfully treated conservatively. Our findings suggest that HP is a valid treatment option for rectal cancer when anastomosis is inappropriate, even in patients receiving neoadjuvant radiotherapy.

The complication profile of low Hartmann's in rectal cancer: a systematic review and meta-analysis

BACKGROUND

Non-restorative options for low rectal cancer not invading the sphincter includes low Hartmann's procedure (LH) and inter-sphincteric abdominoperineal resection (ISAPR). There is currently little comparative data to differentiate these options.

OBJECTIVES

The aim of this review was to assess the peri-operative morbidity of LH, and then to compare it to that of ISAPR.

DATA SOURCES

An up-to-date systematic review was performed on the available literature between 2000-2020 on PubMed, EMBASE, Medline, and Cochrane Library databases.

STUDY SELECTION

All studies reporting on non-restorative surgeries for rectal cancer were analysed. Outcomes were firstly analysed between LH and non-LH groups, with further sub-analysis comparing the LH and ISAPR groups.

MAIN OUTCOME MEASURE

The main outcome measures were the rates of pelvic sepsis, rates of overall post-operative complication rates, oncological outcomes, and survival.

RESULTS

A total of 12 observational studies were included. There were 3526 patients (61.1%) in the LH group, and 2238 patients (38.9%) in the non-LH group, which included 461 patients who underwent ISAPR. The LH group had a higher rate of pelvic sepsis as compared to the non-LH group (OR: 1.79, 95% CI: 1.39-2.29, P < 0.001). The difference is more marked in the sub-analysis comparing LH and ISAPR alone (OR: 3.94, 95% CI: 1.88-7.84, P < 0.01) corresponding to a higher rate of unplanned re-intervention. LH was associated with a higher rate of short-term post-operative mortality as compared to the non-LH group.

CONCLUSION

ISAPR is the preferred option for non-restorative rectal surgery, with a more favourable peri-operative morbidity and short-term mortality profile as compared to LH.

A meta-analysis of low Hartmann's procedure versus abdominoperineal resection for non-restorative treatment of rectal cancer

BACKGROUND

Non-restorative surgery for rectal cancer is indicated in patients with comorbidities, advanced disease and poor continence. The aim of this meta-analysis was to compare the postoperative morbidity of Hartmann's procedure (HP) with that of extrasphincteric and intersphincteric abdominoperineal resection (APR) in the treatment of rectal cancer.

METHODS

The Medline, Embase and Cochrane databases were searched for publications comparing postoperative morbidity of HP and APR. The incidence of overall surgical complications, pelvic-perineal complications and pelvic abscess was analysed as primary endpoints. Readmissions requiring reintervention and postoperative mortality were also compared.

RESULTS

A cumulative analysis showed a significantly higher rate of overall complications (odds ratio (OR) 0.553, 95% confidence interval (CI) 0.320 to 0.953 and P value 0.033) and pelvic-perineal complications (OR 0.464, 95% CI 0.250 to 0.861 and P value 0.015) after APR. The incidence of isolated pelvic abscess formation was significantly higher after HP (OR 2.523, 95% CI 1.383 to 4.602 and P value 0.003). A subgroup analysis of intersphincteric APR compared with HP did not show any significant difference in the incidence of overall complications, pelvic-perineal complications or pelvic abscess formation (P values of 0.452, 0.258 and 0.100, respectively). There was no significant difference in readmissions, reinterventions and mortality after HP and APR (P 0.992, 0.198 and 0.151).

CONCLUSION

An extrasphincteric APR is associated with higher overall and pelvic-perineal complications and may be reserved for tumours invading the anal sphincter complex. In the absence of sphincter involvement, both HP and intersphincteric APR are better alternatives with comparable morbidity.

Management of rectal stump leak following emergency Hartmann’s procedure

We report on the management of three cases of rectal stump leak and sepsis following urgent Hartmann’s procedure for perforated sigmoid diverticulitis or large bowel obstruction. Two patients had significant risk factors for poor tissue healing. All patients developed features of sepsis and computer tomography scans demonstrated rectal stump leak with adjacent collections. All patients required reoperation for drainage and washout of abscess. An intraperitoneal catheter system was introduced together with drains in order to continue on the ward until tract was formed. There was no mortality and minimal morbidity. The key to management of rectal stump leak is the early and aggressive drainage of the associated collection and continued irrigation of the stump.

Hartmann's procedure versus intersphincteric abdominoperineal excision (HiP Study): a multicentre prospective cohort study

AIM

In patients with low rectal cancer it is occasionally necessary to avoid a low coloanal anastomosis due to patient frailty or poor function. In such situations there are two alternative approaches: Hartmann's procedure (HP) or intersphincteric abdominoperineal excision (IAPE). There are few data to guide surgeons as to which of these two procedures is the safest. The aim of this study was to determine the surgical complication rates associated with each procedure.

METHOD

This was a multicentre, nonrandomized prospective cohort study of patients undergoing either HP or IAPE. The primary objective was to determine surgical complication rates. Secondary objectives included length of stay, time to adjuvant therapy and quality of life at 90 days.

RESULTS

One hundred and seventy nine patients were recruited between April 2016 and June 2019; approximately two thirds of patients underwent HP and one third IAPE. The overall complication rate was high in both groups (54% for the HP group and 52% for the IAPE group). Surgery-specific complication rates were also high, but not significantly different: 43% for HP and 48% for IAPE. The pelvic abscess rate in HP was 11% and was significantly higher in patients with a palpable staple line (15% vs 2%). There was a higher incidence of serious medical complications following IAPE (16% vs 5%), along with a reduction in 90-day quality of life scores.

CONCLUSION

This is the largest prospective study to compare HP and IAPE in patients undergoing rectal cancer surgery where primary anastomosis is not deemed appropriate. With similar complication rates, these data support the ongoing use of either HP or IAPE in this patient group.

Rectal Cancer Surgery in Patients Older Than 80 Years: Is Hartmann's Procedure Safe?

BACKGROUND/AIM

The current study aimed to identify the safety and efficacy of Hartmann's procedure (HP) among elderly patients (age ≥80 years) with rectal cancer.

PATIENTS AND METHODS

Data on surgical outcome, survival rate, and incidence of stoma reversal were retrospectively compared between patients aged over 80 years who underwent anterior resection (AR) and HP.

RESULTS

In total, 79 elderly patients underwent rectal cancer surgery. Of these patients, 54 (68.4%) underwent AR and 25 (31.6%) HP. The two groups did not differ significantly in terms of age, nutrient status, and tumor characteristics. Eight (14.8%) patients who underwent AR and six (24.0%) who underwent HP presented with intra-abdominal complications (p=0.35). The overall survival and recurrent-free survival rates between the two groups did not differ.

CONCLUSION

HP for elderly patients with rectal cancer has similar complication rates to AR, and achieved similar oncological outcomes.

Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era

BACKGROUND

Despite advances in the rates of total mesorectal excision (TME) for rectal cancer surgery, decreased local recurrence rates and increased 5-year survival, there still exists large variation in the quality of treatment received. Up to 30 per cent of rectal cancers are locally advanced at presentation and approximately 5-10 per cent still breach the mesorectal plane and invade adjacent structures despite neoadjuvant therapy. With the evolution of extended resections for rectal cancers beyond the TME plane, proponents advocate that these resections should be performed only in specialist centres. The aim was to assess the prognostic factors and patterns of failure after beyond TME surgery for T4 rectal cancers.

METHODS

Data were collected from prospective databases at three high-volume institutions specializing in beyond TME surgery for T4 rectal cancers between 1990 and 2013. The primary outcome measures were overall survival, local recurrence and patterns of first failure.

RESULTS

Three hundred and sixty patients were identified. The negative resection margin (R0) rate was 82·8 per cent (298 patients) and the local recurrence rate was 12·5 per cent (45 patients). The type of surgical procedure (Hartmann's: hazard ratio (HR) 4·49, 95 per cent c.i. 1·99 to 10·14; P = 0·002) and lymphovascular invasion (HR 2·02, 1·08 to 3·77; P = 0·032) were independent predictors of local recurrence. The 5-year overall survival rate for all patients was 61 (95 per cent c.i. 55 to 67) per cent. The 5-year cumulative incidence of first failure was 8 per cent for local recurrence, 6 per cent for local and distant disease, and 18 per cent for distant disease.

CONCLUSION

This study has demonstrated that a coordinated approach in specialist centres for beyond TME surgery can offer good oncological and long-term survival in patients with T4 rectal cancers.

Low Incidence of Pelvic Sepsis after Hartmann's Procedure: Radiation Therapy May Be a Risk Factor

Purpose

Hartmann's procedure is a well-established alternative in colorectal surgery when a primary anastomosis is contraindicated. However, the rectal remnant may cause complications. This study was designed to investigate the occurrence of pelvic sepsis after Hartmann's procedure and identify possible risk factors.

Methods

All patients who underwent Hartmann's procedure between 2005 and 2012 were identified by the in-hospital registry. Information about pelvic sepsis and potential preoperative, perioperative, and postoperative risk factors was obtained by review of the medical records.

Results

172 patients were identified (97 females); they were aged 74 ± 11 years. Surgery was performed due to cancer (49%) or diverticulitis (35%) and other benign disease (16%). Rectal transection was carried out anywhere between the pelvic floor and the promontory. Pelvic sepsis developed in 6.4% (11/172) of patients. Pelvic sepsis was associated with preoperative radiotherapy (p = 0.03) and Hinchey grade III and IV (p = 0.02) in those patients who underwent Hartmann's procedure for diverticular disease.

Conclusion

Hartmann's procedure is a safe operation when an anastomosis is contraindicated since the incidence of pelvic sepsis is low. Preoperative radiotherapy and Hinchey grade III and IV may be risk factors for the development of pelvic sepsis.

Low Hartmann's procedure or intersphincteric abdominoperineal resection in the primary treatment of low rectal cancer; a survey among surgeons evaluating current practice

BACKGROUND

Low Hartmann's procedure (LHP) and intersphincteric abdominoperineal resection (iAPR) are both surgical options in the treatment of distal rectal cancer when there is no intention to restore bowel continuity. This study aimed to evaluate current practice among members of the Dutch Association of Coloproctology (WCP).

METHODS

An online survey among members of the WCP who represent 66 Dutch hospitals was conducted. The survey consisted of 15 questions addressing indications for surgical procedures and complications.

RESULTS

Surgeons from 37 hospitals (56%) responded. Thirty-six percent does not distinguish low from high Hartmann's procedures based on estimated length of the rectal remnant. Overall, iAPR was the preferred technique in 86%. If asking whether operative approach would be different in tumours at 1 cm from the pelvic floor compared to 5 cm distance, 62% stated that they would consider a different technique. The incidence of pelvic abscess after LHP was thought to be higher, equal or lower than iAPR in 36%, 36% and 21%, respectively, with the remaining respondents not answering this question.

CONCLUSIONS

The vast majority of the respondents considers iAPR as the preferred non-restorative procedure for rectal cancer not invading the sphincter complex, which contradicts with population based data from 2011.

Total Mesorectal Excision for Mid-Rectal Cancer Without Anastomosis: Low Hartmann’s Operation or Intersphincteric Abdomino-Perineal Excision?

Background and Aims:

In mid-rectal cancer, the low colorectal anastomosis is, although feasible, sometimes avoided. The aim was to compare low Hartmann’s procedure with intersphincteric abdomino-perineal excision of the rectum, in patients operated with total mesorectal excision for mid-rectal cancer in whom the low anastomosis was technically feasible but for patient-related reasons undesired.

Material and Methods:

A total of 64 consecutive patients with mid-rectal cancer who underwent low Hartmann’s procedure (n = 34) or intersphincteric abdomino-perineal excision (n = 30) at one colorectal unit were compared regarding patient demography, short-term oncology, surgical outcome at 3 and 24 months, and long-term overall survival.

Results:

There were no significant differences between intersphincteric abdomino-perineal excision and Hartmann’s procedure regarding age, gender distribution, body mass index, preoperative radiotherapy, tumor level, or cancer stages. Operation time was shorter in Hartmann’s procedure as compared with intersphincteric abdomino-perineal excision, median 174 and 256 min, (P < 0.001), and intraoperative blood loss was increased, 600 and 500 mL, respectively (P = 0.045). Number of lymph nodes and circumferential resection margin were comparable. In Hartmann’s procedure compared with intersphincteric abdomino-perineal excision, the need for reoperation was 24% and 3%, (P = 0.020), complications classified as Clavien–Dindo 3–4 occurred in 32% and 10%, (P = 0.031), pelvic abscess in 21% and 10%, (P = 0.313), and mortality within 90 days was 3% and 0%, respectively, (P = 0.938). In intersphincteric abdomino-perineal excision, the perineal wound was not healed at 3 months in 13%, and in Hartmann’s procedure 15% had chronic secretion from the anorectal remnant at 2 years postoperatively.

Conclusion:

The results from this study suggest that intersphincteric abdomino-perineal excision might be an alternative to Hartmann’s procedure in patients with mid-rectal cancer, in whom a low colorectal anastomosis is undesired.

What to do with the rectal stump during sphincter preserving rectal cancer resection with end colostomy: a collaborative snapshot study

AIM

Low Hartmann's resection (LHR) and intersphincteric abdominoperineal excision (iAPR) are both feasible options in the treatment of rectal cancer when restoration of bowel continuity is not desired. The aim of this study was to compare the incidence of pelvic abscess and associated need for re-intervention and readmission after LHR and iAPR.

METHOD

From a snapshot research project in which all rectal cancer resections from 71 Dutch hospitals in 2011 were evaluated, patients who underwent LHR or iAPR were selected.

RESULTS

A total of 185 patients were included: 139 LHR and 46 iAPR. No differences in baseline characteristics were found except for more multivisceral resections in the iAPR group (22% vs 10%; P = 0.041). Pelvic abscesses were diagnosed in 17% of the LHR group after a median of 21 days (interquartile range 10-151 days), compared to 11% in the iAPR group (P = 0.352) after a median of 90 days (interquartile range 44-269 days; P = 0.102). All 28 patients with a pelvic abscess underwent at least one re-intervention. Four patients (9%) in the iAPR group and nine (7%) after LHR were readmitted because of a pelvic abscess over a median 39 months of follow-up.

CONCLUSION

This cross-sectional multicentre study suggests that cross-stapling and intersphincteric resection of the rectal stump, during non-restorative rectal cancer resection, are associated with an equal risk of pelvic abscess formation and have a similar need for re-intervention and readmission.

Low risk of intra-abdominal infections in rectal cancer patients treated with Hartmann's procedure: a report from a national registry

PURPOSE

To describe the postoperative surgical complications in patients with rectal cancer undergoing Hartmann's procedure (HP).

METHODS

Data were retrieved from the Swedish Colorectal Cancer Registry for all patients with rectal cancer undergoing HP in 2007-2014. A retrospective analysis was performed using prospectively recorded data. Characteristics of patients and risk factors for intra-abdominal infection and re-laparotomy were analysed.

RESULTS

Of 10,940 patients resected for rectal cancer, 1452 (13%) underwent HP (median age, 77 years). The American Society of Anesthesiologists (ASA) score was 3-4 in 43% of patients; 15% had distant metastases and 62% underwent a low HP. The intra-abdominal infection rate was 8% and re-laparotomy rate was 10%. Multivariable logistic regression analysis identified preoperative radiotherapy (OR, 1.78; 95% CI, 1.14-2.77), intra-operative bowel perforation (OR, 1.99; 95% CI, 1.08-3.67), T4 tumours (OR, 1.68; 95% CI 1.04-2.69) and female gender (OR, 1.73; 95% CI, 1.15-2.61) as risk factors for intra-abdominal infection. ASA score 3-4 (OR, 1.62; 95% CI, 1.12-2.34), elevated BMI (OR, 1.05; 95% CI, 1.02-1.09) and female gender (OR, 2.06; CI, 1.41-3.00) were risk factors for re-laparotomy after HP. The rate of intra-abdominal infection was not increased after a low HP.

CONCLUSIONS

Despite older age and co-morbidities including more advanced cancer, patients undergoing Hartmann's procedure had low rates of serious postoperative complications and re-laparotomy. A low HP was not associated with a higher rate of intra-abdominal infection. HP seems to be appropriate for old and frail patients with rectal cancer.

Abdominoperineal Excision: Technical Challenges in Optimal Surgical and Oncological Outcomes after Abdominoperineal Excision for Rectal Cancer

Treatment results in rectal cancer have improved significantly during the recent two decades, but local control and survival after abdominoperineal excision (APE) have not improved to the same degree as that seen after anterior resection (AR). The reason for this is an increased risk of inadvertent bowel perforations and tumor involved margins after APE as compared with AR. The conventional synchronous combined APE has not been a standardized procedure and consequently oncological outcomes have varied considerably between different institutions and in different reports. With the new concept of APE, based on well-defined anatomical structures, the procedure can be categorized as intersphincteric APE, extralevator APE, and ischioanal APE. This article discusses the technical aspects and results from this approach.

The importance of rectal washout for the oncological outcome after Hartmann's procedure for rectal cancer: analysis of population-based data from the Swedish Colorectal Cancer Registry

BACKGROUND

During rectal cancer surgery the bowel may contain viable, exfoliated cancer cells, a potential source for local recurrence (LR). The amount and viability of these cells can be reduced using intraoperative rectal washout, a procedure that reduces the LR risk after anterior resection. The aim of this study was to analyse the impact of washout on oncological outcome when performed in Hartmann's procedure (HP) for rectal cancer.

METHODS

A national cohort study on data for patients registered from 1995 to 2007 in the Swedish Colorectal Cancer Registry was carried out. The final analysis included patients belonging to TNM stages I-III who had undergone R0 HP with a registered 5-year follow-up. Multivariate analysis was performed.

RESULTS

A total of 1188 patients were analysed (686 washout and 502 no washout). No differences were detected between the washout group and the no washout group concerning rates of LR [7% (49/686) vs. 10% (49/502); p = 0.13], distant metastasis (DM) [17% (119/686) vs. 18% (93/502); p = 0.65], and overall recurrence (OAR) [21% (145/686) vs. 24% (120/502); p = 0.29]. For both groups, the 5-year cancer-specific survival was below 50%. In multivariate analysis, washout neither decreased the risk of LR, DM, or OAR nor increased overall or the cancer-specific 5-year survival.

CONCLUSIONS

The oncological outcome did not improve when washout was performed in HP for rectal cancer.

Low Hartmann's procedure or intersphincteric proctectomy for distal rectal cancer: a retrospective comparative cohort study

PURPOSE

Two non-restorative options for low rectal cancer not invading the sphincter are the low Hartmann's procedure (LH) or intersphincteric proctectomy (IP). The aim of this study was to compare postoperative morbidity with emphasis on pelvic abscesses after LH and IP.

METHODS

All patients that had LH or IP for low rectal cancer were included in three centres between 2008 and 2014 in this retrospective cohort study. Follow-up was performed for at least 12 months.

RESULTS

A total of 52 patients were included: 40 LH and 12 IP. Median follow-up was 29 months (IQR 23). There were no differences between groups in gender, age and ASA classification. Seven patients in the LH group (18%) and four patients in the IP group (33%) developed a complication within 30-day postoperative with a Clavien-Dindo classification grade III or higher (P = 0.253). Four out of 40 patients (10%) in the LH group and two out of 12 patients (17%) in the IP group developed a pelvic abscess (P = 0.612). Reinterventions were performed in 11 (28%) patients in the LH group and five (42%) patients in the IP group (P = 0.478), with a total number of reinterventions of 13 and 20, respectively. Six and 15 interventions were related to pelvic abscesses, respectively.

CONCLUSION

Pelvic abscesses seem to occur in a similar rate after both LH and IP. Previous reports from the literature suggesting that IP might be associated with less infectious pelvic complications compared to LH are not supported by this study, although numbers are small.

Comparison of a low Hartmann's procedure with low colorectal anastomosis with and without defunctioning ileostomy after radiotherapy for rectal cancer: results from a national registry

AIM

This study used a national registry to compare the outcome after a low Hartmann's procedure (LHP), defined as removal of most of the rectum to leave a short anorectal stump and an end colostomy, and low anterior resection (LA) with or without a diverting ileostomy (DI) in rectal cancer patients all of whom had received preoperative neoadjuvant radiotherapy (RT).

METHOD

Patients who underwent LHP or LA with or without DI for rectal cancer after RT between 2009 and 2013 were identified from the Dutch Surgical Colorectal Audit. The postoperative outcome was compared between the three groups and risk of complications, reoperation and mortality were analysed in a multivariable model.

RESULTS

The study included 4288 patients were included, of whom 27.8% underwent LHP, 20.2% LA and 52.0% LA with DI. Thirty-day mortality was higher after LHP (3.2% vs 1.3% and 1.3% for LA with or without DI, P < 0.001), but LHP was not an independent predictor of mortality in multivariable analysis. LHP and LA with DI were associated with a lower rate of abdominal infective complications (6.5% and 10.1% vs 16.2%, P < 0.001) and reoperation (7.3% and 8.1% vs 16.5%, P < 0.001). In multivariable analysis, LHP (OR 0.35, 95% CI 0.26-0.47) and LA with DI (OR 0.43, 95% CI 0.33-0.54) were associated with a lower risk of reoperation than LA alone. LHP was associated with a lower risk of any postoperative complication than LA with or without DI (OR 0.81, 95% CI 0.66-0.98).

CONCLUSION

LHP and LA with DI were associated with fewer infective complications and reoperations than LA alone. The rate of any complication was less after LHR than LA with or without DI.

Hartmann's procedure vs abdominoperineal resection with intersphincteric dissection in patients with rectal cancer: a randomized multicentre trial (HAPIrect)

Background

The use of Hartmann’s procedure in the old and frail and/or in patients with fecal incontinence is increasing, even though some data have reported high postoperative rates of pelvic abscesses. Abdominoperineal excision with intersphincteric dissection has been proposed as a better alternative and is performed increasingly both nationally and internationally. However, no studies have been performed to support this. The aim of this study is to randomize patients between Hartmann’s procedure and abdominoperineal excision with intersphincteric dissection and compare post-operative surgical morbidity and quality of life. The hypothesis is that intersphincteric abdominoperineal excision provides less pelvic and perineal morbidity.

Methods/design

In this multicentre randomized controlled study, Hartmann’s procedure will be compared with intersphincteric abdominoperineal excision in patients with rectal cancer unsuitable for an anterior resection. The patients are operated in different ways around the ano-rectum, otherwise the same procedure is performed with total mesorectal excision and all will receive a colostomy. The one-month postoperative control will focus on post-operative surgical complications, especially the perineal-pelvic, reoperations and other interventions. After one year, late complications such as pain in the perineal or pelvic area or disorders such as secretion or bleeding from the anorectal stump will be recorded and a follow-up of quality of life performed. Histological and oncological data will also be recorded, the latter up to 5 years post-operatively.

Discussion

The HAPIrect trial is the first randomized controlled trial comparing standard low Hartmann’s procedure with intersphincteric abdominoperineal excision in patients with rectal cancer with the aim of categorizing the post-operative surgical morbidity.

Trial registration

ClinicalTrials.gov Identifier: NCT01995396. Date of registration November 25, 2013.

Techniques and Outcome of Surgery for Locally Advanced and Local Recurrent Rectal Cancer

Locally advanced primary rectal cancer is variably defined, but generally refers to T3 and T4 tumours. Radical surgery is the mainstay of treatment for these tumours but there is a high-risk for local recurrence. National Institute for Health and Care Excellence (2011) guidelines recommend that patients with these tumours be considered for preoperative chemoradiotherapy and this is the starting point for any discussion, as it is standard care. However, there are many refinements of this pathway and these are the subject of this overview. In surgical terms, there are two broad settings: (i) patients with tumours contained within the mesorectal envelope, or in the lower rectum, limited to invading the sphincter muscles (namely some T2 and most T3 tumours); and (ii) patients with tumours directly invading or adherent to pelvic organs or structures, mainly T4 tumours - here referred to as primary rectal cancer beyond total mesorectal excision (PRC-bTME). Major surgical resection using the principles of TME is the mainstay of treatment for the former. Where anal sphincter sacrifice is indicated for low rectal cancers, variations of abdominoperineal resection - referred to as tailored excision - including the extralevator abdominoperineal excision (ELAPE), are required. There is debate whether or not plastic reconstruction or mesh repair is required after these surgical procedures. To achieve cure in PRC-bTME tumours, most patients require extended multivisceral exenterative surgery, carried out within specialist multidisciplinary centres. The surgical principles governing the treatment of recurrent rectal cancer (RRC) parallel those for PRC-bTME, but typically only half of these patients are suitable for this type of major surgery. Peri-operative morbidity and mortality are considerable after surgery for PRC-bTME and RRC, but unacceptable levels of variation in clinical practice and outcome exist globally. To address this, there are now major efforts to standardise terminology and classifications, to allow appropriate comparisons in future studies.

Impact of Neoadjuvant Radiotherapy on Complications After Hartmann Procedure for Rectal Cancer

BACKGROUND

The effects of neoadjuvant radiotherapy on healing of the rectal stump after a Hartmann procedure for rectal cancer are unknown.

OBJECTIVE

The purpose of this study was to analyze the impact of radiotherapy on postoperative complications after a Hartmann procedure for rectal cancer at a population level.

DESIGN

This was a population-based observational study. Postoperative outcomes were compared between Hartmann procedures with and without radiotherapy. Risk factors for postoperative intra-abdominal abscess requiring reintervention, any reintervention, and 30-day or in-hospital mortality were analyzed using a multivariable model.

SETTINGS

The study included in-hospital registration for the Dutch Surgical Colorectal Audit.

PATIENTS

Patients with rectal cancer who underwent a Hartmann procedure (total or partial mesorectal excision with end colostomy) between 2009 and 2013 were included.

MAIN OUTCOME MEASURES

Abdominal abscess requiring reintervention, any reintervention, and 30-day or in-hospital mortality were measured.

RESULTS

Of 1728 patients who underwent a Hartmann procedure for rectal cancer, 90.5% (n = 1563) received preoperative radiotherapy. Intra-abdominal abscess formation was significantly increased after radiotherapy (7.0% vs 3.0%; p = 0.049). Overall reinterventions (15.2% vs 15.4%; p = 0.90) and 30-day mortality (2.4% vs 3.5%; p = 0.48) were not associated with radiotherapy in univariable analysis. In multivariable analysis, radiotherapy was an independent predictor of postoperative intra-abdominal abscess requiring reintervention (OR, 2.81 (95% CI, 1.01-7.78)) but was not associated with overall reinterventions or mortality.

LIMITATIONS

This study was limited by the data being self-reported. Case-mix adjustment was limited to information available in the data set, and no long-term outcome data were available.

CONCLUSIONS

Based on these population-based data, radiotherapy is independently associated with an increased risk of postoperative intra-abdominal abscess requiring reintervention after Hartmann procedure for rectal cancer. This finding is relevant for patient-tailored postoperative care but should probably not influence indication for radiotherapy, because it did not affect overall reinterventions and mortality (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A193).

Hartmann's procedure in rectal cancer: a population-based study of postoperative complications

PURPOSE

Hartmann's procedure for rectal cancer patients is increasingly performed but few studies have reported the postoperative outcome. The purpose was to report postoperative complications and analyse risk factors in rectal cancer patients operated with Hartmann's procedure. To describe the selection and postoperative complication patterns, all bowel-resected rectal cancer patients were included.

METHODS

Population-based data were from the county of Västmanland, Sweden. All rectal cancer patients operated with an elective bowel resection between 1996 and 2012 were included. Demographics and postoperative complications were prospectively registered and data retrospectively analysed.

RESULTS

Of the 624 patients included, 396 (64%) were operated with an anterior resection, 159 (25%) with an abdominoperineal excision and 69 (11%) a Hartmann's procedure of which 90% were low Hartmann's. Patients operated with a Hartmann's procedure were significantly older, had higher ASA-score, poorer WHO performance score and lower serum albumin levels. Operative time for Hartmann's procedure was a median of 49 and 99 min shorter than after anterior resection and abdominoperineal excision, respectively, and entailed less bleeding. Complications related to the pelvic and perineal dissections were more common after abdominoperineal excision compared with anterior resection and Hartmann's procedure (32 vs. 9 and 13%, p < 0.001).

CONCLUSIONS

Few rectal cancer patients, operated with Hartmann's procedure, developed pelvic complications despite a higher age, more co-morbidities, metastases in different localities and functional inferiority when compared with the patients operated with anterior resection or abdominoperineal excision. Hartmann's procedure is a valid alternative procedure in the old and frail rectal cancer patient.

High 1-year complication rate after anterior resection for rectal cancer

BACKGROUND

Surgical options after anterior resection for rectal cancer include a primary anastomosis, anastomosis with a defunctioning stoma, and an end colostomy. This study describes short-term and 1-year outcomes of these different surgical strategies.

METHODS

Patients undergoing surgical resection for primary mid and high rectal cancer were retrospectively studied in seven Dutch hospitals with 1-year follow-up. Short-term endpoints were postoperative complications, re-interventions, prolonged hospital stay, and mortality. One-year endpoints were unplanned readmissions and re-interventions, presence of stoma, and mortality.

RESULTS

Nineteen percent of 388 included patients received a primary anastomosis, 55% an anastomosis with defunctioning stoma, and 27% an end colostomy. Short-term anastomotic leakage was 10% in patients with a primary anastomosis vs. 7% with a defunctioning stoma (P = 0.46). An end colostomy was associated with less severe re-interventions. One-year outcomes showed low morbidity and mortality rates in patients with an anastomosis. Patients with a defunctioning stoma had high (18%) readmissions and re-intervention (12%) rates, mostly due to anastomotic leakage. An end colostomy was associated with unplanned re-interventions due to stoma/abscess problems. During follow-up, there was a 30% increase in patients with an end colostomy.

CONCLUSIONS

This study showed a high 1-year morbidity rate after anterior resection for rectal cancer. A defunctioning stoma was associated with a high risk for late complications including anastomotic leakage. An end colostomy is a safe alternative to prevent anastomotic leakage, but stomal problems cannot be ignored. Selecting low-risk patients for an anastomosis may lead to favorable short- and 1-year outcomes.

High complication rate after low anterior resection for mid and high rectal cancer; results of a population-based study

BACKGROUND

Surgical resection is the cornerstone of treatment for rectal cancer patients. Treatment options consist of a primary anastomosis, anastomosis with defunctioning stoma or end-colostomy with closure of the distal rectal stump. This study aimed to compare postoperative outcome of these three surgical options.

METHODS

Data was derived from the national database of the Dutch Surgical Colorectal Audit. Mid and high rectal cancer patients who underwent rectal cancer resection between January 2011 and December 2012 were included. Endpoints were postoperative complications including anastomotic leakage, reinterventions, hospital stay and mortality within 30 days postoperative.

RESULTS

In total, 2585 patients were included. Twenty-five per cent of all patients received a primary anastomosis; 51% an anastomosis with defunctioning stoma, and 24% an end-colostomy. More than one third of patients developed postoperative complications, the lowest rate being in the primary anastomosis group. Anastomotic leakage rates were 12% in patients with a primary anastomosis, and 9% in patients with an anastomosis with defunctioning stoma (p < 0.05). Multivariate analysis showed more postoperative complications, prolonged hospital stay, and increased mortality rates in patients with a defunctioning stoma or end-colostomy. The latter had proportionally less invasive reinterventions when compared to the other two groups.

CONCLUSIONS

Patients with a primary anastomosis had the best postoperative outcome. A defunctioning stoma leads to a lower anastomotic leakage rate, though is associated with higher rates of complications, prolonged hospital stay and mortality. The decision to create a defunctioning stoma should be focus of future studies.

Treatment of chronic presacral sinus after low anterior resection

AIM

The aim of this retrospective study was to determine patient and treatment characteristics with corresponding clinical outcome of symptomatic chronic presacral sinus after low anterior resection.

METHOD

Twenty-two patients were treated for a presacral sinus persisting for at least 12 months after low anterior resection for rectal carcinoma between January 2005 and March 2012. Patient charts were reviewed and analysed using descriptive statistics.

RESULTS

Fistula formation was the most frequently observed secondary complication in 55% of patients. A median of 6 (1-44) surgical, endoscopic or radiological interventions related to the presacral sinus were performed. Overall, the chronic presacral sinus healed after multimodality treatment in nine (41%) patients at a median interval from primary surgery of 45 (24-93) months. If basic treatment principles were followed (anastomotic reconstruction or completion proctectomy with filling of the cavity), healing rate of the sinus was higher than where these principles were not adhered to (62% vs 11%).

CONCLUSION

Successful treatment of a chronic presacral sinus after low anterior resection appears to be achieved by salvage surgery with anastomotic reconstruction in highly selected patients or intersphincteric completion proctectomy and omentoplasty.

What is the risk for a permanent stoma after low anterior resection of the rectum for cancer? A six-year follow-up of a multicenter trial

PURPOSE

The aim of this study was to assess the risk for permanent stoma after low anterior resection of the rectum for cancer.

METHODS

In a nationwide multicenter trial 234 patients undergoing low anterior resection of the rectum were randomly assigned to a group with defunctioning stomas (n = 116) or a group with no defunctioning stomas (n = 118). The median age was 68 years, 45% of the patients were women, 79% had preoperative radiotherapy, and 4% had International Union Against Cancer cancer stage IV. The patients were analyzed with regard to the presence of a permanent stoma, the type of stoma, the time point at which the stoma was constructed or considered as permanent, and the reasons for obtaining a permanent stoma. Median follow-up was 72 months (42-108). One patient with a defunctioning stoma who died within 30 days after the rectal resection was excluded from the analysis.

RESULTS

During the study period 19% (45/233) of the patients obtained a permanent stoma: 25 received an end sigmoid stoma and 20 received a loop ileostomy. The end sigmoid stomas were constructed at a median of 22 months (1-71) after the low anterior resection of the rectum, and the loop ileostomies were considered as permanent at a median of 12.5 months (1-47) after the initial rectal resection. The reasons for loop ileostomy were metastatic disease (n = 6), unsatisfactory anorectal function (n = 6), deteriorated general medical condition (n = 3), new noncolorectal cancer (n = 2), patient refusal of further surgery (n = 2), and chronic constipation (n = 1). Reasons for end sigmoid stoma were unsatisfactory anorectal function (n = 22) and urgent surgery owing to anastomotic leakage (n = 3). The risk for permanent stomas in patients with symptomatic anastomotic leakage was 56% (25/45) compared with 11% (20/188) in those without symptomatic anastomotic leakage (P < .001).

CONCLUSION

One patient of 5 ended up with a permanent stoma after low anterior resection of the rectum for cancer, and half of the patients with a permanent stoma had previous symptomatic anastomotic leakage.

The impact of chronic smoking on rectal mucosal blood flow

BACKGROUND

Chronic smoking adversely affects peripheral vasculature. The aim of the present study was to investigate the effect of chronic cigarette smoking on rectal microvascular blood flow.

METHODS

Rectal mucosal blood flow (MBF) was measured in 80 subjects (44 smokers and 36 non-smokers). The MBF was measured in the four quadrants of the rectum by laser Doppler flowmetry.

RESULTS

Rectal perfusion was found to be significantly lower in posterior midline compared to the other sites. In chronic smokers the observed MBF measured at the posterior and ventral sites was significantly lower compared to non-smokers (P = 0.04 and P = 0.03, respectively).

CONCLUSIONS

Our results suggest that rectal mucosal blood flow is reduced in chronic smokers.

[Tissue adhesive treatment of persistent recto-cutaneous fistula following Hartmann procedure]

BACKGROUND

Cutaneous fistulas from the rectal stump after Hartmann procedure are not rare. Rarely do they require operative intervention, but they may result in prolonged skin care during hospitalization.

PURPOSE

of study: To describe the use of fibrin glue in the treatment of rectocutaneous fistulas occurring after Hartmann procedure.

STUDY DESIGN

Ten patients underwent irrigation of the fistulous tract followed by fibrin glue injection. The glue was reconstituted using the usual two syringe admixture technique; the tract was catheterized as far as the rectal stump, and the glue was injected as the catheter was withdrawn to skin level.

RESULTS

No complications were noted and the discharge from seven out of ten fistulas dried up completely.

CONCLUSION

Biologic glue occlusion of rectocutaneous fistulas simplified local care and decreased hospital stay.

The management of rectal cancer in a resource poor environment - a review

Rectal cancer is an increasing problem in the developing world. There is little written on how to manage this problem outside the confines of major teaching hospitals in Western Countries. In these centres debate surrounds preoperative staging, the use of preoperative radiotherapy and sophisticated sphincter preserving procedures. The literature is complex and of little relevance to those faced with a patient with rectal cancer in rural Africa or Asia far from the ivory towers. This review aims to combine the best of evidence based medical practice related to the management of rectal cancer with the practical realities of operating in resource poor environments. In this situation staging is by means of simple radiology and a clinical examination supplemented by an examination under anaesthetic. If there are no distant metastases and the tumour is freely mobile a resection can be attempted. An abdominoperineal resection is a good operation with a proven track record. If an anastomosis can be fashioned then an anterior resection is an excellent operation and should be performed extrafascially to avoid local recurrence. It is vital to counsel the patient preoperatively. The pros and cons of referral to a centre of excellence need to be discussed with the patient prior to any intervention.