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Hartmann’s procedure and laparoscopic reversal versus primary anastomosis and ileostomy closure for left colonic perforation

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Abstract

Purpose

Emergency surgical strategies for acute left-sided colonic perforation are evolving preferring primary anastomosis (PA) with ileostomy to Hartmann’s procedure (HP) based on the morbidity and reversal rates. However, HP is still commonly performed. Hartmann’s reversal is associated with considerable morbidity. It is of interest whether laparoscopic reversal results in a lower morbidity as retrospective data suggest. Here, we compared the combined morbidity rates for two surgical strategies: strategy A, HP followed by laparoscopic reversal, and strategy B, sigmoid resection with PA followed by ileostomy closure.

Methods

Prospectively collected data of all consecutive patients undergoing HP for benign left-sided colonic perforation between 2010 and 2014 were retrospectively compared to data of patients undergoing PA. Groups were matched for age and Charlson comorbidity index. Additionally, patients were analyzed for American Society of Anesthesiologists score, body mass index, and peritonitis stage. End points were morbidity, operation time, reversal rate, time to reversal, and length of hospital stay.

Results

The study included 32 patients for whom Hartmann’s reversal was planned, along with 32 matched patients who underwent PA and diverting ileostomy. Median age was 75 and 72 years, Charlson score was 6 (4–9) and 6 (5–7), and patients classified by the American Society of Anesthesiologists (ASA) higher than III were 81 % in both groups. Combined major morbidity rates were 21 % for strategy A and 20 % for strategy B (p = 1.0). Combined comprehensive complication index was 16.4 ± 14.1 and 12.3 ± 19.1 (p = 0.08). HP reversal by laparoscopy was achieved in 71 %. The colostomy reversal rate was 75 % compared to ileostomy closure rate of 88 % (p = 0.34).

Conclusions

Laparoscopic Hartmann’s reversal is achievable in a high proportion of patients. Strategy B tends to have lower overall morbidity; meanwhile, major morbidity seems to be similar. Yet, in critically ill patients and in the absence of expertise of the surgeon on call, HP followed by elective laparoscopic reversal represents a viable alternative.

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Conflicts of interest

None.

Authors’ contributions

DCS, TS, AZ, and AN were responsible for the study conception and design. DCS, TS, PL, and SHL contributed to the acquisition of the data, analysis and interpretation of the data, and drafting of the manuscript. AZ and AN critically revised the manuscript. DCS and TS contributed equally to the study.

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    Authors and Affiliations

    1. Department of Surgery, Cantonal Hospital Baselland, Bruderholz, CH-4101, Bruderholz, Switzerland

      D. C. Steinemann, T. Stierle, A. Zerz & S. H. Lamm

    2. Division of Visceral and Transplantation Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091, Zürich, Switzerland

      P. Limani & A. Nocito

    3. Department of Surgery, Cantonal Hospital Baden, CH-5404, Baden, Switzerland

      A. Nocito

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    1. D. C. Steinemann
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    2. T. Stierle
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    Correspondence to D. C. Steinemann.

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    D. C. Steinemann and T. Stierle contributed equally to this work.

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    Steinemann, D.C., Stierle, T., Zerz, A. et al. Hartmann’s procedure and laparoscopic reversal versus primary anastomosis and ileostomy closure for left colonic perforation. Langenbecks Arch Surg 400, 609–616 (2015). https://doi.org/10.1007/s00423-015-1319-6

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    • DOI: https://doi.org/10.1007/s00423-015-1319-6

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