Effects of Laparoscopic Hartmann Reversal on Short-term Operative Outcomes Among Vietnamese Patients

Background The reestablishment of continuity after Hartmann operation is considered a major surgical procedure with high morbidity and mortality. The optimal interval time between the Hartman procedure and reversal is controversial. Our study aimed to evaluate the effectiveness of laparoscopic Hartmann reversal and to determine the optimal timing of operation. Methods All patients who underwent laparoscopic Hartmann reversal from 2008 to 2019 (11 years) at the University Medical Center (UMC) in Ho Chi Minh City were recruited and divided into 2 groups according to the interval time (≤ 4 or > 4 months). The short-term operative outcomes of these groups were compared. Results There were 66 patients who underwent laparoscopic Hartmann reversal (mean age: 63.2 years old); ∼ 77% of them had colorectal cancer, and 17% had complicated diverticular disease. The mortality rate, anastomotic leakage rate, and overall complication rate were 0%, 1.5%, and 13.2%, respectively. Early operation was performed in 36 patients, and late reversal in 28 patients. There was no difference in mortality, anastomotic leakage, operative complications, and hospital stay between the two groups. Conclusion Laparoscopic Hartmann reversal was effective with acceptable morbidity and mortality at the UMC. There was no observed impact of the interval time between the Hartmann procedure and laparoscopic Hartmann reversal on the short-term operative outcomes.

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.

Synchronous Hartmann reversal and incisional hernia repair is associated with higher complication rate compared to a staged procedure

Post operative ventral hernias are common following Hartmann's procedure. There is a debate whether hernia repair is safe when performed concomitantly with colostomy closure. In this study we aimed to evaluate the outcomes of synchronous Hartmann reversal (HR) with a hernia repair, compared to a staged procedure. A retrospective multi-center study was conducted, including all patients who underwent Hartmann’s procedure from January 2004 to July 2017 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. Two hundred and seventy-four patients underwent colostomy reversal following Hartmann's procedure. In 107 patients (39%) a concomitant ventral hernia was reported during the Hartmann's reversal. Out of this cohort, 62 patients (58%) underwent hernia repair during follow-up. Thirty two patients (52%) underwent a synchronous hernia repair and 30 patients (48%) underwent hernia repair as a separate procedure. Post operative complication rate was significantly higher in the colostomy reversal with synchronous hernia repair group when compared to HR alone group (53% vs. 20%; p < 0.01; OR 4.5). In addition, severe complication rate (Clavien–Dindo score ≥ 3) was higher in the synchronous hernia repair group (25% vs. 7%). A tendency for higher hernia recurrence rate was noted in the synchronous group (56% vs. 40%). Median follow up time was 2.53 years (range 1–13.3 years). Synchronous colostomy closure and ventral hernia repair following Hartmann's procedure carries a significant risk for post operative complications, indicating that a staged procedure might be preferable.

THE STOMA REVERSAL AFTER HARTMANN PROCEDURE IN PATIENTS WITH COLORECTAL CANCER OPERATED IN EMERGENCY

The Hartmann procedure still has an important place in the surgical therapy of complicated colorectal cancers. The morbidity rate can be very high and many patients never undergo the stoma reversal. We conducted a retrospective study on 431 patients with colorectal cancer operated in the second clinic of General Surgery of the Clinical Emergency County Hospital Galati between 2008-2017. 42,53 % of the patients with Hartmann operation had a stoma reversal after a medium period of 5,7 months. The 5-years survival rate in patients with stoma reversal was 4,9 %. The reversal rate in our study is similar to those found in the literature in recent studies, that report percentages of 23,3 %-55,17 %. In our study, the medium period between the emergency Hartmann procedure and the reversal of the stoma was 5,7 months, which is also similar to the data in the literature. We found a 5-years survival rate of 4,9 % in patients with Hartmann reversal, much lower than others’ results. Many stomas initially intended to be temporary, may not be reversed. It is important to optimize the timing of stoma closure. A period of approximately 6 months between the initial operation and the reversal seem to be adequate.

Hartmann’s rectal stump revisited preoperative evaluation prior to reversal

Hartmann’s procedure is the gold standard surgical intervention in a variety of emergencies. Hartmann's Reversal is a complex procedure and has high rates of intra-operative and post-operative complications. There are no clear guidelines or recommendations for pre-operative evaluation of the remnant colorectal pouch prior to restoration of intestinal continuity. We present two patients who underwent Hartmann reversal. In both cases, during pre-operative endoscopic evaluation of the Hartmann colorectal pouch, a stricture was incorrectly thought to be the pouch’s blind end and the anastomosis was formed proximal to that stricture. In case 1, a partial obstruction developed that was successfully treated with endoscopic balloon dilatation. In case 2, a complete obstruction occurred, requiring emergent re-operation with formation of a bypass around the stricture. Surgeons and gastroenterologists should be aware of this diagnostic pitfall, and consider pre-operative evaluation that includes both endoscopic and radiologic evaluation in patients being considered for reversal.