Factores pronósticos de mortalidad en la peritonitis de colon izquierdo. Un nuevo sistema de puntuación

Reversal of Hartmann's procedure: a single-centre experience of 533 consecutive cases

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.

Estado actual de la intervención de Hartmann en nuestro medio

INTRODUCTION

The therapeutic alternatives in emergency surgery of the colon are a constant subject of debate and the Hartmann procedure is one of the most controversial techniques. The aim of the present study was to analyze when, why and in whom this procedure is performed, as well as its results.

PATIENTS AND METHOD

We performed a descriptive analysis of 105 emergency Hartmann procedures. Clinical variables (age, sex, antecedents, symptoms, risk factors, preoperative diagnosis) were analyzed and correlated with surgical variables (surgical findings, surgeon) indicating the Hartmann procedure depending on general and local factors.

RESULTS

The mean age was 69.3 years and 56% of the patients were men. Seventy-three percent had personal antecedents. Presenting symptoms were occlusion in 48%, acute abdomen in 30% and septic shock in 12%. Seventy-eight percent were ASA III-IV. The most frequent surgical findings were intestinal occlusion (39%), purulent peritonitis (22%) and fecal peritonitis (18%). Perforation of the colon was found in 14%. Morbidity was 51% and mortality was 11%. Sixty-three percent of the procedures were performed by general surgeons and 37% by specialists in colorectal surgery. In 20 patients intestinal continuity was restored after a mean wait of 9 months. Retrospective evaluation of the indications for the Hartmann procedure revealed that 50.5% of the patients could have undergone anastomosis and the reasons for not performing this procedure were analyzed.

CONCLUSION

In our experience the Hartmann procedure is performed primarily for factors related to the patient (risk factors, general status and local status of the abdomen) and secondly due to factors related to the duty surgeon.