Identification of risk factors for morbidity and mortality after Hartmann's reversal surgery - a retrospective study from two French centers

Body composition assessment by artificial intelligence can be a predictive tool for short-term postoperative complications in Hartmann's reversals

BACKGROUND

Hartmann's reversal, a complex elective surgery, reverses and closes the colostomy in individuals who previously underwent a Hartmann's procedure due to colonic pathology like cancer or diverticulitis. It demands careful planning and patient optimisation to help reduce postoperative complications. Preoperative evaluation of body composition has been useful in identifying patients at high risk of short-term postoperative outcomes following colorectal cancer surgery. We sought to explore the use of our in-house derived Artificial Intelligence (AI) algorithm to measure body composition within patients undergoing Hartmann's reversal procedure in the prediction of short-term postoperative complications.

METHODS

A retrospective study of all patients who underwent Hartmann's reversal within a single tertiary referral centre (Western) in Melbourne, Australia and who had a preoperative Computerised Tomography (CT) scan performed. Body composition was measured using our previously validated AI algorithm for body segmentation developed by the Department of Surgery, Western Precinct, University of Melbourne. Sarcopenia in our study was defined as a skeletal muscle index (SMI), calculated as Skeletal Muscle Area (SMA) /height2 < 38.5 cm2/m2 in women and < 52.4 cm2/m2 in men.

RESULTS

Between 2010 and 2020, 47 patients (mean age 63.1 ± 12.3 years; male, n = 28 (59.6%) underwent body composition analysis. Twenty-one patients (44.7%) were sarcopenic, and 12 (25.5%) had evidence of sarcopenic obesity. The most common postoperative complication was surgical site infection (SSI) (n = 8, 17%). Sarcopenia (n = 7, 87.5%, p = 0.02) and sarcopenic obesity (n = 5, 62.5%, p = 0.02) were significantly associated with SSIs. The risks of developing an SSI were 8.7 times greater when sarcopenia was present.

CONCLUSION

Sarcopenia and sarcopenic obesity were related to postoperative complications following Hartmann's reversal. Body composition measured by a validated AI algorithm may be a beneficial tool for predicting short-term surgical outcomes for these patients.

The use of colonic stents as a bridge to surgery in malignant colonic obstruction - A dual trust experience over 10 years

Introduction

Worldwide colonic cancer is the third most common cancer with up to 30% of cases presenting with large bowel obstruction. Self-expanding metal stents (SEMS) have been used as a bridge to surgery (BTS) in the treatment of this malignant obstruction. We review the outcomes of SEMS as a BTS across two high volume colorectal units.

Methodology

A retrospective analysis of patients undergoing colonic stenting as a bridge to surgery was performed; outcomes were compared to previously published figures on emergency colonic resections. Inclusion criteria were adults (>18 years of age) undergoing colonic stenting for colonic obstruction with a view to elective resection. Patients undergoing stenting for palliation of symptoms were excluded.

Results

39 patients were identified across both trusts over a ten-year period. 90 day mortality following BTS was found to be 3.6% and there was an 82.1% (32/39) technical success rate. 46.4% proceeded to an elective resection which was started laparoscopically. Permanent stoma rate was observed at 14.3% for elective surgery.

Conclusion

Stenting for relief of acute malignant obstruction as a bridge to surgery is a viable option in select patients. Further research is required to determine oncological safety and rate of local recurrences.

Functional outcome after Hartmann's reversal surgery using LARS, COREFO & QoL scores

BACKGROUND

Functional complaints after colorectal surgery have a profound effect on quality of life (QoL). Our goal was to investigate the prevalence of functional complaints and quality of life after Hartmann's reversal surgery.

METHOD

A cross-sectional study was performed where one hundred nineteen patients were included. All patients underwent Hartmann's reversal procedure between 2007 and 2019. All patients were asked to complete 3 validated questionnaires related to bowel function in benign and colorectal cancer surgery as well as general QoL.

RESULTS

The response rate was 67%. Among responders, 32.8% reported LARS-like symptoms whereas 25% had significant COREFO Scores (>15). Higher LARS and COREFO scores were significantly associated with worse global QoL and several QoL domain scores (p < 0.05).

CONCLUSION

This study highlights the prevalence of bowel dysfunction after Hartmann's reversal surgery. Patients undergoing this procedure show similar functional complaints compared to those in literature who had a resection without colostomy.

Which factors influence the decision to perform Hartmann's reversal in various causative disease situations? A retrospective cohort study between 2006 and 2021

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.

Reversal of Hartmann's procedure: timelines, preoperative investigations and early outcomes. A single Australian institution's ten-year experience

BACKGROUND

Real-world data on outcomes following Hartmann's reversal is necessary to help optimize the patient experience. We have explored the timing between the index operation and its reversal; what investigations were carried out prior to this, and the associated short-term outcomes.

METHODS

A retrospective study of all patients who underwent Hartmann's reversal from 2010 to 2020 within a tertiary referral centre in Melbourne, Australia. One hundred from a total of 406 (25%) who underwent an emergency Hartmann's procedure had a subsequent reversal. Complete patient data was available for 83 of these patients.

RESULTS

The average patient age was 60 years, and the median time for reversal was 14.0 (IQR 10-23) months. Seventy-nine of 83 (95%) reversals had a preoperative endoscopic evaluation of both their rectal stump and a complete colonoscopy. Stoma stenosis (n = 2), patient refusal (n = 1) and emergency reversal (n = 1) were cited reasons for not undergoing preoperative endoscopic evaluation. A third (n = 28, 34%) had a computed tomography prior to reversal; the majority was due to their underlying cancer surveillance (n = 21, 75%). Reversal was associated with a morbidity rate of 47% (n = 39). Surgical site infections (SSIs) (n = 21, 25%) were the most common type of complications encountered, with the majority being superficial (n = 15, 71%). SSIs were associated with steroid use (5/21 versus 4/62, p = 0.03) and greater hospital length of stay (6 versus 10 days, p = 0.03).

CONCLUSION

Only a quarter of emergency Hartmann's procedures within our institution were reversed. A significant proportion developed postoperative complications. Surgical site infection was the most common morbidity.

Hartmann's reversal is associated with worse outcomes compared to elective left colectomy: A NSQIP analysis of 36,794 cases

BACKGROUND

Hartmann's reversal (HR) is associated with significant technical difficulty and morbidity. Using the ACS-NSQIP database, we assessed the outcomes of HR as compared to elective left colectomy (LC).

METHODS

The 2016-2019 ACS-NSQIP datasets were queried to identify patients undergoing HR and elective LC. Patients' demographics, comorbidities, and short-term surgical outcomes were evaluated using both univariable and multivariable methods.

RESULTS

The study included 7,632 HR cases and 29,162 LC cases. The HR group had more patients with ASA grade III (50% vs. 42.4%). HR had more open-operative cases (69.4 vs. 18.5%) and longer mean operative times (213 vs. 191 min) than LC. Postoperatively, the HR group had a longer mean hospital stay (5.5 vs. 4.1 days) and higher complication rate (18.3% vs. 10.3%). HR was associated with increased odds of having a concurrent ileostomy (OR 2.11), deep space/organ infection (OR 1.55), and at least one complication (OR 1.56).

CONCLUSION

HR is a more challenging operation with patients who fared worse than their LC counterparts. Consideration should be given to alternatives of the index Hartmann's procedure.

A nutritional screening threshold for optimal outcomes after Hartmann's reversal

PURPOSE

Determining is nutritionally replete enough for Hartmann's reversal (HR) can be controversial and multifactorial. While there are many preoperative nutritional screening tools, the impact of malnourishment on HR has not been evaluated. The study aims to clarify how often patients undergoing HR are high risk for malnourishment at the time of surgery and how this impacts postoperative outcomes.

METHODS

From 2012-2019, all elective HRs were identified in ACS-NSQIP. Patients were categorized in a malnourished group if they met one of the following criteria: (1) BMI < 18.5 kg/m², (2) albumin < 3.5 g/dL, or (3) > 10% body weight loss in the last 6 months. Bivariate associations of preoperative demographics and postoperative outcomes were analyzed. Multivariable logistic regression was performed to identify independent predictors for 30-day mortality and organ space wound infection.

RESULTS

8878 procedures were evaluated (well-nourished = 7116 and malnourished = 1762). The malnourished group had higher mortality (p < 0.001), shorter operating time (p < .001), longer length of stay (p = 0.016), and higher rates of infection (p = 0.011), reintubation (p = 0.002), bleeding (p < 0.001), sepsis (p = 0.001), and reoperation (p = 0.018). In multivariate regression models, malnourishment was an independent predictor for mortality (OR = 2.72, p < 0.001) and wound infection (OR = 1.19, p = 0.028).

CONCLUSION

A large percentage of patients undergoing HR were classified as being high-risk for malnutrition. Malnourishment was associated with some worse postoperative compilations including death and wound infection. Surgeons should routinely use preoperative screening for malnutrition to identify and attempt to optimize nutritional status prior to undergoing Hartmann's Reversal.

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.