Comparison of Short-term Outcomes After Laparoscopic Versus Open Hartmann Reversal: A Case-matched Study

Laparoscopic versus open Hartmann reversal: a propensity score matching analysis

PURPOSE

The purpose of this study was to compare the short-term outcomes between laparoscopic Hartmann reversal (LHR) and open Hartmann reversal (OHR) in patients who had undergone Hartmann surgery for colorectal cancer (CRC).

METHODS

The patients who underwent Hartmann reversal (HR) at the First Affiliated Hospital of Chongqing Medical University from Jun 2013 to Jun 2022 were retrospectively enrolled. The LHR group and the OHR group were compared using propensity score matching (PSM) analysis.

RESULTS

A total of 89 patients who underwent Hartmann reversal (HR) were enrolled in this study. There were 48 (53.9%) patients in the LHR group and 41 (46.1%) patients in the OHR group. After 1:1 ratio PSM, no difference in baseline information remained (p > 0.05). There was no significant difference in operation time, blood loss, postoperative hospital stay, and postoperative complications (p > 0.05) before and after PSM. In the multivariable logistic regression analysis, pre-operative albumin < 42.0 g/L was an independent risk factor (p = 0.013 < 0.05, OR = 0.248, 95% CI = 0.083-0.741) for the HR-related complications; however, LHR/OHR was not a predictive risk factor (p = 0.663, OR = 1.250, 95% CI = 0.500-3.122).

CONCLUSION

Based on the current evidence, although there was no difference in short-term prognosis, LHR still had some advantages considering that it was less invasive to the patient.

Hartmann’s Reversal: Controversies of a Challenging Operation

Purpose. Hartmann’s reversal is a complex operation with a high morbidity rate. Minimally invasive surgery has been used to reduce the impact of surgery on fragile patients. The aim of this comparative study is to look at the results of Hartmann’s reversal procedures with different approaches. Methods. All the patients who underwent Hartmann’s reversal were collected retrospectively (124 cases). Sixty-four patients (50.4%) had an open operation, 6 cases (5%) were treated with a conventional laparoscopic approach, 34 patients (28.1%) underwent single incision laparoscopic surgery (SILS), and 20 (16.5%) required other additional trocars. Results. SILS operations were slightly longer than the open procedures (175 min vs 150 min), with the same rate of postoperative complications and reoperations (p = 0.83 and p = 0.42), but with a shorter hospital stay (5 days p = 0.007). Age (p = 0.03), long operative time (p = 0.01), and ASA score (p = 0.05) were identified as independent factors affecting postoperative morbidity. The grade of adhesions caused a longer operative time (p = 0.001) and a higher risk of conversion $\left(p<0.001\right)$ , and short rectal stump increased the risk of protective loop ileostomy (p = 0.008). Patients with grade 2-3 of adhesions had a longer length of stay (p = 0.05). Conclusions. Minimally invasive procedures had a shorter hospital stay and did not show any increase in morbidity rate when compared with open cases. Age, longer operative time, and ASA score increased the risk of postoperative complications. Furthermore, patients with a short rectal stump had a higher chance of having a defunctioning ileostomy.

Laparoscopic Hartmann's reversal has better clinical outcomes compared to open surgery: An international multicenter cohort study involving 502 patients

Background

Hartmann's procedure (HP) is used in surgical emergencies such as colonic perforation and colonic obstruction. “Temporary” colostomy performed during HP is not always reversed in part due to potential morbidity and mortality associated with reversal. There are several contributing factors for patients requiring a permanent colostomy following HP. Therefore, there is still some discussion about which technique to use. The aim of this study was to evaluate perioperative variables of patients undergoing Hartmann's reversal using a laparoscopic and open approach.

Methods

The multicenter retrospective cohort study was done between January 2009 and December 2019 at 14 institutions globally. Patients who underwent Hartmann's reversal laparoscopic (LS) and open (OS) approaches were evaluated and compared. Sociodemographic, preoperative, intraoperative variables, and surgical outcomes were analyzed. The main outcomes evaluated were 30‐day mortality, length of stay, complications, and postoperative outcomes.

Results

Five hundred and two patients (264 in the LS and 238 in the OS group) were included. The most prevalent sex was male in 53.7%, the most common indication was complicated diverticular disease in 69.9%, and 85% were American Society of Anesthesiologist (ASA) II‐III. Intraoperative complications were noted in 5.3% and 3.4% in the LS and OS groups, respectively. Small bowel injuries were the most common intraoperative injury in 8.3%, with a higher incidence in the OS group compared with the LS group (12.2% vs. 4.9%, p < 0.5). Inadvertent injuries were more common in the small bowel (3%) in the LS group. A total of 17.2% in the OS versus 13.3% in the LS group required intensive care unit (ICU) admission (p = 0.2). The most frequent postoperative complication was ileus (12.6% in OS vs. 9.8% in LS group, p = 0.4)). Reintervention was required mainly in the OS group (15.5% vs. 5.3% in LS group, p < 0.5); mortality rate was 1%.

Conclusions

Laparoscopic Hartmann's reversal is safe and feasible, associated with superior clinical outcomes compared with open surgery.

Is laparoscopy a reliable alternative to laparotomy in Hartmann's reversal? An updated meta-analysis

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.

Outcomes of colostomy takedown following Hartmann's procedure: successful restoration of continuity comes with a high risk of morbidity

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.

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.

Reversal of Hartmann's Procedure: Evaluating Outcomes of Single-Port Laparoscopic Approach Versus Conventional Approach

Bowel restoration following Hartmann's procedure (HP) remains a topic of discussion and innovation. This article seeks to highlight and analyze the outcomes of conventional reversal approaches such as open surgery (OS) and conventional laparoscopic (CL) to single-port laparoscopic reversal (SPLR) approach to evaluate whether SPLR is a feasible alternative to the OS or CL approach. A PubMed search using keywords yielded 5,750 articles. After applying the inclusion/exclusion criteria, 40 articles of relevance were reviewed, and endpoints considered. These included 13 systematic reviews and 27 observational reviews, three of which identified themselves as retrospective or comparative studies. The analysis showed overwhelming support for CL over OS as a choice for HP reversal. Studies comparing SPLR to CL showed SPLR to be a safe and feasible alternative, given its significantly shorter operating times, hospitalization times, and complication rates.

Laparoscopic Hartmann's Reversal: Application of a Single-Port Approach Through the Colostomy Site

PURPOSE

Recently, laparoscopic reversal of Hartmann's colostomy was performed with favorable outcomes by many surgeons. We partially applied the concepts of single-port laparoscopic procedure through the colostomy site to remove intraperitoneal adhesion during initial step of the laparoscopic Hartmann's reversal. This study aimed to evaluate the feasibility and safety of the laparoscopic reversal of Hartmann's colostomy with the application of single-port laparoscopic techniques through the colostomy site.

METHODS

From October 2008 to November 2018, the laparoscopic Hartmann's reversal was attempted in 20 patients. After colostomy take-downs, the single-port device was installed at the colostomy site and the single-port laparoscopic procedure was performed to remove intraperitoneal adhesions to provide space for additional trocars. After additional trocars were inserted, the descending colon and rectal stump were mobilized, and the colorectal anastomosis was completed. We retrospectively reviewed the medical records and analyzed the data to identify the perioperative complication rates as the primary outcome.

RESULTS

Of the 20 patients, 3 patients (15.0%) had open conversions due to severe adhesions. Intraoperative small bowel injuries occurred in 2 patients (10.0%) and these were repaired through the colostomy site. Postoperative complications developed in 4 patients (20.0%) and were managed with medical treatments or wound closures under local anesthesia.

CONCLUSION

The single-port laparoscopic procedure through the colostomy site is sufficiently safe in order to complete the Hartmann's reversal. We recommend that the colostomy site should be used as the access route into the abdominal cavity for the Hartmann's reversal.

Conventional Versus Minimally Invasive Hartmann Takedown: A Meta-analysis of the Literature

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.

Emergency Hartmann's Procedure and Its Reversal: A Totally Laparoscopic 2-Step Surgery for the Treatment of Hinchey III and IV Diverticulitis

BACKGROUND

Hartmann's procedure (HP) followed by reversal restoration is the first choice for treatment of diffuse diverticular peritonitis. There is no unanimous consensus regarding the use of laparoscopy to treat the same condition.

METHODS

Data from 60 patients with diverticular diffuse peritonitis who underwent urgent HP followed by laparoscopic reversal were retrospectively analyzed. Patients were divided into 2 groups according to the open or laparoscopic HP (OHP, 24 patients; LHP, 36 patients). Outcomes were measured in terms of functional recovery, morbidity, mortality, and length of hospital stay.

RESULTS

HPs showed no differences among the groups in terms of operative time, blood loss, and length of intensive care unit stay. Overall morbidity was significantly lower in LHP than in OHP, corresponding to 33.3% and 66.7% respectively ( P = .018). The incidence of both surgical and medical complications was higher in OHP than in LHP (41.7% vs 22.2% [ P = .044] and 45.8% vs 24.3% [ P = .023], respectively). Mortality was 16.6% for each group. LHP showed a faster return to bowel movements and a shorter hospital stay than OHP. The secondary intestinal reversal was possible in 92% of cases, successfully completed laparoscopically in 91.3%. No patients of LHP group required a conversion to open intestinal reversal.

CONCLUSION

LHP for treatment of diverticular diffuse peritonitis showed significantly lower morbidity, faster recovery, shorter hospital stay, and higher rates of successful laparoscopic reversal when compared with OHP.