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Ritter AS, Dumm N, Deisenhofer JM, Franz C, Al-Saeedi M, Büchler MW, Schneider M. Risk Factors for Rectal Stump Leakage After Discontinuity Resection: Stump Length Matters Most. Dis Colon Rectum 2024; 67:138-150. [PMID: 37792564 DOI: 10.1097/dcr.0000000000002929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
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 ).
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Affiliation(s)
- Alina S Ritter
- Surgical Oncology Unit, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Noemi Dumm
- Surgical Oncology Unit, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Julian M Deisenhofer
- Surgical Oncology Unit, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Clemens Franz
- Surgical Oncology Unit, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Mohammed Al-Saeedi
- Surgical Oncology Unit, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Martin Schneider
- Surgical Oncology Unit, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, Gießen University Hospital, Gießen, Germany
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Ostomy Surgery. Dis Colon Rectum 2022; 65:1173-1190. [PMID: 35616386 DOI: 10.1097/dcr.0000000000002498] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Clementi M, Pietroletti R, Carletti F, Sista F, Grasso A, Fiasca F, Cappelli S, Balla A, Rizza V, Ciarrocchi A, Guadagni S. Colostomy Reversal following Hartmann’s Procedure: The Importance of Timing in Short- and Long-Term Complications: A Retrospective Multicentric Study. J Clin Med 2022; 11:jcm11154388. [PMID: 35956003 PMCID: PMC9369122 DOI: 10.3390/jcm11154388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/23/2022] [Accepted: 07/23/2022] [Indexed: 01/19/2023] Open
Abstract
The restoration of bowel continuity following Hartmann’s Procedure (HP) has been reported hitherto with high morbidity and mortality rates. No clear guidelines exist about timing in Hartmann’s Reversal (HR), the literature data being conflicting. We have sought to investigate the effect of the interval time between HP and HR in short- and long-term HR outcomes through a retrospective study based on consecutive patients undergoing HR between 2009 and 2017 in two regional hospitals in Italy. Demographic characteristics, comorbidities, intra- and post-operative data, as well as early complications, were recorded. Long-term data were collected on the surgical site occurrences of Incisional Ventral Hernia (IVH). One hundred and five patients were recruited for the study. Late HR, female gender, and long operating time were related to the highest incidence of peri-operative complications. Patients who developed IVH had undergone HR at significantly shorter times and had a higher Body Mass Index (BMI). The timing of HR seems to be an important variable linked to the onset of early and late post-operative complications. The patients submitted to early HR show a significantly lower complication rate but, at the same time, a higher rate of IVH incidence after restorative surgery. These data, in our opinion, reflect the need for planning, where possible, an early restoration of bowel continuity after HP.
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Affiliation(s)
- Marco Clementi
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
- Correspondence: ; Tel.: +39-33-5538-6225
| | - Renato Pietroletti
- Unit of Proctology and Colorectal Surgery, Val Vibrata-Sant’Omero Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (R.P.); (V.R.)
| | - Filippo Carletti
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
| | - Federico Sista
- Hepatic Pancreatic and Biliary Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy;
| | - Antonella Grasso
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
| | - Fabiana Fiasca
- Public Health Unit, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy;
| | - Sonia Cappelli
- Department of Surgery, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy;
| | - Andrea Balla
- General and Minimally Invasive Surgical Unit, San Paolo Hospital, 00053 Civitavecchia, Italy;
| | - Vinicio Rizza
- Unit of Proctology and Colorectal Surgery, Val Vibrata-Sant’Omero Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (R.P.); (V.R.)
| | - Andrea Ciarrocchi
- General Surgical Unit, Maria ss. dello Splendore Hospital, 67021 Giulianova, Italy;
| | - Stefano Guadagni
- General Surgical Unit, San Salvatore Hospital, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio, 67100 Coppito, Italy; (F.C.); (A.G.); (S.G.)
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Vernooij LM, van Klei WA, Moons KG, Takada T, van Waes J, Damen JA. The comparative and added prognostic value of biomarkers to the Revised Cardiac Risk Index for preoperative prediction of major adverse cardiac events and all-cause mortality in patients who undergo noncardiac surgery. Cochrane Database Syst Rev 2021; 12:CD013139. [PMID: 34931303 PMCID: PMC8689147 DOI: 10.1002/14651858.cd013139.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Revised Cardiac Risk Index (RCRI) is a widely acknowledged prognostic model to estimate preoperatively the probability of developing in-hospital major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the RCRI does not always make accurate predictions, so various studies have investigated whether biomarkers added to or compared with the RCRI could improve this. OBJECTIVES Primary: To investigate the added predictive value of biomarkers to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Secondary: To investigate the prognostic value of biomarkers compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Tertiary: To investigate the prognostic value of other prediction models compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. SEARCH METHODS We searched MEDLINE and Embase from 1 January 1999 (the year that the RCRI was published) until 25 June 2020. We also searched ISI Web of Science and SCOPUS for articles referring to the original RCRI development study in that period. SELECTION CRITERIA We included studies among adults who underwent noncardiac surgery, reporting on (external) validation of the RCRI and: - the addition of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of the RCRI to other models. Besides MACE, all other adverse outcomes were considered for inclusion. DATA COLLECTION AND ANALYSIS We developed a data extraction form based on the CHARMS checklist. Independent pairs of authors screened references, extracted data and assessed risk of bias and concerns regarding applicability according to PROBAST. For biomarkers and prediction models that were added or compared to the RCRI in ≥ 3 different articles, we described study characteristics and findings in further detail. We did not apply GRADE as no guidance is available for prognostic model reviews. MAIN RESULTS We screened 3960 records and included 107 articles. Over all objectives we rated risk of bias as high in ≥ 1 domain in 90% of included studies, particularly in the analysis domain. Statistical pooling or meta-analysis of reported results was impossible due to heterogeneity in various aspects: outcomes used, scale by which the biomarker was added/compared to the RCRI, prediction horizons and studied populations. Added predictive value of biomarkers to the RCRI Fifty-one studies reported on the added value of biomarkers to the RCRI. Sixty-nine different predictors were identified derived from blood (29%), imaging (33%) or other sources (38%). Addition of NT-proBNP, troponin or their combination improved the RCRI for predicting MACE (median delta c-statistics: 0.08, 0.14 and 0.12 for NT-proBNP, troponin and their combination, respectively). The median total net reclassification index (NRI) was 0.16 and 0.74 after addition of troponin and NT-proBNP to the RCRI, respectively. Calibration was not reported. To predict myocardial infarction, the median delta c-statistic when NT-proBNP was added to the RCRI was 0.09, and 0.06 for prediction of all-cause mortality and MACE combined. For BNP and copeptin, data were not sufficient to provide results on their added predictive performance, for any of the outcomes. Comparison of the predictive value of biomarkers to the RCRI Fifty-one studies assessed the predictive performance of biomarkers alone compared to the RCRI. We identified 60 unique predictors derived from blood (38%), imaging (30%) or other sources, such as the American Society of Anesthesiologists (ASA) classification (32%). Predictions were similar between the ASA classification and the RCRI for all studied outcomes. In studies different from those identified in objective 1, the median delta c-statistic was 0.15 and 0.12 in favour of BNP and NT-proBNP alone, respectively, when compared to the RCRI, for the prediction of MACE. For C-reactive protein, the predictive performance was similar to the RCRI. For other biomarkers and outcomes, data were insufficient to provide summary results. One study reported on calibration and none on reclassification. Comparison of the predictive value of other prognostic models to the RCRI Fifty-two articles compared the predictive ability of the RCRI to other prognostic models. Of these, 42% developed a new prediction model, 22% updated the RCRI, or another prediction model, and 37% validated an existing prediction model. None of the other prediction models showed better performance in predicting MACE than the RCRI. To predict myocardial infarction and cardiac arrest, ACS-NSQIP-MICA had a higher median delta c-statistic of 0.11 compared to the RCRI. To predict all-cause mortality, the median delta c-statistic was 0.15 higher in favour of ACS-NSQIP-SRS compared to the RCRI. Predictive performance was not better for CHADS2, CHA2DS2-VASc, R2CHADS2, Goldman index, Detsky index or VSG-CRI compared to the RCRI for any of the outcomes. Calibration and reclassification were reported in only one and three studies, respectively. AUTHORS' CONCLUSIONS Studies included in this review suggest that the predictive performance of the RCRI in predicting MACE is improved when NT-proBNP, troponin or their combination are added. Other studies indicate that BNP and NT-proBNP, when used in isolation, may even have a higher discriminative performance than the RCRI. There was insufficient evidence of a difference between the predictive accuracy of the RCRI and other prediction models in predicting MACE. However, ACS-NSQIP-MICA and ACS-NSQIP-SRS outperformed the RCRI in predicting myocardial infarction and cardiac arrest combined, and all-cause mortality, respectively. Nevertheless, the results cannot be interpreted as conclusive due to high risks of bias in a majority of papers, and pooling was impossible due to heterogeneity in outcomes, prediction horizons, biomarkers and studied populations. Future research on the added prognostic value of biomarkers to existing prediction models should focus on biomarkers with good predictive accuracy in other settings (e.g. diagnosis of myocardial infarction) and identification of biomarkers from omics data. They should be compared to novel biomarkers with so far insufficient evidence compared to established ones, including NT-proBNP or troponins. Adherence to recent guidance for prediction model studies (e.g. TRIPOD; PROBAST) and use of standardised outcome definitions in primary studies is highly recommended to facilitate systematic review and meta-analyses in the future.
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Affiliation(s)
- Lisette M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Anesthesiologist and R. Fraser Elliott Chair in Cardiac Anesthesia, Department of Anesthesia and Pain Management Toronto General Hospital, University Health Network and Professor, Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Karel Gm Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Judith van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Johanna Aag Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Reversal of Hartmann’s procedure – Is Single incision laparoscopic reversal the way forward? Indian J Surg 2021. [DOI: 10.1007/s12262-020-02673-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Lee DB, Shin S, Yang CS. Patient outcomes and prognostic factors associated with colonic perforation surgery: a retrospective study. Yeungnam Univ J Med 2021; 39:133-140. [PMID: 34710320 PMCID: PMC8913914 DOI: 10.12701/yujm.2021.01445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background Despite advances in surgery and intensive perioperative care, fecal peritonitis secondary to colonic perforation is associated with high rates of morbidity and mortality. This study was performed to review the outcomes of patients who underwent colonic perforation surgery and to evaluate the prognostic factors associated with mortality. Methods A retrospective analysis was performed on 224 consecutive patients who underwent emergency colonic perforation surgery between January 2008 and May 2019. We divided the patients into survivor and non-survivor groups and compared their surgical outcomes. Results The most common cause of colon perforation was malignancy in 54 patients (24.1%), followed by iatrogenic perforation in 41 (18.3%), stercoral perforation in 39 (17.4%), and diverticulitis in 37 (16.5%). The sigmoid colon (n=124, 55.4%) was the most common location of perforation, followed by the ascending colon, rectum, and cecum. Forty-five patients (20.1%) died within 1 month after surgery. Comparing the 179 survivors with the 45 non-survivors, the patient characteristics associated with mortality were advanced age, low systolic blood pressure, tachycardia, organ failure, high C-reactive protein, high creatinine, prolonged prothrombin time, and high lactate level. The presence of free or feculent fluid, diffuse peritonitis, and right-sided perforation were associated with mortality. In multivariate analysis, advanced age, organ failure, right-sided perforation, and diffuse peritonitis independently predicted mortality within 1 month after surgery. Conclusion Age and organ failure were prognostic factors for mortality associated with colon perforation. Furthermore, right-sided perforation and diffuse peritonitis demonstrated a significant association with patient mortality.
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Affiliation(s)
- Do-Bin Lee
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Seonhui Shin
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Chun-Seok Yang
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
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Lazzaron AR, Silveira I, Machado PS, Damin DC. The role of Hartmann's procedure in the elective management of rectal cancer: results of a Brazilian cohort study. Rev Col Bras Cir 2021; 48:e20212977. [PMID: 34378751 PMCID: PMC10683413 DOI: 10.1590/0100-6991e-20212977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/13/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND although preservation of bowel continuity is a major goal in rectal cancer surgery, a colorectal anastomosis may be considered an unacceptably high-risk procedure, particularly for patients with multiple comorbidities. We aimed to assess rates of surgical complications in rectal cancer patients according to the type of procedure they had undergone. MATERIALS AND METHODS this cohort included all rectal cancer patients undergoing elective resection at a referral academic hospital over 16 years. There were three study groups according to the type of performed operation: (1) rectal resection with anastomosis without defunctioning stoma (DS); (2) rectal resection with anastomosis and DS; and (3) Hartmann's procedure (HP). Postoperative complications and clinical outcomes were assessed. RESULTS four-hundred and two patients were studied. The 118 patients in group 3 were significantly older (>10 years), had higher Charlson Comorbidity Index scores, and more ASA class ≥3 than patients in the other two groups. Sixty-seven patients (16.7%) had Clavien-Dindo complications grade ≥ III, corresponding to an incidence of 11.8%, 20.9%, and 14.4% in groups 1, 2, and 3, respectively (p=0.10). Twenty-nine patients (7.2%) had major septic complications that required reoperation, with an incidence of 10.8%, 8.2% and 2.5% in groups 1, 2 and 3, respectively (p=0.048). Twenty-one percent of the group 2 patients did not undergo the stoma closure after a 24-month follow-up. CONCLUSION HP was associated with a lower incidence of reoperation due to intra-abdominal septic complications. This procedure remains an option for patients in whom serious surgical complications are anticipated.
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Affiliation(s)
- Anderson Rech Lazzaron
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
| | - Ingrid Silveira
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
| | - Pauline Simas Machado
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
| | - Daniel C Damin
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
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Giuliani G, Formisano G, Milone M, Salaj A, Salvischiani L, Bianchi PP. Full robotic Hartmann's reversal: technical aspects and preliminary experience. Colorectal Dis 2020; 22:1734-1740. [PMID: 32643856 DOI: 10.1111/codi.15249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 05/18/2020] [Accepted: 06/22/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- G Giuliani
- Department of Surgery, Unit of General and Minimally Invasive Surgery, Ospedale Misericordia, Grosseto, Italy
| | - G Formisano
- Department of Surgery, Unit of General and Minimally Invasive Surgery, Ospedale Misericordia, Grosseto, Italy
| | - M Milone
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - A Salaj
- Department of Surgery, Unit of General and Minimally Invasive Surgery, Ospedale Misericordia, Grosseto, Italy
| | - L Salvischiani
- Department of Surgery, Unit of General and Minimally Invasive Surgery, Ospedale Misericordia, Grosseto, Italy
| | - P P Bianchi
- Department of Surgery, Unit of General and Minimally Invasive Surgery, Ospedale Misericordia, Grosseto, Italy
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Kang JH, Kang BM, Yoon SN, Kim JY, Park JH, Oh BY, Kim JW. Analysis of factors affecting reversal of Hartmann's procedure and post-reversal complications. Sci Rep 2020; 10:16820. [PMID: 33033297 PMCID: PMC7545186 DOI: 10.1038/s41598-020-73791-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/10/2020] [Indexed: 02/02/2023] Open
Abstract
Although Hartmann’s procedure (HP) is commonly used as emergency treatment for colorectal disease, the reversal of HP (HR) is infrequently performed. The aims were to evaluate the rate of HR and determine the factors predictive of achieving HR. We retrospectively reviewed the medical records of patients who underwent HP between January 2007 and June 2019 at six Hallym University-affiliated hospitals. Multivariable analysis was performed to identify which factors were independently associated with HR. In the study period, 437 patients underwent HP, and 127 (29.0%) subsequently underwent HR. Of these, 46 (35.9%) patients experienced post-HR complications. In multivariable analysis, an interval between HP and HR of > 6 months was associated with the only lower rate of post-HR complications. Multivariate analysis showed that HR was less likely in patients aged > 70 years, those with American Society of Anesthesiologists (ASA) class III or IV, elective surgery, those experiencing more than two HP-related complications, and those with a malignancy (an indication for HP). One-third of the patients underwent HR. Age > 70 years, ASA class III or IV, elective surgery, more than two HP-related complications, and malignancy were associated with a non-HR rate.
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Affiliation(s)
- Jae Hyun Kang
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 40, Sukwoo-Dong, Hwaseong-si, 445-170, Gyeonggi-do, Republic of Korea
| | - Byung Mo Kang
- Department of Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon-si, 200-950, Republic of Korea
| | - Sang Nam Yoon
- Department of Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, 1, Shingil-ro, Yeongdeungpo-gu, Seoul, 150-950, Republic of Korea
| | - Jeong Yeon Kim
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 40, Sukwoo-Dong, Hwaseong-si, 445-170, Gyeonggi-do, Republic of Korea
| | - Jun Ho Park
- Department of Surgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 445 Gil-1-dong, Gangdong-gu, Seoul, 134-701, Republic of Korea
| | - Bo Young Oh
- Department of Surgery, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, 445-907, Republic of Korea
| | - Jong Wan Kim
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 40, Sukwoo-Dong, Hwaseong-si, 445-170, Gyeonggi-do, Republic of Korea.
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10
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Joo Y, Lee Y, Yoo T, Kim J, Park I, Gwak G, Cho H, Yang K, Kim K, Bae BN. Prognostic Factors and Management for Left Colonic Perforation: Can Hartmann's Procedure Be Preventable? Ann Coloproctol 2020; 36:178-185. [PMID: 32674547 PMCID: PMC7392568 DOI: 10.3393/ac.2019.11.14.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/14/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To identify factors significantly associated with the mortality of patients with left colonic perforation, and to compare the outcome of Hartmann's procedure (HP) and primary repair (PR) or primary anastomosis (PA) in patients with left colonic perforation without factors associated with mortality. METHODS This retrospective study included patients who underwent surgery for left colonic perforation from January 2009 to February 2018. Preoperative factors related to postoperative mortality, including vital signs, laboratory findings, and intraoperative findings, were analyzed by type of operation. The chi-square, Fisher exact, and Mann-Whitney U-tests were used to analyze the data. RESULTS Ninety-one patients were included (36 men, 55 women), and 15 (16.5%) died postoperatively. Prognostic factors were age, leukopenia, thrombocytopenia, bleeding tendency, acute kidney injury, hemodynamic instability, and the existence of feculent ascites. Leukopenia and longer operative time were independent risk factors for mortality. Seventy-nine patients did not have leukopenia and 30 of these patients who underwent PR without diversion were excluded from the subanalysis. HP was performed in 30 patients, and PR with diversion and PA with or without diversion were performed in 19. Compared to the other operative methods, HP had no advantage in reducing hospital mortality (P=0.458) and morbidity. CONCLUSION Leukopenia could be an objective prognostic factor for left colonic perforation. Although HP is the gold standard for septic left colonic perforation, it did not improve the hospital mortality of the patients without leukopenia. For such patients, PR or PA may be suggested as an alternative option for left colonic perforation.
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Affiliation(s)
- Yilseok Joo
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Yujin Lee
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Taeyoung Yoo
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Jungbin Kim
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Inseok Park
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Geumhee Gwak
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Hyunjin Cho
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Keunho Yang
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Kiwhan Kim
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Byung-Noe Bae
- Department of Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
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11
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Trans-stomal single-port laparoscopic Hartmann's reversal is an efficacious and efficient procedure: a case-controlled study. Tech Coloproctol 2020; 24:455-462. [PMID: 32200457 DOI: 10.1007/s10151-020-02166-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/07/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hartman's reversal remains challenging and is associated with a widely variable success rate. In a previous study, we reported that laparoscopy may lower the mortality and morbidity rates of the procedure. The aim of the current study was to assess the operative results of single-port laparoscopic Hartmann's reversal (SP-HR) as compared to the more standard, multi-port laparoscopic variant (MP-HR). METHODS We performed a retrospective, non-randomized, case-controlled study of 44 consecutive patients who had SP-HR (Group A) compared to 44 patients who had MP-HR (Group B). The study was conducted in a high-volume colorectal unit in a 1200-bed university affiliated hospital, The Poissy-Saint Germain Medical Complex, France. RESULTS Preoperative patients' characteristics (sex, body mass index, American Society of Anesthesiologists status, prior surgery, comorbidities, colonic disease) were comparable in both groups. The conversion rate was 13.6% and 4.5% in Group A and in Group B, respectively (p = 0.084) and consisted of placement of any additional ports. Conversion to open surgery did not occur in any patient in either group (p = 1). Mean operative time was shorter in Group A than in in Group B, (105 vs. 155 min; p = 0.0133). The mortality rate was 2.2% in Group A and 0% in Group B (p = 0.3145). The overall morbidity rate was 11.4% in Group A and 18.2% in Group B (p = 0.5344). The median length of hospital stay was significantly shorter in Group than in Group B (4.8 vs. 6.8 days; p = 0.0102). CONCLUSIONS The SP-HR technique was found to be safe and efficient. It compares favorably with MP-HR. Moreover, indirect cost savings could be induced by the reduction in the length of hospital stay.
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12
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Horesh N, Lessing Y, Rudnicki Y, Kent I, Kammar H, Ben-Yaacov A, Dreznik Y, Zbar AP, Tulchinsky H, Avital S, Mavor E, Kashtan H, Klausner JM, Gutman M, Zmora O, Wasserberg N. Timing of colostomy reversal following Hartmann's procedure for perforated diverticulitis. J Visc Surg 2020; 157:395-400. [PMID: 31954631 DOI: 10.1016/j.jviscsurg.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
AIM Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome. PATIENTS AND METHODS A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. RESULTS One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P=0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P=0.16), Major (Clavien-Dindo score of 3 or more) complications (P=0.19), Minor (Clavien Dindo 1-2) and no complications (P=0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P=0.4). CONCLUSION Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.
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Affiliation(s)
- N Horesh
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel.
| | - Y Lessing
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, 6423906 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - Y Rudnicki
- Department of Surgery B, Meir Medical Center, Kfar Saba, 4428164 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - I Kent
- Department of Surgery B, Meir Medical Center, Kfar Saba, 4428164 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - H Kammar
- Department of Surgery, Kaplan Medical Center, Rehovot, 7661041 Israel; The Hebrew University-Hadassah Medical School, Jerusalem 9112001 Israel
| | - A Ben-Yaacov
- Department of Surgery B, Rabin Medical Center-Beilinson Hospital, Petach Tikva 4941492 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - Y Dreznik
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - A P Zbar
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - H Tulchinsky
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, 6423906 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - S Avital
- Department of Surgery B, Meir Medical Center, Kfar Saba, 4428164 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - E Mavor
- Department of Surgery, Kaplan Medical Center, Rehovot, 7661041 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - H Kashtan
- Department of Surgery B, Rabin Medical Center-Beilinson Hospital, Petach Tikva 4941492 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - J M Klausner
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, 6423906 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - M Gutman
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - O Zmora
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - N Wasserberg
- Department of Surgery B, Rabin Medical Center-Beilinson Hospital, Petach Tikva 4941492 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
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13
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Conventional Versus Minimally Invasive Hartmann Takedown: A Meta-analysis of the Literature. World J Surg 2019; 43:1820-1828. [PMID: 30824963 DOI: 10.1007/s00268-019-04962-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
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.
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14
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Halim H, Askari A, Nunn R, Hollingshead J. Primary resection anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis. World J Emerg Surg 2019; 14:32. [PMID: 31338117 PMCID: PMC6625026 DOI: 10.1186/s13017-019-0251-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/25/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction Surgical management of Hinchey III and IV diverticulitis utilizes either Hartmann’s procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. The aim of this meta-analysis is to determine which of the two procedures has a more favorable outcome. Methods A systematic review of the existing literature was performed using the PRISMA guidelines. A meta-analysis was carried out using a Mantel-Haenszel, random effects model, and forest plots were generated. The Newcastle-Ottawa and Jadad scoring tools were used to assess the included studies. Results A total of 25 studies involving 3546 patients were included in this study. The overall mortality in the HP group was 10.8% across the observational studies and 9.4% in the randomized controlled trials (RCTs). The mortality rate in the PRA group was lower than that in the HP group, at 8.2% in the observational studies and 4.3% in the RCTs. A comparison of PRA vs HP demonstrated a 40% lower mortality rate in the PRA group than in the HP (OR 0.60, 95% CI 0.38–0.95, p = 0.03) when analyzing the observational studies. However, meta-analysis of the three RCTs did not demonstrate any difference in mortality, (OR 0.44 (95% CI 0.14–1.34, p = 0.15). Wound infection rates between the two groups were comparable (OR 0.75, 95% CI 0.20–2.78, p = 0.67). Conclusion Analysis of observational studies suggests that PRA may be associated with a lower overall mortality. There were no differences in wound infection rates. Based on the current evidence, both surgical strategies appear to be acceptable.
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Affiliation(s)
- Hosam Halim
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
| | - Alan Askari
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
| | - Rebecca Nunn
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
| | - James Hollingshead
- West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0BU UK
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15
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Curran T, Jensen CC, Kwaan MR, Madoff RD, Gaertner WB. Combined Hartmann's Reversal and Abdominal Wall Reconstruction: Defining Postoperative Morbidity. J Surg Res 2019; 240:136-144. [PMID: 30928771 DOI: 10.1016/j.jss.2019.02.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 01/31/2019] [Accepted: 02/22/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Ventral hernias are common after Hartmann's procedure and add complexity to Hartmann's reversal. Colostomy reversal and abdominal wall reconstruction may be performed in a staged or concurrent fashion, although data are limited as to which strategy is optimal. We aimed to define the complication profile of concurrent abdominal wall reconstruction with colostomy reversal as compared to either procedure alone. MATERIALS AND METHODS For this retrospective cohort study, we used the National Surgery Quality Improvement Project Database from 2012 to 2015. All patients undergoing elective colostomy reversal, abdominal wall reconstruction with component separation, or combined colostomy reversal with component separation were identified. Propensity score matching was used to compare outcomes among similar patients undergoing colostomy reversal alone versus combined procedure. Groups were evaluated for postoperative morbidity including reoperation. RESULTS We identified 11,689 patients; 6951 (64%) underwent component separation alone, 4563 (35%) colostomy reversal alone, and 175 (1%) combined component separation and colostomy reversal. The combined group, as compared to colostomy reversal alone, showed an increased overall complication rate (39% versus 25%; P < 0.01) and increased rate of reoperation (9% versus 5%; P = 0.03). Differences in overall complication rate (43% versus 24%; P < 0.01) and reoperation rate (9% versus 3%; P = 0.03) persisted on propensity matched analysis. CONCLUSIONS This analysis shows that in patients undergoing colostomy takedown, concurrent abdominal wall reconstruction is associated with increased morbidity including increased rate of reoperation, even when controlling for patient factors. Consideration may be given to a staged approach.
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Affiliation(s)
- Thomas Curran
- Department of Surgery, Section of Colon and Rectal Surgery, Medical University of South Carolina, Charleston, South Carolina.
| | - Christine C Jensen
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota; Colon and Rectal Surgery Associates, Minneapolis, Minnesota
| | - Mary R Kwaan
- Division of Colon and Rectal Surgery, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Robert D Madoff
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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16
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Securing the Appendiceal Stump During Emergency Appendicectomy: Options and Influencing Factors in Current UK Surgical Practice. Surg Laparosc Endosc Percutan Tech 2018; 28:209-213. [PMID: 29994869 DOI: 10.1097/sle.0000000000000558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The aim of our study was to identify the most commonly employed methods and influencing factors for securing the appendiceal stump in current NHS practice. METHODS An electronic survey of the Scottish Surgical Research Group network, invitation extended to the UK National Research Collaborative. RESULTS A total of 111 responses were received from 32 surgical centers; 28 (25.2%) consultants, 66 (59.5%) specialty trainees and 12 (10.8%) core trainees. Endoscopic ligatures were the preferred method in 96 (86.5%) with no difference in those with the greatest operative experience (P=0.79), 12 (10.8%) preferred polymeric clips. Ease of application (70.3%) and severity of stump inflammation (65.8%) had the greatest influence on the method chosen. Cost was a factor in 36.0%. CONCLUSIONS The preferred method for securing the appendiceal stump in UK practice is endoscopic ligatures regardless of operative experience. Factors with the greatest influence on the method employed include the ease of application and severity of stump inflammation. Our findings are likely to be representative of current NHS practice in Scotland.
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17
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Sotelo R, Medina LG, Husain FZ, Khazaeli M, Nikkhou K, Cacciamani GE, Landsberger H, Winter M, Hernandez A, Kaiser AM, Gill I. Robotic-assisted laparoscopic repair of rectovesical fistula after Hartmann's reversal procedure. J Robot Surg 2018; 13:339-343. [PMID: 30062640 DOI: 10.1007/s11701-018-0854-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/23/2018] [Indexed: 01/16/2023]
Abstract
The case is of a 59-year-old male with history of severe ischemic colitis following emergent intervention for a ruptured infrarenal aortic aneurysm who subsequently underwent left hemicolectomy, partial proctectomy, and Hartmann colostomy. The patient later underwent reversal of the Hartmann colostomy with diverting ileostomy. The surgery was complicated by a right ureteral and posterior bladder injury that resulted in a large rectovesical fistula involving the right hemitrigone and right ureteral orifice. An attempt to repair the rectovesical fistula at an outside facility was unsuccessful. Then, he underwent a robotic-assisted laparoscopic repair of rectovesical fistula, including simple prostatectomy, excision of rectovesical fistulous tract, rectal closure, peritoneal and omental flap interposition, bladder neck reconstruction, vesicourethral anastomosis and right ureteral reimplantation. There were no intraoperative or postoperative complications, and the patient was discharged at postoperative day 4; cystoscopy at 6-week follow-up demonstrated a successful closure of the fistula, at which time the ureteral stents were removed.
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Affiliation(s)
- R Sotelo
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - L G Medina
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - F Z Husain
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - M Khazaeli
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - K Nikkhou
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - G E Cacciamani
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - H Landsberger
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - M Winter
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A Hernandez
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A M Kaiser
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - I Gill
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Roig JV, Salvador A, Frasson M, García-Mayor L, Espinosa J, Roselló V, Hernandis J, Ruiz-Carmona MD, Uribe N, García-Calvo R, Bernal JC, García-Armengol J, García-Granero E. Reconstrucción de la continuidad digestiva tras cirugía de la diverticulitis aguda complicada. Estudio retrospectivo multicéntrico. Cir Esp 2018. [DOI: 10.1016/j.ciresp.2018.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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19
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Hallam S, Mothe BS, Tirumulaju RMR. Hartmann's procedure, reversal and rate of stoma-free survival. Ann R Coll Surg Engl 2018; 100:301-307. [PMID: 29484943 PMCID: PMC5958852 DOI: 10.1308/rcsann.2018.0006] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 12/24/2022] Open
Abstract
Background Hartmann's procedure is a commonly performed operation for complicated left colon diverticulitis or malignancy. The timing for reversal of Hartmann's is not well defined as it is technically challenging and carries a high complication rate. Methods This study is a retrospective audit of all patients who underwent Hartmann's procedure between 2008 and 2014. Reversal of Hartmann's rate, timing, American Society of Anesthesiologists grade, length of stay and complications (Clavien-Dindo) including 30-day mortality were recorded. Results Hartmann's procedure (n = 228) indications were complicated diverticular disease 44% (n = 100), malignancy 32% (n = 74) and other causes 24%, (n = 56). Reversal of Hartmann's rate was 47% (n = 108). Median age of patients was 58 years (range 21-84 years), American Society of Anesthesiologists grade 2 (range 1-4), length of stay was eight days (range 2-42 days). Median time to reversal of Hartmann's was 11 months (range 4-96 months). The overall complication rate from reversal of Hartmann's was 21%; 3.7% had a major complication of IIIa or above including three anastomotic leaks and one deep wound dehiscence. Failure of reversal and permanent stoma was less than 1% (n = 2). Thirty-day mortality following Hartmann's procedure was 7% (n = 15). Where Hartmann's procedure wass not reversed, for 30% (n = 31) this was the patient's choice and 70% (n = 74) were either high risk or unfit. Conclusions Hartmann's procedure is reversed less frequently than thought and consented for. Only 46% of Hartmann's procedures were stoma free at the end of the audit period. The anastomotic complication rate of 1% is also low for reversal of Hartmann's procedure in this study.
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Affiliation(s)
- S Hallam
- Department of Colorectal Surgery, Good Hope Hospital, Sutton Coldfield, Birmingham, UK
| | - BS Mothe
- Royal Liverpool Hospital, Liverpool, UK
| | - RMR Tirumulaju
- Department of Colorectal Surgery, Good Hope Hospital, Sutton Coldfield, Birmingham, UK
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20
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Reversal of Hartmann’s procedure: still a complicated operation. Tech Coloproctol 2017; 22:81-87. [DOI: 10.1007/s10151-017-1735-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 11/19/2017] [Indexed: 12/11/2022]
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21
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Horesh N, Lessing Y, Rudnicki Y, Kent I, Kammar H, Ben-Yaacov A, Dreznik Y, Tulchinsky H, Avital S, Mavor E, Wasserberg N, Kashtan H, Klausner JM, Gutman M, Zmora O. Considerations for Hartmann's reversal and Hartmann's reversal outcomes-a multicenter study. Int J Colorectal Dis 2017; 32:1577-1582. [PMID: 28879552 DOI: 10.1007/s00384-017-2897-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Hartmann's procedure is commonly practiced in emergent cases with the restoration of bowel continuity planned at a second stage. This study assessed the rate of restorations following Hartmann's procedure and evaluated factors affecting decision-making. METHODS Data on patient demographics, comorbidities, causes for Hartmann's procedure, reversal rate, and complications were collected in a multicenter retrospective cohort study of patients who underwent Hartmann's procedure in five medical centers. RESULTS Six hundred forty patients underwent Hartmann's procedure for diverticular disease (36.1%), obstructing malignancy (31.8%), benign obstruction (5%), and other reasons (23.1%). Overall, 260 (40.6%) patients underwent subsequent restoration of bowel continuity. One hundred twenty-one (46.5%) patients had post-reversal complications, with an average Clavien-Dindo score of 1.4 and a mortality rate of 0.77%. Decision to avoid reversal was mostly related to comorbidities (49.7%) and metastatic disease (21.6%). Factors associated with the decision to restore bowel continuity included male gender (P = 0.02), patient age (62.3 years in Hartmann's reversal patients vs 73.5 years in non-reversal patients; P < 0.0001), number of comorbidities (1.1 vs 1.58; P < 0.001), average Charlson score (1.93 vs 3.44; P < 0.001), and a neoplastic etiology (P < 0.0001). A sub-analysis excluding all patients who died in the 30 days following Hartmann's procedure showed similar factors associated with ostomy closure. CONCLUSION Many patients do not have restoration of bowel continuity after undergoing Hartmann's procedure. Hartmann's reversal is associated with a significant postoperative morbidity. Surgeons and patients should be aware of the possibility that the colostomy might become permanent.
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Affiliation(s)
- Nir Horesh
- Department of General Surgery and Transplantations B, Sheba Medical Center, Ramat Gan, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. .,Department of Surgery and Transplantations B, Sheba Medical Center, 52621, Tel-Hashomer, Israel.
| | - Yonatan Lessing
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Yaron Rudnicki
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | - Ilan Kent
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | - Haguy Kammar
- Department of Surgery, Kaplan Medical Center, Rehovot, Israel.,School of Medicine, Hadassah-Hebrew University, Jerusalem, Israel
| | - Almog Ben-Yaacov
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Rabin Medical Center, Petah Tikva, Israel
| | - Yael Dreznik
- Department of General Surgery and Transplantations B, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Tulchinsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Shmuel Avital
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | - Eli Mavor
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Nir Wasserberg
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Rabin Medical Center, Petah Tikva, Israel
| | - Hanoch Kashtan
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Rabin Medical Center, Petah Tikva, Israel
| | - Joseph M Klausner
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Mordechai Gutman
- Department of General Surgery and Transplantations B, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Zmora
- Department of General Surgery and Transplantations B, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
Temporary stomas are frequently used in the management of diverticulitis, colorectal cancer, and inflammatory bowel disease. These temporary stomas are used to try to mitigate septic complications from anastomotic leaks and to avoid the need for reoperation. Once acute medical conditions have improved and after the anastomosis has been proven to be healed, stomas can be reversed. Contrast enemas, digital rectal examination, and endoscopic evaluation are used to evaluate the anastomosis prior to reversal. Stoma reversal is associated with complications including anastomotic leak, postoperative ileus, bowel obstruction, enterocutaneous fistula, and, most commonly, surgical site infection. Furthermore, many stomas, which were intended to be temporary, may not be reversed due to postoperative complications, adjuvant therapy, or prohibitive comorbidities.
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Affiliation(s)
- Karen L Sherman
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
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Sartelli M, Griffiths EA, Nestori M. The challenge of post-operative peritonitis after gastrointestinal surgery. Updates Surg 2015; 67:373-81. [DOI: 10.1007/s13304-015-0324-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/11/2015] [Indexed: 12/13/2022]
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