Surgical and clinical predictors of successful Hartmann reversal procedure after perforated diverticulitis

The feasibility of Hartmann reversal after an Hartmann procedure for perforated diverticulitis has long been debated. This retrospective multicentered study assessed the outcomes of Hartmann reversal and the risk factors of its failure.

Patients who underwent Hartmann reversal for perforated diverticulitis in the last 5 years with at least 12 months of postoperative follow-up within the Diverticular Disease Registry (ClinicalTrials.gov NCT04907383) were recruited. A successful Hartmann reversal was defined as a minimally invasive surgery without conversion, without protective ileostomy, and without major surgical complications defined as Clavien-Dindo ≥ 3.

242 patients were enrolled. One-hundred-thirty-three (70%) were males, the mean age was 59.5 (± 11.6) years, the mean Body Mass Index was 26 (± 3.5) kg/m². Abdominal abscesses were present in 8.4% (n = 16) of cases, while 25.3% (n = 48) had localized peritonitis, and 66.3% (n = 126) had diffuse peritonitis. Laparoscopic surgery was performed in 63.7% (n = 121) of cases, with a conversion rate of 19% (n = 23). Major complications were seen in 6.7% (n = 16) of cases. One-hundred-ninety (78.6%) patients underwent Hartmann reversal with a median time from Hartmann procedure to Hartmann reversal of 243 (178.5-327) days. Of these, 122 (64.2%) had successful Hartmann reversal. The risk factors for an unsuccessful Hartmann reversal at the multivariate Cox regression analysis were a high Body Mass Index at Hartmann reversal, an open Hartmann procedure, splenic flexure mobilization during Hartmann procedure, and superior rectal artery ligation at Hartmann procedure.

Hartmann reversal after Hartmann procedure for perforated diverticulitis was performed in 78.6% of patients, with a success rate of 64.2%. Patients should be advised to lose weight before an Hartmann reversal. Open Hartmann procedure, splenic flexure mobilization, and superior rectal artery ligation during the index operation were associated with lower rates of successful reversal.