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Surgical considerations in the Hartmann's procedure
1Department of Surgery, Tan Tock Seng Hospital, Singapore.
Insights
This study on Hartmann
Area of Science:
- Colorectal Surgery
- Surgical Outcomes
- Patient Management
Background:
- Hartmann's procedure and Hartmann-type operations are common for colorectal emergencies.
- Rectal stump management and colorectal anastomosis are critical aspects influencing patient outcomes.
- Understanding complications and functional recovery is essential for surgical decision-making.
Purpose of the Study:
- To evaluate surgical outcomes of Hartmann's and Hartmann-type procedures.
- To analyze problems associated with rectal stump remnants and colorectal anastomosis.
- To compare patient outcomes based on surgical approach and stump type.
Main Methods:
- A retrospective analysis of 105 consecutive patients (mean age 66).
- Evaluation of surgical morbidity and mortality in relation to colorectal pathology and rectal stump type.
- Review of surviving patients regarding second-stage anastomosis reversal.
Main Results:
- Obstructed/perforated malignancies (65%) and complicated diverticular disease (16%) were primary indications.
- Peri-operative mortality and morbidity rates were 11.4% and 24%, respectively.
- Stump blowout occurred in 3% of intraperitoneal and 25% of extraperitoneal stumps; local recurrence and diversion proctitis were also noted.
Conclusions:
- While extraperitoneal stumps have an anatomical advantage, stump blowout rates are not significantly different between intraperitoneal and extraperitoneal stumps.
- Functional rectal recovery is significantly better for benign diseases (68%) compared to malignant conditions (32%).
- Timing of second-stage re-anastomosis closure is not critical if the septic episode has resolved.
Background:
The present study examines the surgical outcome of the Hartmann's and Hartmann-type procedures, the problems with the remnant rectal stump and the issues related to the colorectal anastomosis as well as the differences in patient outcome.
Methods:
One hundred and five consecutive patients (mean age 66) were evaluated. Surgical morbidity and mortality were analysed with regard to the colorectal pathology and the type of rectal stump remnant. The surviving patients were reviewed according to whether they had second-stage anastomosis.
Results:
In 65% of cases there were obstructed or perforated malignancies and in 16% complicated diverticular diseases. The peri-operative mortality and morbidity were 11.4% and 24%, respectively. Seventy-two patients had intraperitoneal rectal stumps and stump blowout occurred in three intraperitoneal and one extraperitoneal remnant stumps. Local tumour recurrence (four) and diversion proctitis (three) were diagnosed in the rectal stump among asymptomatic patients. When the second-stage reversal of Hartmann's procedure was considered (35 cases), twice as many were performed for diverticular and other benign conditions as for tumour cases.
Conclusions:
Although there is a good anatomical basis for advocating extraperitoneal rather than intraperitoneal stumps, in practice the stump blowout rate is not statistically significant (3% vs 4.1%). However, the chances of regaining normal rectal function are much better for benign disease (68% vs 32%--Fisher's exact test, P = 0.004). Complications from second-stage re-anastomosis are not determined by timing of the closure, provided the septic episode has subsided.