Cirugía urgente del colon ocluido, perforado o sangrante. Estudio multicéntrico de 38 hospitales

Hartmann's operation: how often is it reversed and at what cost? A multicentre study

AIM

The study evaluated the rate of reversal of Hartmann's operation after the initial surgery and its morbidity.

METHOD

A multicentre retrospective study was carried out in seven hospitals in the Valencia area of patients who underwent Hartmann's operation from 2004 to 2008. The incidence of reversal was determined.

RESULTS

Four hundred and fifty-two patients of mean age 67.5 ± 15.4 years were included, of whom 78.8% had an emergency operation. The most common diagnosis was cancer (58.6%), although diverticulitis predominated in the emergency setting. At a median follow up of 44 months, 159 (35.2%) patients had undergone reversal, including 16.6% after elective surgery and 40.4% after an emergency Hartmann's procedure (P < 0.001). The most frequent reason why reversal was not done was death (74 [25%] patients). Patients undergoing reversal were younger and had a low ASA risk. Trauma was associated with a higher rate of reversal, followed by diverticular disease. Surgery was performed at a median of 10 months. An open approach with stapled anastomosis was used in most cases. The mortality was 3.5%. Complications occurred in 45.2%, with a 6.2% rate of anastomotic leakage. Complications were associated with age, diabetes mellitus, arteriosclerosis, obesity, smoking, chemotherapy and COPD.

CONCLUSION

Hartmann's reversal was performed in a small percentage of patients, mostly including those with benign disease. It had a significant morbidity.

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.