Yosef Nasseri, Andy Liu, Eli Kasheri, Kimberly Oka, Jason Cohen, Joshua Ellenhorn, Roberto Bergamaschi, Moshe Barnajian
Hartmann’s procedure, colonic resection with an end colostomy and rectal closure, is commonly performed in patients with colonic obstruction and/or perforation. Hartmann’s reversal or colostomy closure is associated with significant technical difficulty and morbidity. High grade evidence studies related to Hartmann’s reversal are scarce. We sought to better gauge the complexity of outcome of Hartmann’s reversal by comparing it to left colectomy, a common elective operation with similar resultant left sided colonic anastomosis. As such, we examine the short-term outcomes of Hartmann’s reversal (HR) and left colectomy (LC) for cancer (LCC) and diverticulitis (LCD).
A retrospective review of a prospective database was performed. Preoperative risk factors, intraoperative events, and 30-day postoperative outcomes were compared. Student’s t-test and Pearson’s chi-squared test were used for continuous and categorical variables. The Mann-Whitney U test was used to analyze the differences in the distributions of complications on a continuous scale.
Between January 2014 and March 2021, 114 patients were included: 27 HR and 87 LC (41 LCC and 46 LCD). There were no significant differences between HR and LC in age (64.7 vs. 60.0, p=0.18), gender (48.1% vs. 52.9% male, p=.67), mean BMI (27.1 vs. 28.4, p=.38), mean robotic time (138.0 vs. 97.6, p=0.06), and mean estimated blood loss (97.0 vs. 87.9 mL, p=.62). There were significantly higher mean ASA scores (2.67 vs. 2.43, p=.04) and mean Charlson Comorbidity Index scores (5.07 vs. 3.32, p=.02) in HR than LC.
There were significantly more open cases in HR than LC (22.2% vs. 2.3%, p<.0005) and fewer robotic cases (44.4% vs. 69.0%, p=.02). Total operative time was significantly longer in HR than LC (258.7 vs. 209.6 mins, p=0.02). There were significantly more intraoperative complications in HR than LC (14.8% vs 2.3%, p=0.01). There were no significant differences between HR and LC in overall postoperative complications per patient (0.85 vs. 0.54, p=.27), rates of ileus/small bowel obstruction (SBO) (25.9% vs. 17.2%, p=.32), and superficial or deep wound infections (11.1% vs. 6.9%, p=.48). Although not significant, the mean length of stay (LOS) was longer (9.00 vs 6.89 days, p=.17), and the 30-day readmission rate was higher in HR than LC (14.8% vs. 5.7%, p=.13). Time to first flatus/bowel movement was significantly longer in HR than LC (3.59 vs. 2.51 days, p<.005).
We performed subgroup analyses for HR vs. LCC and HR vs. LCD. In the HR vs. LCC comparison, there were no significant differences in demographics or comorbidities. Mean robotic console time and total operative time were longer in HR than LCC. There were no significant differences in post-operative outcomes. Time to first flatus/bowel movement was significantly longer in HR than LCC.
In the HR vs. LCD comparison, there were no significant differences in demographics. HR patients had significantly higher mean total ASA scores, Charlson Comorbidity Index scores, more open cases, and longer total operative time. There were no significant differences in intraoperative complications or postoperative outcomes. Time to first flatus/bowel movement was significantly longer in HR than LCC.
Hartmann’s reversal is a more complex surgical procedure compared with left colectomy. Careful patient selection and surgical planning is important for favorable surgical outcomes.