Current indications for the Hartmann procedure

Low Hartmann's procedure versus abdominoperineal resection for rectal cancer, a propensity score matching cohort study

BACKGROUND

This study aimed to compare low Hartmann's procedure (LHP) with abdominoperineal resection (APR) for rectal cancer (RC) regarding postoperative complications.

METHOD

RC patients receiving radical LHP or APR from 2015 to 2019 in our center were retrospectively enrolled. Patients' demographic and surgical information was collected and analyzed. Propensity score matching (PSM) was used to balance the baseline information. The primary outcome was the incidence of major complications. All the statistical analysis was performed by SPSS 22.0 and R.

RESULTS

342 individuals were primarily included and 134 remained after PSM with a 1:2 ratio (50 in LHP and 84 in APR). Patients in the LHP group were associated with higher tumor height (P < 0.001). No significant difference was observed between the two groups for the incidence of major complications (6.0% vs. 1.2%, P = 0.290), and severe pelvic abscess (2% vs. 0%, P = 0.373). However, the occurrence rate of minor complications was significantly higher in the LHP group (52% vs. 21.4%, P < 0.001), and the difference mainly lay in abdominal wound infection (10% vs. 0%, P = 0.006) and bowel obstruction (16% vs. 4.8%, P = 0.028). LHP was not the independent risk factor of pelvic abscess in the multivariate analysis.

CONCLUSION

Our data demonstrated a comparable incidence of major complications between LHP and APR. LHP was still a reliable alternative in selected RC patients when primary anastomosis was not recommended.

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 ).

Robotic Hartmann's reversal-feasibility and technical aspects

Hartmann's reversal as a staged procedure after emergency surgery is a major abdominal operation with undeniable skill-demanding steps. The robotic approach and its advantages seem to be a safe and feasible technique and could overcome necessary technical compromises of laparoscopy, ensuring a significant reduction in restoration failures or conversion.

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.

Are Patients Requiring Hartmann's Procedure Being Adequately Optimised for Surgery: An Audit Cycle

Introduction Hartmann's procedures are common surgical operations indicated in a wide variety of presentations including colon malignancy, diverticular disease, volvulus, and colovesical and colovaginal fistulas. The procedure is a major undertaking for the patient and those presenting in the emergency setting are often clinically unwell with deranged laboratory investigations. Numerous studies have demonstrated that pre-operative anaemia contributes to increased morbidity and mortality. Applying the conclusions of one study recommending a minimum haemoglobin >12 g/dL level pre-operatively, this audit assessed patient optimisation prior to Hartmann's procedure. Materials and methods Patients undergoing Hartmann's procedures between May 2016 and February 2020 were identified. Data was collected retrospectively to analyse American Society of Anesthesiology (ASA) grade and pre-operative haemoglobin level. Pre-operative haemoglobin and group and save blood test values were identified pre-and post-intervention. Results Pre-intervention, 15 (21%) of 70 patients had a haemoglobin level <12 g/dL and 63 patients (90%) had a group and save blood test completed on admission. Post-intervention data was collected from 45 patients, with figures improving to five (11%) and 44 (97%) patients, respectively. Conclusion Our flowchart poster distribution and addition to the surgical proforma led to increased patient optimisation prior to Hartmann's procedure.

Laparoscopic Reintervention for Intraperitoneal Leaks After Colonic Surgery: Do We Need a Routine Stoma?

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.

Outcomes of Laparoscopic vs. Open Reversal of Hartmann's Procedure: A Single Centre Experience

Introduction

Hartmann’s procedure is widely performed to fix colonic obstruction and perforation. It should ideally be followed by a reversal to restore bowel continuity. Reversal of Hartmann’s procedure was traditionally performed using an open technique. However, in recent days, the use of a laparoscopic approach has become increasingly popular. In our retrospective observational study, we aim to investigate the outcomes of laparoscopic versus open reversal of Hartmann’s procedure in a UK tertiary centre.

Methods

All patients who underwent reversal of their Hartmann’s procedure between January 2017 and December 2019 were included in the study. Data including demographics, days between primary operation and reversal, laparoscopic or open reversal, length of hospital stay following reversal procedure, 30-day readmission, mortality, and complication rate were collected. Statistical analysis was performed using t-test and chi-squared test.

Results

Forty-nine patients underwent reversal of Hartmann’s procedure from January 2017 to December 2019. The mean age of our cohort was 59.6 ± 13.2 years. There was no significant difference in baseline demographics of both groups, apart from the number of days between the primary operation and reversal procedure. There was also no statistical difference in length of stay, 30-day readmission, and mortality between laparoscopic and open reversal techniques. However, there was a higher incidence of wound complications in patients who underwent open reversal of Hartmann’s procedure.

Conclusion

The reversal of Hartmann’s procedure is a challenging operation. We found no significant difference between both open and laparoscopic approaches, but our study might be confounded by various factors including small sample size and selection bias. A larger, randomised study with greater statistical power is needed to confirm our findings.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Laparoscopic Versus Open Hartmann Reversal: A Case-Control Study

Background

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

Materials and Methods

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

Results

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

Correlation between ASA Grade with reversal of Hartmann's procedure - a retrospective study

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.

[Palliative Surgery in Colorectal Cancer - Which Factors Should Influence the Choice of the Surgical Procedure?]

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.

Full robotic Hartmann's reversal: technical aspects and preliminary experience

AIM

Laparoscopic Hartmann's reversal (HR) is a major abdominal operation that is associated with considerable morbidity and mortality. The robotic approach, with its intrinsic advantages, could potentially overcome the technical complexity of laparoscopy. The aim of this study was to evaluate the short-term results of a series of 24 robotic HR cases.

METHOD

The data from 24 patients who underwent robotic HR between September 2016 and July 2019 at two different institutions were prospectively collected and retrospectively analysed. A full robotic single-docking reversal procedure with intracorporeal anastomosis was performed in all patients.

RESULTS

The mean age and body mass index of the patients were 69 years and 26 kg/m² , respectively. Of the patients, 58% were ≥ 70 years old and 42% had comorbidities (mean Charlson Comorbidity Index 3). The mean operating time was 240 min. There were no cases of conversion to the open or laparoscopic approach. No diverting loop ileostomies were constructed. The mean length of hospital stay was 6 days. Minor complications were recorded in three patients. Neither major complications nor 30-day readmissions were registered.

CONCLUSIONS

Robotic HR is a feasible and safe procedure. The robotic approach has low rates of major complications and conversion and could potentially increase the number of patients undergoing HR.

A Review of Normal Intestinal Healing, Intestinal Anastomosis, and the Pathophysiology and Treatment of Intestinal Dehiscence in Foreign Body Obstructions in Dogs

Small intestinal anastomoses are commonly performed in veterinary medicine following resection of diseased or devitalized intestinal tissue. Traditionally, suture has been employed to anastomose intestinal ends. However, use of intestinal staplers has become increasingly popular due to the ability to produce a rapid anastomosis with purported superior healing properties. Under normal conditions, intestinal healing occurs in three phases: inflammatory, proliferative, and maturation. Dehiscence, a devastating consequence of intestinal anastomosis surgery, most often occurs during the inflammatory phase of healing where the biomechanical strength of the anastomosis is almost entirely dependent on the anastomotic technique (suture or staple line). The resulting septic peritonitis is associated with a staggering morbidity rate upwards of 85% secondary to the severe systemic aberrations and financial burden induced by septic peritonitis and requirement of a second surgery, respectively. Intraoperative and postoperative consideration of the multifactorial nature of dehiscence is required for successful patient management to mitigate recurrence. Moreover, intensive postoperative critical care management is necessitated and includes antibiotic and fluid therapy, vasopressor or colloidal support, and monitoring of the patient's fluid balance and cardiovascular status. An understanding of anastomotic techniques and their relation to intestinal healing will facilitate intraoperative decision-making and may minimize the occurrence of postoperative dehiscence.

Endoscopic vacuum therapy for treatment of rectal stump leakage

BACKGROUND

Symptomatic rectal stump leakage (RSL) is a serious complication after discontinuity resection and requires immediate surgical, interventional, or endoscopic therapy. Re-operations are associated with high morbidity and mortality in these mostly very ill patients. Endoscopic vacuum therapy (EVT) has been established for management of anastomotic leakage; however, its effectiveness for RSL treatment has not been analyzed in detail yet.

METHODS

A retrospective analysis of patients treated with EVT for RSL between 2001 and 2018 analyzing factors predicting therapy success and duration was carried out.

RESULTS

Fifty-six patients with RSL at a median age of 66 years were included. Of these, 18 patients (32%) had been referred for EVT from external departments or institutions. RSL was associated with a relevant clinical deterioration in all patients, and 55 patients (98%) had been classified as ASA 3 and 4, preoperatively. In 9 patients (16%), additional surgical revision was necessary with initiation of EVT. In 47 patients (84%), EVT was successful and local control of the inflammatory focus was achieved. The median duration of therapy was 20 days. Two patients (4%) suffered from minor EVT-associated bleeding that was endoscopically controlled. Preoperative radiation of the pelvis was significantly associated with EVT failure (P = 0.035), whereas patient age represented a predictive factor for therapy length (P = 0.039). In 12 patients (21%), restoration of intestinal continuity was achieved in the further course.

CONCLUSIONS

We present the first specific series on EVT for RSL. EVT for RSL was shown to be an effective and safe minimal-invasive treatment option, avoiding surgical revision in the majority of patients.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Economic Disparities in Patients Undergoing Sigmoidectomy

Background and Objectives:

Disparities in health care outcomes and resources utilized are present in the treatment of many conditions and represent an area for targeted improvement. This study analyzes the differences in outcomes and total hospital charges between the highest and lowest income quartiles of patients undergoing sigmoid colectomy.

Methods:

This retrospective cohort study included patients undergoing sigmoid colectomy from 2013 to 2014 queried from the Agency for Healthcare Research and Quality National Inpatient Sample Database who were categorized as the lowest and highest income quartile based on average income of the patient's ZIP code. Patients were grouped into income quartiles, as defined by average income in the ZIP code of residence. In-hospital complications were the primary outcome of this study. We hypothesized that patients in the lowest income quartile would have poorer outcomes than those in the highest income quartile prior to data collection.

Results:

The lowest (n = 40,995) and highest (n = 40,940) income quartiles are not significantly different based on age or gender. The lowest income quartile was sicker, with higher mean scores for the All Patient Refined Diagnosis Related Group Severity Index and All Patient Refined Diagnosis Related Group Risk of Mortality Index. The lowest income quartile cohort had higher rates of postoperative complications and higher total charges than those in the highest income quartile. Adjusted regression analysis showed significantly lower total charges for the lowest income quartile but no significant differences in overall complications, mortality rates, or nonhome discharge.

Conclusions:

Patients in the highest income quartile utilize more hospital resources than the lowest income quartile. Additional study is required to understand why these differences exist.

Key Points:

1. Significant differences in outcomes and hospital charges exist between socioeconomic groups undergoing sigmoidectomy. 2. There does not seem to be a difference in outcomes after sigmoidectomy among different socioeconomic groups. 3. Elective and laparoscopic sigmoid colectomy is more frequently applied to higher socioeconomic groups. 4. Hospital charges are also greater among patients of higher socioeconomic groups undergoing sigmoid colectomy.

Question:

Does socioeconomic status affect outcomes and total charges in patients undergoing sigmoid colectomy?

Findings:

Unadjusted analysis showed significant disparities between the highest and lowest income quartile in outcomes after sigmoid colon resection. Adjusted analysis showed no difference in outcomes, with patients in the highest income quartile having higher total charges.

Meaning:

There is a value difference between high-income and low-income patients undergoing sigmoid colectomy.

Safety of primary anastomosis following emergency left sided colorectal resection: an international, multi-centre prospective audit

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.

Reversal after Hartmann's procedure in patients with complicated sigmoid diverticulitis

AIM

Hartmann's procedure (HP) is commonly used for the emergency treatment of complicated sigmoid diverticulitis (CSD). It is intended to restore intestinal continuity; however, in practice, reversal is not carried out in all patients. It is important to know the frequency of reversal and the impact of patient-related factors on the decision for reversal.

METHOD

A retrospective study was conducted on all patients who underwent HP for CSD at a tertiary referral hospital between 1 May 2005 and 31 December 2010. We assessed the frequency of reversal over time and the prognostic factors affecting the decision for reversal.

RESULTS

Of 67 patients [median age 76 (interquartile range: 68-81) years] who had HP for CSD, 28 (42%) underwent reversal. The cumulative incidence of reversal after 48 weeks was 48% (95% CI: 36-62%). Reversal was less likely in elderly patients [hazard ratio (HR) per decade increase = 0.43; 95% CI: 0.26-0.71], with cardiac insufficiency or coronary heart disease (HR = 0.60; 95% CI: 0.26-1.40) and with preoperative immunosuppression or chemotherapy (HR = 0.31; 95% CI: 0.07-1.33). There was no apparent effect of these factors on mortality.

CONCLUSION

Approximately half of the patients having HP for CSD undergo reversal within 48 weeks of the initial operation. The finding that age, cardiac or coronary heart disease and preoperative immunosuppression or chemotherapy have an impact on the decision for reversal is relevant to healthcare professionals and patients.

Post-operative colon and urinary diversions: surgical techniques, anatomy, and imaging findings

This article discusses the commonly encountered operative procedures of the colon and urinary diversions and provides a comprehensive review of indications, contraindications, surgical techniques with emphasis on normal and abnormal multimodality imaging findings.