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Lee KY, Lee J, Oh ST, Lee CS, Kim NS, Song JM, Yoo RN, Choi BJ. Postoperative effects of laparoscopic Hartmann reversal: A multicenter propensity score matched study. PLoS One 2023; 18:e0286562. [PMID: 37267375 DOI: 10.1371/journal.pone.0286562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/18/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Although the advantages of laparoscopic Hartmann reversal (LHR) compared to open Hartmann reversal (OHR) have been reported in the literature, the number of multicenter studies with good matching investigating this topic is rare. In the present study, we aimed to confirm the advantages of LHR in terms of short-term outcomes through propensity score matching of LHR and OHR groups, using data collected from multiple institutions. METHODS Patients who underwent Hartmann reversal at six institutions under the Catholic Medical Center of the Catholic University of Korea between January 1, 2005, and December 31, 2021, were included. The patients were divided into the LHR and OHR groups based on the technique used. The two groups were matched using propensity score matching (1:1 ratio, logistic regression with the nearest-neighbor method). The primary outcome was postoperative ileus (POI) frequency, and secondary outcomes were time to solid diet (days) and length of stay (days). RESULTS Among 337 patients, propensity score matching was performed on 322, after excluding 15 who had undergone open conversion. Of these, 63 patients were assigned to each group through propensity score matching. There was no difference in the frequency of adhesiolysis (77.8% vs. 82.5%, p = 0.503) or the operation time. (210 (IQR 159-290) vs. 233 (IQR 160-280), p = 0.718) between the two groups. As the primary outcome, the LHR group showed significantly lower POI frequency than the OHR group. (4.8% vs. 22.2%, p = 0.0041) Regarding the secondary outcomes, the LHR group showed a shorter period to solid diet than the OHR group. The length of hospital stay was also significantly shorter in the LHR group (4 vs. 6, p < 0.0001; 9 vs. 12, p<0.0001). CONCLUSION LHR is an effective method to ensure faster recovery of patients after surgery compared to OHR.
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Affiliation(s)
- Kil-Yong Lee
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Jaeim Lee
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Seong Taek Oh
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Chul Seung Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Nam Suk Kim
- Department of Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Myung Song
- Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea
| | - Ri-Na Yoo
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Byung Jo Choi
- Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Republic of Korea
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Bradea C, Tarcoveanu E, Munteanu V, Lupascu CD, Andriesi-Rusu FD, Ciobanu DG, Vasilescu AM. Laparoscopic Hartmann Procedure—A Surgery That Still Saves Lives. Life (Basel) 2023; 13:life13040914. [PMID: 37109443 PMCID: PMC10142299 DOI: 10.3390/life13040914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Background: A Hartmann operation, which is the intervention by which the lower part of the sigmoid and the upper part of the rectum are resected with the closing of the rectal stump and end colostomy, has as its indications: advanced or complicated rectosigmoid neoplasm, moderate biological condition of the patient, peritoneal sepsis, intestinal occlusion and fragile colonic wall, especially in the context of inflammatory changes. The Hartmann procedure can save lives even at the cost of a stoma reversal failure. Methods: The cases operated with the Hartmann procedure by an open approach or laparoscopic approach in our clinic, between 1 January 2016 and 31 December 2020, were admitted in this study and their medical records were reviewed, also making a comparison between the two types of approach. Univariate statistical comparisons but also a multivariate analysis was performed. Results: We performed 985 operations for intestinal and colonic occlusion (7.15% of the total operations in the clinic), 531 (54%) were non-tumor occlusions and 454 (46%) were occlusive tumors (88 Hartmann operations). Of these, 7.3% were laparoscopically performed (7 laparoscopic Hartmann operations and 23 diagnostic laparoscopies). A total of 11 cases (18%) also had colonic perforation. We compared laparoscopic Hartmann with open Hartmann and observed the benefits of laparoscopy for postoperative morbidity and mortality. The presence of pulmonary and cardiac morbidities is associated with the occurrence of general postoperative morbidities, while peritonitis is statistically significantly associated with the occurrence of local complications that are absent after the laparoscopic approach. Conclusions: The Hartmann procedure is still nowadays an operation widely used in emergency situations. Laparoscopy may become standard for the Hartmann procedure and reversal of the Hartmann procedure, but the percentage of laparoscopy remains low due to advanced or complicated colorectal cancer, poor general condition both at the first and second intervention, and the difficulties of reversal of the Hartmann procedure.
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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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Son JT, Kim YB, Kim HO, Min C, Park Y, Lee SR, Jung KU, Kim H. Short-term and long-term outcomes of subtotal/total colectomy in the management of obstructive left colon cancer. Ann Coloproctol 2022:ac.2022.00101.0014. [PMID: 35611549 DOI: 10.3393/ac.2022.00101.0014] [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: 01/20/2022] [Accepted: 04/16/2022] [Indexed: 10/18/2022] Open
Abstract
Purpose Surgical management of obstructive left colon cancer (OLCC) is still a matter of debate. The classic Hartmann procedure (HP) has a disadvantage that requires a second major operation. Subtotal colectomy/total abdominal colectomy (STC/TC) with ileo-sigmoid or ileo-rectal anastomosis is proposed as an alternative procedure to avoid stoma and anastomotic leakage. However, doubts about morbidity and functional outcome and lack of long-term outcomes have made surgeons hesitate to perform this procedure. Therefore, this trial was designed to provide data for morbidity, functional outcomes, and long-term outcomes of STC/TC. Methods This study retrospectively analyzed consecutive cases of OLCC that were treated by STC/TC between January 2000 and November 2020 at a single tertiary referral center. Perioperative outcomes and long-term outcomes of STC/TC were analyzed. Results Twenty-five descending colon cancer (45.5%) and 30 sigmoid colon cancer cases (54.5%) were enrolled in this study. Postoperative complications occurred in 12 patients. The majority complication was postoperative ileus (10 of 12). Anastomotic leakage and perioperative mortality were not observed. At 6 to 12 weeks after the surgery, the median frequency of defecation was twice per day (interquartile range, 1-3 times per day). Eight patients (14.5%) required medication during this period, but only 3 of 8 patients required medication after 1 year. The 3-year disease-free survival was 72.7% and 3-year overall survival was 86.7%. Conclusion The risk of anastomotic leakage is low after STC/TC. Functional and long-term outcomes are also acceptable. Therefore, STC/TC for OLCC is a safe, 1-stage procedure that does not require diverting stoma.
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Affiliation(s)
- Jung Tak Son
- Department of Surgery, H Plus Yangji Hospital, Seoul, Korea
| | - Yong Bog Kim
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea.,Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Ook Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chungki Min
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yongjun Park
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Ryol Lee
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Uk Jung
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hungdai Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Is length of the rectal stump predictive for postoperative outcome in Hartmann's reversal surgery? A multicenter experience of 105 consecutive cases. Int J Colorectal Dis 2022; 37:617-622. [PMID: 35091774 DOI: 10.1007/s00384-021-04090-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Although Hartmann's procedure is commonly performed, subsequent reversal is less frequent. The most common reasons for reversal surgery are advanced age, comorbidities, and perceived surgical difficulties. The main objective of this study was to investigate if the length of the rectal stump influences the outcome of Hartmann's reversal surgery. METHOD We conducted a retrospective case study analyzing data from 105 patients who underwent Hartmann's reversal procedure between 2007 and 2019 in two centers. We evaluated patient demographics, length of rectal stump, intraoperative surgical details, short-term and long-term outcomes. RESULTS From 2007 to 2019, 105 patients underwent Hartmann's reversal surgery. Short-term morbidity rate was 58% (61 patients), including 16% (17 patients) with severe postoperative complication (Clavien-Dindo ≥ 3). Anastomotic leakage rate was 2.9% (3 patients). Long-term complications were present in 41% (43 patients) of which abdominal wall defect was the most frequent complication. The mean length of the rectal stump was 15 cm. In almost 1 out of 5 patients (17%) the rectal stump was shorter than 10 cm. The three anastomotic leakages appeared in the long rectal stump group (3.6% vs. 0%, p = 0.273). The complication rate for patients with a short rectal stump was similar to those with a longer rectal stump (50% vs. 63%, p = 0.275). Smoking, high ASA score, obesity, and advanced age did not influence the outcomes of the reversal procedure either. CONCLUSION Length of the rectal stump is not a predictive factor for postoperative complications after Hartmann's reversal surgery.
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Chen YC, Fingerhut A, Tsai YY, Chang SC, Ke TW, Shen MY, Tzu-Liang Chen W. Laparoscopic Reintervention for Intraperitoneal Leaks After Colonic Surgery: Do We Need a Routine Stoma? Surg Innov 2022; 29:697-704. [PMID: 35227152 DOI: 10.1177/15533506211070177] [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: 11/15/2022]
Abstract
INTRODUCTION No universal consensus exists on the management of intraperitoneal anastomosis leakage after colonic surgery. The aim of the study was to evaluate the outcomes of laparoscopic reintervention without stoma creation for intraperitoneal leaks after colonic surgery. MATERIAL AND METHODS Single tertiary center study conducted from January 2010 to December 2020. 54 patients with intraperitoneal leakage were divided into 2 groups according to whether they received a stoma (n = 37) or not (n = 17) during laparoscopic reintervention. Short term outcome was analyzed. RESULTS Patients in the no stoma group had lower American Society of Anesthesiologists (ASA) score (P = .009), lower Acute Physiology And Chronic Health Evaluation II (APACHE II) score (5 vs. 10; P < .001) compared with the stoma group. Intensive care unit admission (43.2% vs. 5.8%; P = .006) and major complications (35.1% vs. 5.8%; P = .015) occurred more in the stoma group compared to the no stoma group. After multivariate logistic regression analysis, initial surgical procedure (P = .001) and APACHE II score (P = .039) were significant predictors of no stoma. The APACHE II score(P = .035) was an independent predictor of major complications. Finally, Receiver Operating Characteristic curve analysis showed that the cutoff value of APACHE II score for no stoma was 7.5. CONCLUSIONS In our study, APACHE II score was an independent predictor of stoma formation and the cutoff value of APACHE II score for no stoma was 7.5. Our results need to be confirmed by larger and randomized studies. In particular, a specific APACHE II threshold to omit a stoma in this setting remains to be determined.
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Affiliation(s)
- Yi-Chang Chen
- Attending Surgeon, Department of Colorectal Surgery, RinggoldID:%2038020China Medical University Hospital, Taichung, Taiwan
| | - Abe Fingerhut
- Associate professor Surgical Research Unit, Department of Surgery, Medical University of Graz, and Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Poissy, France
| | - Yuan-Yao Tsai
- Attending Surgeon, Department of Colorectal Surgery, RinggoldID:%2038020China Medical University Hospital, Taichung, Taiwan
| | - Sheng-Chi Chang
- Attending Surgeon, Department of Colorectal Surgery, RinggoldID:%2038020China Medical University Hospital, Taichung, Taiwan
| | - Tao-Wei Ke
- Attending Surgeon, Department of Colorectal Surgery, RinggoldID:%2038020China Medical University Hospital, Taichung, Taiwan
| | - Ming-Yin Shen
- Director, Department of Colorectal Surgery, RinggoldID:%2038020China Medical University Hospital, Taiwan, China
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Is laparoscopy a reliable alternative to laparotomy in Hartmann's reversal? An updated meta-analysis. Tech Coloproctol 2022; 26:239-252. [PMID: 35133538 DOI: 10.1007/s10151-021-02560-2] [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: 10/13/2020] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of this study was to perform a systematic review of the literature on and updated meta-analysis of surgical postoperative complications after laparoscopic Hartmann's reversal (LHR) and open Hartmann's reversal (OHR). METHODS Studies comparing LHR versus OHR published from inception until June 2020 were selected and submitted to a systematic review and meta-analysis. Articles were searched in the MEDLINE and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0. RESULTS Twenty-three retrospective comparative studies (including 5 case-controlled studies) with a total of 3139 patients with LHR and a total of 10,325 patients with OHR were included. Meta-analysis showed that LHR was significantly associated with a decreased rate of revision surgery (OR = 0.73, 95% CI = 0.60-0.89, p < 0.001), anastomotic leakage (OR = 0.61, 95% CI = 0.49-0.75, p < 0.00001), postoperative morbidity (OR = 0.53, 95% CI = 0.47-0.58, p < 0.00001), intra-abdominal abscess (OR = 0.67 [0.52-0.87], 95% CI = , p = 0.003), wound abscess (OR = 0.53 [0.46-0.61], 95% CI = , p < 0.00001), and postoperative ileus (OR = 0.46, 95% CI = 0.29-0.72, p = 0.0008), respectively. Conversely, mortality was comparable between LHR and OHR. CONCLUSIONS These results suggest that LHR significantly improved surgical postoperative outcomes. However, considering the low level of evidence, further randomized trials are required to validate these findings.
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Uncut Diverting End Colostomy: End of Nightmare. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02150-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Mirza KL, Wickham CJ, Noren ER, Hwang GS, Ault GT, Ortega AE, Jafari MD, Cologne KG. Outcomes of colostomy takedown following Hartmann's procedure: successful restoration of continuity comes with a high risk of morbidity. Colorectal Dis 2021; 23:967-974. [PMID: 33231908 DOI: 10.1111/codi.15456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/21/2020] [Accepted: 10/13/2020] [Indexed: 02/08/2023]
Abstract
AIM Restoration of bowel continuity following a Hartmann's procedure is a major surgical undertaking associated with significant morbidity. The aim of this study was to review the authors' experience with Hartmann's reversal. METHOD This was a retrospective review of consecutive patients from institutional databases who were selected to undergo open or laparoscopic Hartmann's reversal at two tertiary academic referral centres and a public safety net hospital (2010-2019). The main outcome measure was the rate of successful stoma reversal. Secondary outcomes included 30-day postoperative outcomes and procedural details. RESULTS One hundred and fifty patients underwent attempted reversal during the study period, which was successful in all but three patients (98%). Patients were 59% Hispanic and 73% male, with a mean age of 48.7 ± 14.1 years, mean American Society of Anesthesiologists classification of 2.2 ± 0.6 and mean body mass index (BMI) of 28.6 ± 5.3 kg/m2 , with 39% of patients having a BMI > 30 kg/m2 . The mean time interval between the index procedure and reversal was 14.4 months, 53% of the index cases were performed at outside institutions and the most common index diagnoses were diverticulitis (54%), abdominal trauma (16%) and colorectal malignancy (15%). In 22% of cases a laparoscopic approach was used, with 42% of these requiring conversion to open. Proximal diverting stomas were created in 32 patients (21%), of which 94% were reversed. The overall morbidity rate was 54%, comprising ileus (32%), wound infection (15%) and anastomotic leak (6%), with a major morbidity rate (Clavien-Dindo ≥ 3) of 23%. CONCLUSION Hartmann's reversal remains a highly morbid procedure. Our results suggest that operative candidates can be successfully reversed, but there is significant morbidity associated with restoration of intestinal continuity, particularly in obese patients. A laparoscopic approach may decrease morbidity in selected patients but such cases have a high conversion rate.
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Affiliation(s)
- Kasim L Mirza
- Department of Surgery, Division of Colorectal Surgery, University of Southern California, Los Angeles, California, USA
| | - Carey J Wickham
- Department of Surgery, Division of Colorectal Surgery, University of Southern California, Los Angeles, California, USA
| | - Erik R Noren
- Department of Surgery, Division of Colorectal Surgery, University of Southern California, Los Angeles, California, USA
| | | | - Glenn T Ault
- Department of Surgery, Division of Colorectal Surgery, University of Southern California, Los Angeles, California, USA
| | - Adrian E Ortega
- Department of Surgery, Division of Colorectal Surgery, University of Southern California, Los Angeles, California, USA
| | - Mehraneh D Jafari
- Department of Surgery, Division of Colon and Rectal Surgery, University of California Irvine, Orange, California, USA
| | - Kyle G Cologne
- Department of Surgery, Division of Colorectal Surgery, University of Southern California, Los Angeles, California, USA
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Farah M, Sorelli P, Kerwat R, Oke O, Ng P. Correlation between ASA Grade with reversal of Hartmann's procedure - a retrospective study. J Med Life 2021; 14:756-761. [PMID: 35126744 PMCID: PMC8811660 DOI: 10.25122/jml-2020-0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 04/06/2021] [Indexed: 11/11/2022] Open
Abstract
Hartmann's procedure involves resecting the rectosigmoid colon, closure of the distal rectal stump, and forming an end colostomy for complicated left colon diverticulitis or malignancy. Recovery from the initial operation can, in a second stage, be followed by a reversal stage with the restoration of bowel continuity. This study aimed to assess the reversal rate and its correlation with demographic data, ASA grade, and length of hospital stay. All patients who underwent Hartmann's emergency procedure from 2014 to 2018 at Lewisham and Greenwich hospital were enrolled in this retrospective study. Data was collected from the inpatient electronic files and NELA (UK National Laparotomy Audit). 118 patients were included in the study, with 57.6% females and a median age of patients of 69 years (range 35-91). Findings of the study indicate that the most common indications for Hartmann's procedure were diverticular complications 60% (n=71) and benign perforated sigmoid or rectosigmoid cancer 16% (n=19). The average length of hospital stay was 24 days (range n=2 - 212 days). The reversal rate was 34.9% (41/118 cases). No significant difference was observed between gender and length of hospital stay in relation to the reversal rate while there was a significant correlation between age and ASA grade in relation to reversal rate; the calculated P values were recorded as (<0.000) and (<0.009) respectively. Our results show that the highest reversal rate was observed in younger and fitter (I-II) ASA grade patients. The most common medical complication from reversal of Hartmann's procedure was an anastomotic leak (n=6, 16.7%). Reversal rate of Hartmann's procedure was 34.9%. The average timeframe for reversal was within 18-20 months. There was a significant correlation between age and ASA grade in relation to reversal rate.
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Affiliation(s)
- Muhaned Farah
- Department of Colorectal Surgery, Lewisham and Greenwich Trust, London, United Kingdom
| | - Paolo Sorelli
- Department of Colorectal Surgery, Lewisham and Greenwich Trust, London, United Kingdom
| | - Rajab Kerwat
- Department of Colorectal Surgery, Lewisham and Greenwich Trust, London, United Kingdom
| | - Okatokundo Oke
- Department of Colorectal Surgery, Lewisham and Greenwich Trust, London, United Kingdom
| | - Philip Ng
- Department of Colorectal Surgery, Lewisham and Greenwich Trust, London, United Kingdom
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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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12
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Whitney S, Gross BD, Mui A, Hahn S, Read B, Bauer J. Hartmann's reversal: factors affecting complications and outcomes. Int J Colorectal Dis 2020; 35:1875-1880. [PMID: 32504334 DOI: 10.1007/s00384-020-03653-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2020] [Indexed: 02/04/2023]
Abstract
AIM Hartmann's procedure is commonly performed emergently for infectious, inflammatory, or malignant processes. Most patients historically do not undergo reversal, and those who do have been found to suffer significant morbidity. The aim of this study was to study factors associated with complications after Hartmann's reversal and to provide information and guidance to surgeons. METHOD A retrospective review of patients undergoing Hartmann's reversal between May 2002 and October 2017 was conducted at a tertiary medical center. Data included patient characteristics at the time of surgery and intra- and postoperative complications. Chi-square test was used for categorical variables. The Wilcoxon signed rank or t test where appropriate was used for multivariate analysis. RESULTS Two hundred forty-nine patients were included. Mean age at reversal was 58.8 years, and 114 (58%) were male. Sixty-two (31.8%) patients experienced a major complication following reversal. Eight (4%) patients had an anastomotic leak. Thirteen (6.67%) patients had an intra-abdominal abscess which required either IR or operative drainage. Patients who experienced a major complication were more likely to have an ASA 4 at time of reversal (14.3% vs. 4.24%, p = 0.019), liver disease (6.6% vs. 0.8%, p = 0.021), and BMI < 30 (35% vs. 17.3%, p = 0.020). CONCLUSIONS Nearly one-third of patients who had reversal surgery experienced a major complication. Four percent of patients undergoing reversal had an anastomotic leak, comparable to previously reported rates. Patients with ASA 4, liver disease, and BMI < 30 were at higher risk of a major complication following reversal. Patients who underwent laparoscopic reversal had no significant difference in outcomes. AIM What does this paper add to the literature? The decision of whether to reverse a colostomy after Hartmann's procedure. Our study aims to identify risk factors associated with complications after Hartmann's reversal to better guide surgeon's facing the dilemma of whether or not to reverse the stoma.
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Affiliation(s)
- Stewart Whitney
- Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY, 10128, USA.
| | - Benjamin D Gross
- Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY, 10128, USA
| | - Alex Mui
- Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY, 10128, USA
| | - Sue Hahn
- Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY, 10128, USA
| | - Blake Read
- Department of Surgery, Sutter Health Network, Burlingame, CA, USA
| | - Joel Bauer
- Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY, 10128, USA
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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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15
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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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16
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Conventional Versus Minimally Invasive Hartmann Takedown: A Meta-analysis of the Literature. World J Surg 2019; 43:1820-1828. [PMID: 30824963 DOI: 10.1007/s00268-019-04962-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Although end colostomy closure following Hartmann's procedure is a major surgery that is traditionally performed by conventional celiotomy, over the last decade there has been a growing interest toward the application of different minimally invasive techniques. We aimed at evaluating the relative outcomes of conventional surgery versus minimally invasive surgery by meta-analyzing the available data from the medical literature. The PubMed/MEDLINE, Cochrane Library and EMBASE electronic databases were searched through August 2018. Inclusion criteria considered eligible all comparative studies evaluating open versus minimally invasive procedures. Conventional laparoscopy, robotic and single-port laparoscopy were considered as minimally invasive techniques. Overall morbidity, rate of anastomotic failure, rate of wound complications and mortality were evaluated as primary outcomes. Perioperative details and surgical outcomes were also assessed. The data of a total of 13,740 patients from 26 studies were eventually included in the analysis. There were no significant differences on baseline characteristics such as age, BMI and proportion of high-risk patients between the two groups of patients. As compared to the conventional technique, minimally invasive surgery proved significantly superior in terms of postoperative morbidity, length of hospital stay and rate of incisional hernia. The current literature suggests that minimally invasive surgery should be considered in performing Hartmann's reversal, if technically viable. However, due to the low level of the available evidence it is impossible to draw definitive conclusions.
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17
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Dreifuss NH, Schlottmann F, Piatti JM, Bun ME, Rotholtz NA. Safety and feasibility of laparoscopic sigmoid resection without diversion in perforated diverticulitis. Surg Endosc 2019; 34:1336-1342. [DOI: 10.1007/s00464-019-06910-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/11/2019] [Indexed: 12/15/2022]
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18
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Turner MC, Talbott MD, Reed C, Sun Z, Cox ML, Ezekian B, Sherman KL, Mantyh CR, Migaly J. Disparities in colostomy reversal after Hartmann’s procedure for diverticulitis. Tech Coloproctol 2019; 23:445-451. [DOI: 10.1007/s10151-019-01995-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 04/19/2019] [Indexed: 12/12/2022]
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Moro-Valdezate D, Royo-Aznar A, Martín-Arévalo J, Pla-Martí V, García-Botello S, León-Espinoza C, Fernández-Moreno MC, Espín-Basany E, Espí-Macías A. Outcomes of Hartmann's procedure and subsequent intestinal restoration. Which patients are most likely to undergo reversal? Am J Surg 2019; 218:918-927. [PMID: 30853093 DOI: 10.1016/j.amjsurg.2019.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/06/2019] [Accepted: 02/14/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aim of the study was to describe characteristics and outcomes of Hartmann's procedure (HP) and subsequent intestinal restoration. METHODS Retrospective study including all patients who underwent HP over a period of 16 consecutive years. We propose a classification and regression tree for a more accurate view of the relationship between the variables related to intestinal restoration and their weighting in the decision to reverse HP. RESULTS 533 patients were included. Overall morbidity rate of HP was 53.5% and mortality 21.0%. Overall morbidity of the intestinal continuity reconstruction was 47.3% and mortality 0.9%. Patients with a benign disease, aged under 69 years and with low comorbidity, had an 84.4% probability of undergoing intestinal reconstruction. CONCLUSIONS HP is associated with high morbidity and mortality. Restoration of intestinal continuity involves minor, but frequent, morbidity and a low mortality rate. Age and comorbidities can decrease, and even override, the decision to reverse HP.
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Affiliation(s)
- D Moro-Valdezate
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain.
| | - A Royo-Aznar
- Department of Surgery, Universtitat Autònoma de Barcelona, Barcelona, Spain
| | - J Martín-Arévalo
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - V Pla-Martí
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - S García-Botello
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - C León-Espinoza
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - M C Fernández-Moreno
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - E Espín-Basany
- Department of Surgery, Universtitat Autònoma de Barcelona, Barcelona, Spain
| | - A Espí-Macías
- Department of Surgery, University of Valencia, Valencia, Spain
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Fonseca AZ, Uramoto E, Santos-Rosa OM, Santin S, Ribeiro M. COLOSTOMY CLOSURE: RISK FACTORS FOR COMPLICATIONS. ACTA ACUST UNITED AC 2018; 30:231-234. [PMID: 29340543 PMCID: PMC5793137 DOI: 10.1590/0102-6720201700040001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 08/22/2017] [Indexed: 12/15/2022]
Abstract
Background : The restoration of intestinal continuity is an elective procedure that is not free of complications; on the contrary, many studies have proven a high level of morbidity and mortality. It is multifactorial, and has factors inherent to the patients and to the surgical technique. Aim : To identify epidemiological features of patients that underwent ostomy closure analyzing the information about the surgical procedure and its arising complications. Method : It was realized a retrospective analysis of medical records of patients who underwent ostomy closure over a period of seven years (2009-2015). Results : A total of 39 patients were included, 53.8% male and 46.2% female, with mean age of 52.4 years. Hartmann´s procedure and ileostomy were the mainly reasons for restoration of intestinal continuity, representing together 87%. Termino-terminal anastomosis was performed in 71.8% of cases, by using mainly the manual technique. 25.6% developed complications, highlighting anastomotic leakage; there were three deaths (7.6%). The surgical time, the necessity of ICU and blood transfusion significantly related to post-operative complications. Conclusion : It was found that the majority of the patients were male, with an average age of 52 years. It was observed that the surgical time, the necessity of blood transfusion and ICU were factors significantly associated with complications.
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Affiliation(s)
| | - Edson Uramoto
- Department of Surgery, University of Santo Amaro, São Paulo, SP, Brazil
| | | | - Stephanie Santin
- Department of Surgery, University of Santo Amaro, São Paulo, SP, Brazil
| | - Marcelo Ribeiro
- Department of Surgery, University of Santo Amaro, São Paulo, SP, Brazil
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21
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Safety of primary anastomosis following emergency left sided colorectal resection: an international, multi-centre prospective audit. Colorectal Dis 2018; 20 Suppl 6:47-57. [PMID: 30255647 DOI: 10.1111/codi.14373] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/06/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Some evidence suggests that primary anastomosis following left sided colorectal resection in the emergency setting may be safe in selected patients, and confer favourable outcomes to permanent enterostomy. The aim of this study was to compare the major postoperative complication rate in patients undergoing end stoma vs primary anastomosis following emergency left sided colorectal resection. METHODS A pre-planned analysis of the European Society of Coloproctology 2017 audit. Adult patients (> 16 years) who underwent emergency (unplanned, within 24 h of hospital admission) left sided colonic or rectal resection were included. The primary endpoint was the 30-day major complication rate (Clavien-Dindo grade 3 to 5). RESULTS From 591 patients, 455 (77%) received an end stoma, 103 a primary anastomosis (17%) and 33 primary anastomosis with defunctioning stoma (6%). In multivariable models, anastomosis was associated with a similar major complication rate to end stoma (adjusted odds ratio for end stoma 1.52, 95%CI 0.83-2.79, P = 0.173). Although a defunctioning stoma was not associated with reduced anastomotic leak (12% defunctioned [4/33] vs 13% not defunctioned [13/97], adjusted odds ratio 2.19, 95%CI 0.43-11.02, P = 0.343), it was associated with less severe complications (75% [3/4] with defunctioning stoma, 86.7% anastomosis only [13/15]), a lower mortality rate (0% [0/4] vs 20% [3/15]), and fewer reoperations (50% [2/4] vs 73% [11/15]) when a leak did occur. CONCLUSIONS Primary anastomosis in selected patients appears safe after left sided emergency colorectal resection. A defunctioning stoma might mitigate against risk of subsequent complications.
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Affiliation(s)
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- European Society of Coloproctology (ESCP) Cohort Studies Committee, Hospital Universitari i Politècnic la Fe, València, Spain
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22
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Sotelo R, Medina LG, Husain FZ, Khazaeli M, Nikkhou K, Cacciamani GE, Landsberger H, Winter M, Hernandez A, Kaiser AM, Gill I. Robotic-assisted laparoscopic repair of rectovesical fistula after Hartmann's reversal procedure. J Robot Surg 2018; 13:339-343. [PMID: 30062640 DOI: 10.1007/s11701-018-0854-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/23/2018] [Indexed: 01/16/2023]
Abstract
The case is of a 59-year-old male with history of severe ischemic colitis following emergent intervention for a ruptured infrarenal aortic aneurysm who subsequently underwent left hemicolectomy, partial proctectomy, and Hartmann colostomy. The patient later underwent reversal of the Hartmann colostomy with diverting ileostomy. The surgery was complicated by a right ureteral and posterior bladder injury that resulted in a large rectovesical fistula involving the right hemitrigone and right ureteral orifice. An attempt to repair the rectovesical fistula at an outside facility was unsuccessful. Then, he underwent a robotic-assisted laparoscopic repair of rectovesical fistula, including simple prostatectomy, excision of rectovesical fistulous tract, rectal closure, peritoneal and omental flap interposition, bladder neck reconstruction, vesicourethral anastomosis and right ureteral reimplantation. There were no intraoperative or postoperative complications, and the patient was discharged at postoperative day 4; cystoscopy at 6-week follow-up demonstrated a successful closure of the fistula, at which time the ureteral stents were removed.
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Affiliation(s)
- R Sotelo
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - L G Medina
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - F Z Husain
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - M Khazaeli
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - K Nikkhou
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - G E Cacciamani
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - H Landsberger
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - M Winter
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A Hernandez
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A M Kaiser
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - I Gill
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Royo-Aznar A, Moro-Valdezate D, Martín-Arévalo J, Pla-Martí V, García-Botello S, Espín-Basany E, Espí-Macías A. Reversal of Hartmann's procedure: a single-centre experience of 533 consecutive cases. Colorectal Dis 2018; 20:631-638. [PMID: 29430804 DOI: 10.1111/codi.14049] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 01/07/2018] [Indexed: 12/12/2022]
Abstract
AIM Hartmann's procedure (HP) is common. However, restoration of intestinal continuity is not so frequent. The aim of this study was to determine predictive factors which might influence outcomes following the reversal of HP. METHOD All consecutive patients who underwent elective and emergency HP in a single institution between January 1999 and December 2014 were included. Data concerning patient, disease and treatment features were collected. Univariate and multivariate binary logistic regression models were used to determine prognostic factors. RESULTS A total of 533 consecutive patients underwent HP over the 16-year period. Factors that were associated with a higher probability of reversal were age (< 69 years), American Society of Anesthesiologists (ASA) grade (I or II), indication for HP (likelihood of anastomotic leakage) and length of rectal stump reaching or exceeding the sacral promontory. A reduced probability of intestinal reconstruction was associated with anal incontinence, Stage IV cancer, postoperative transfusion or elective surgery. CONCLUSION Age, ASA grade, the indication for HP, the length of rectal stump, anal incontinence, tumour stage, postoperative transfusion and elective surgery determine the probability of reversal.
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Affiliation(s)
- A Royo-Aznar
- Department of Surgery, Universtitat Autònoma de Barcelona, Barcelona, Spain
| | - D Moro-Valdezate
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - J Martín-Arévalo
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - V Pla-Martí
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - S García-Botello
- Department of Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - E Espín-Basany
- Department of Surgery, Universtitat Autònoma de Barcelona, Barcelona, Spain
| | - A Espí-Macías
- Department of Surgery, University of Valencia, Valencia, Spain
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Hallam S, Mothe BS, Tirumulaju RMR. Hartmann's procedure, reversal and rate of stoma-free survival. Ann R Coll Surg Engl 2018; 100:301-307. [PMID: 29484943 PMCID: PMC5958852 DOI: 10.1308/rcsann.2018.0006] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 12/24/2022] Open
Abstract
Background Hartmann's procedure is a commonly performed operation for complicated left colon diverticulitis or malignancy. The timing for reversal of Hartmann's is not well defined as it is technically challenging and carries a high complication rate. Methods This study is a retrospective audit of all patients who underwent Hartmann's procedure between 2008 and 2014. Reversal of Hartmann's rate, timing, American Society of Anesthesiologists grade, length of stay and complications (Clavien-Dindo) including 30-day mortality were recorded. Results Hartmann's procedure (n = 228) indications were complicated diverticular disease 44% (n = 100), malignancy 32% (n = 74) and other causes 24%, (n = 56). Reversal of Hartmann's rate was 47% (n = 108). Median age of patients was 58 years (range 21-84 years), American Society of Anesthesiologists grade 2 (range 1-4), length of stay was eight days (range 2-42 days). Median time to reversal of Hartmann's was 11 months (range 4-96 months). The overall complication rate from reversal of Hartmann's was 21%; 3.7% had a major complication of IIIa or above including three anastomotic leaks and one deep wound dehiscence. Failure of reversal and permanent stoma was less than 1% (n = 2). Thirty-day mortality following Hartmann's procedure was 7% (n = 15). Where Hartmann's procedure wass not reversed, for 30% (n = 31) this was the patient's choice and 70% (n = 74) were either high risk or unfit. Conclusions Hartmann's procedure is reversed less frequently than thought and consented for. Only 46% of Hartmann's procedures were stoma free at the end of the audit period. The anastomotic complication rate of 1% is also low for reversal of Hartmann's procedure in this study.
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Affiliation(s)
- S Hallam
- Department of Colorectal Surgery, Good Hope Hospital, Sutton Coldfield, Birmingham, UK
| | - BS Mothe
- Royal Liverpool Hospital, Liverpool, UK
| | - RMR Tirumulaju
- Department of Colorectal Surgery, Good Hope Hospital, Sutton Coldfield, Birmingham, UK
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Stafford C, Francone TD, Marcello PW, Roberts PL, Ricciardi R. Is Diversion with Ileostomy Non-inferior to Hartmann Resection for Left-sided Colorectal Anastomotic Leak? J Gastrointest Surg 2018; 22:503-507. [PMID: 29119532 DOI: 10.1007/s11605-017-3612-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 10/17/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of left-sided colorectal anastomotic leaks often requires fecal stream diversion for prevention of further septic complications. To manage anastomotic leak, it is unclear if diverting ileostomy provides similar outcomes to Hartmann resection with colostomy. METHODS We identified all patients who developed anastomotic leak following left-sided colorectal resections from 1/2012 through 12/2014 using the American College of Surgeons National Surgical Quality Improvement Program. Then, we examined the risk of mortality and abdominal reoperation in patients treated with diverting ileostomy as compared to Hartmann resection. RESULTS There were 1745 patients who experienced an anastomotic leak in a cohort of 63,748 patients (3.7%). Two hundred thirty-five patients had a reoperation for anastomotic leak involving the formation of a diverting ileostomy (n = 77) or Hartmann resection (n = 158). There was no difference in mortality or abdominal reoperation in patients treated with diverting ileostomy (3.9, 7.8%) versus Hartmann resection (3.8, 6.3%) (p = 0.8). CONCLUSION There was no difference in the outcomes of mortality or need for second abdominal reoperation in patients treated with diverting ileostomy as compared to Hartmann resection for left-sided colorectal anastomotic leak. Thus, select patients with left-sided colorectal anastomotic leaks may be safely managed with diverting ileostomy.
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Affiliation(s)
- Caitlin Stafford
- Section of Colon & Rectal Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA
| | - Todd D Francone
- Section of Colon & Rectal Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA
| | - Peter W Marcello
- Department of Colon & Rectal Surgery, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Patricia L Roberts
- Department of Colon & Rectal Surgery, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Rocco Ricciardi
- Section of Colon & Rectal Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA.
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Reversal of Hartmann’s procedure: still a complicated operation. Tech Coloproctol 2017; 22:81-87. [DOI: 10.1007/s10151-017-1735-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 11/19/2017] [Indexed: 12/11/2022]
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Beppu N, Kimura F, Matsubara N, Noda M, Tomita N, Yanagi H, Yamanaka N. Second-look surgery following Hartmann's procedure for obstructive left-sided colorectal cancer. Oncol Lett 2016; 12:3609-3613. [PMID: 27900043 DOI: 10.3892/ol.2016.5084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 01/18/2016] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to investigate the short- and long-term outcomes of patients undergoing second-look surgery following Hartmann's procedure for obstructive left-sided colorectal cancer (LSCC). All patients included in the present study had undergone radical surgery with Hartmann's procedure for obstructive LSCC. Adjuvant chemotherapy was recommended for all patients, and patients with no signs of recurrence following six months of surveillance were planned to undergo second-look surgery. The aim of second-look surgery was early detection of local recurrence and determination of the efficacy of laparoscopic Hartmann procedure reversal. A total of 15 patients with locally advanced colorectal cancer were included in the study. Three patients exhibited peritoneal dissemination at the time of laparoscopic Hartmann procedure reversal and underwent partial peritonectomy. Following adjuvant chemotherapy treatment, laparoscopic Hartmann procedure reversal was performed in all patients. However, two patients underwent colo-anal anastomosis, and two patients underwent right-sided colon or ileum reconstruction. Regarding the oncological outcomes, two of three patients in whom peritoneal dissemination was identified during laparoscopic Hartmann procedure reversal were eventually in remission following the initial surgery and the second-look surgery with partial peritonectomy. Favorable long-term outcomes were observed in 12/15 patients due to no recurrence, which may be due to the surgical techniques used and the timing of the second-look surgery following Hartmann's procedure for the treatment of obstructive LSCC.
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Affiliation(s)
- Naohito Beppu
- Department of Surgery, Meiwa Hospital, Nishinomiya, Hyogo 663-8186, Japan
| | - Fumihiko Kimura
- Department of Surgery, Meiwa Hospital, Nishinomiya, Hyogo 663-8186, Japan
| | - Nagahide Matsubara
- Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Masashi Noda
- Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Naohiro Tomita
- Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Hidenori Yanagi
- Department of Surgery, Meiwa Hospital, Nishinomiya, Hyogo 663-8186, Japan
| | - Naoki Yamanaka
- Department of Surgery, Meiwa Hospital, Nishinomiya, Hyogo 663-8186, Japan
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Retrospective Evaluation of Laparoscopic Versus Open Hartmann's Reversal: A Single-Institution Experience. Surg Laparosc Endosc Percutan Tech 2016; 25:e156-8. [PMID: 26429059 DOI: 10.1097/sle.0000000000000201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Restoration of intestinal continuity after Hartmann's procedure has significant associated morbidity. There has been a trend toward increasing utilization of laparoscopy in colorectal surgery, with improvements in short-term outcomes. This study evaluates our experience with laparoscopic Hartmann's procedure reversal. METHODS All patients who underwent laparoscopic and open reversal of Hartmann's procedure between 2007 and 2010 were reviewed. Demographics, length of stay, postoperative morbidity, and mortality were compared between the 2 groups. RESULTS Nineteen patients underwent laparoscopic Hartmann's reversal and 62 underwent open reversal. There were no statistically significant differences in demographics, comorbidities, mean operative times, blood loss, reoperation, and readmission rates between the groups. The laparoscopic group had a shorter length of hospitalization (5.7 vs. 7.9 d, P<0.01). CONCLUSIONS Laparoscopic reversal of Hartmann's pouch is a safe and feasible alternative to the open reversal technique. Patients who undergo the laparoscopic technique have a shorter length of hospital stay.
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Teixeira Farinha H, Melloul E, Hahnloser D, Demartines N, Hübner M. Emergency right colectomy: which strategy when primary anastomosis is not feasible? World J Emerg Surg 2016; 11:19. [PMID: 27148397 PMCID: PMC4855428 DOI: 10.1186/s13017-016-0073-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 04/25/2016] [Indexed: 12/31/2022] Open
Abstract
Background Primary anastomosis is considered the standard strategy after right emergency colectomy. The present study aimed to evaluate alternative treatment strategies when primary anastomosis is not possible to prevent definitive ostomy. Methods This retrospective study included all consecutive patients who underwent right emergency colectomy between July 2006 and June 2013. Demographics, surgical data, and postoperative outcomes were entered in an anonymized database. Comparative analysis was performed between patients with primary anastomosis (PA group) and those where alternative strategies were employed (no-PA group). Outcomes were 30 days complications rate and rate of bowel continuity restoration. Results One hundred forty-eight patients (57 % male) with a median age of 65 years (15–96) were included. One hundred and sixteen patients underwent PA (78 %) and 32 were in the no-PA group (22 %). No-PA group patients had more comorbidities (Carlson comorbidity index >3: 98 % vs. 54, p < 0.001). Major complications rate (Dindo-Clavien III to IV) was 24 % in PA group, 88 % in no-PA group (p < 0.001). The 30-day mortality rate was 6 % (n = 7) in PA group versus 25 % (n = 8) in no-PA group (p = 0.004). Fourteen patients in the no-PA group had a split stoma and 18 had a two-staged procedure. Five patients had continuity restoration after initial split stoma (36 %) compared to 10 after a two-staged procedure (55 %; p = 0.265). Anastomotic leak occurred in 10 patients of the PA group (9 %) versus 0 in the no-PA group, where 15 out of 32 patients (47 %) had continuity restoration. Conclusion Eighty percent of patients requiring emergency right colectomy were anastomosed primarily. For the remaining a two-staged procedure might facilitate bowel continuity restoration in the long-term.
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Affiliation(s)
- Hugo Teixeira Farinha
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, 1011 Switzerland
| | - Emmanuel Melloul
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, 1011 Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, 1011 Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, 1011 Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, 1011 Switzerland
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Shaw D, Beaty JS, Thorson AG. Reoperative surgery for diverticular disease and its complications. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Krezalek MA, Umanskiy K, Hyman NH. Reoperative surgery following colorectal anastomotic leaks. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Adam N, Rahbar S, Skinner R. Outcomes of Colostomy Reversal in a Public Safety Net Hospital: The End or Beginning of a New Problem? Am Surg 2015. [DOI: 10.1177/000313481508101034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Colostomy reversals can be technically challenging and linked to significant morbidity. There is sparse evidence that evaluates outcomes after colostomy reversals performed by acute care surgeons. We performed a review of 61 colostomy reversals from January 2011 to January 2014. Colostomies for acute diverticulitis were predominate, n = 32 (52%). Traumatic colorectal injuries were n = 15, 25 per cent. Colorectal cancer was n = 8, 13 per cent. Sigmoid volvulus accounted for n = 2 cases. Abdominal sepsis from adhesions was n = 3. A rectal foreign body was for n = 1 case. The time to reversal was 360 ± 506 days. Completion of reversals was successful in 90 per cent of cases and protecting stoma use was in n = 12, (22%). Surgical site infections occurred in n = 20, patients (32%). Surgical site infections were prevalent in obese patients, (55%). Anastomotic leaks (ALs) occurred at 12 per cent, and were prevalent in obese, [obese (22%) vs nonobese (8%), P = 0.1]. The majority of AL n = 6, (85%) were in acute diverticulitis and trauma. There were no ALs in cases with protective diversion. No deaths occurred. The elective nature of colostomy reversals does not imply low morbidity. Obesity and major inflammatory processes were associated with major surgical complications. These data suggest that protective stomas should be applied liberally, particularly in high-risk cases.
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Affiliation(s)
- Nadir Adam
- Department of Surgery, Kern Medical Center, Bakersfield, California
| | - Shahrzad Rahbar
- Department of Surgery, Kern Medical Center, Bakersfield, California
| | - Ruby Skinner
- Department of Surgery, Kern Medical Center, Bakersfield, California
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Focchi S, Carrara A, Avesani EC. Advances in management of patients with acute diverticulitis. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/j.joad.2015.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Identification of diverticulitis patients at high risk for recurrence and poor outcomes. J Trauma Acute Care Surg 2015; 78:112-9. [DOI: 10.1097/ta.0000000000000466] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Landmann RG. Surgical management of anastomotic leak following colorectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Bingham JR, Steele SR. Influence of trauma, peritonitis, and obstruction on restoring intestinal continuity—To connect or not to connect? SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Jafferji MS, Hyman N. Surgeon, not disease severity, often determines the operation for acute complicated diverticulitis. J Am Coll Surg 2014; 218:1156-61. [PMID: 24755189 DOI: 10.1016/j.jamcollsurg.2013.12.063] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 11/06/2013] [Accepted: 12/09/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND The "best" operation in the setting of acute complicated diverticulitis has been debated for decades. Multiple studies, including a recent prospective randomized trial, have reported improved outcomes with primary anastomosis. The aim of this study was to determine whether surgeon or patient-specific factors drives the choice of operative procedure. STUDY DESIGN Consecutive adult patients with sigmoid diverticulitis, requiring emergent operative treatment for acute complicated diverticulitis, from 1997 to 2012 at an academic medical center, were identified from a prospectively maintained complications database. Patient characteristics, surgeon, choice of operation, and outcomes including postoperative complications and stoma reversal were noted. The use of primary anastomosis and associated outcomes between colorectal and noncolorectal surgeons were compared. RESULTS There were 151 patients who underwent urgent resection during the study period, and 136 met inclusion criteria. Eighty-two resections (65.1%) were performed by noncolorectal surgeons and 44 by colorectal surgeons (34.9%). Noncolorectal surgeons performed more Hartmann procedures (68.3% vs 40.9%, p = 0.01) despite similar demographics, American Society of Anesthesiologists (ASA) classification, and Hinchey stage. Length of stay, time to stoma reversal, ICU days, and postoperative complications were lower in the colorectal group (43.2% vs 16.7, p = 0.02). CONCLUSIONS Although patient-specific factors are important, surgeon is a potent predictor of operation performed in the setting of severe acute diverticulitis. A more aggressive approach to primary anastomosis may lower the complication rate after surgical treatment for severe acute diverticulitis.
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Affiliation(s)
- Mohammad S Jafferji
- Department of Surgery, University of Vermont College of Medicine, Burlington, VT
| | - Neil Hyman
- Department of Surgery, University of Vermont College of Medicine, Burlington, VT.
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