• Colostomy
• Complications
• Emergency
• Hartmann’s
• Ileostomy
• Jejunostomy
• Reversal
• Stoma

• Humans
• Retrospective Studies
• Male
• Female
• Middle Aged
• Surgical Stomas/adverse effects
• Aged
• Time Factors
• Adult
• Postoperative Complications
• Cohort Studies
• Reoperation/statistics & numerical data
• Reoperation/methods

• 2083546 Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA)

• Hartmann's procedure
• Hartmann's reversal

• Hartmann’s Procedure
• Hartmann’s Reversal
• early and late complications
• timing

• Anastomosis, Surgical/methods
• Colostomy/adverse effects
• Colostomy/methods
• Humans
• Postoperative Complications/etiology
• Rectum/surgery
• Retrospective Studies
• Treatment Outcome

• adspray
• case report
• reversal of hartmann procedure
• single incision laparoscopic surgery

• Adenocarcinoma
• Colonoscopy
• Constipation/etiology
• Humans
• Laparoscopy
• Male
• Melena/etiology
• Middle Aged
• Rectal Neoplasms/diagnostic imaging
• Rectal Neoplasms/surgery
• Rectum/diagnostic imaging
• Sigmoid Neoplasms/diagnostic imaging
• Sigmoid Neoplasms/surgery
• Surgical Stomas
• Tissue Adhesions/prevention & control
• Treatment Outcome

• hartmann operation
• hartmann reversal
• laparoscopy
• minimally invasive

• Adult
• Aged
• Aged, 80 and over
• Anastomosis, Surgical/methods
• Colon/surgery
• Colostomy/methods
• Female
• Humans
• Laparoscopy/methods
• Male
• Middle Aged
• Minimally Invasive Surgical Procedures
• Operative Time
• Perioperative Period
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Retrospective Studies
• Treatment Outcome

Introduction

Hartmann’s procedure is widely performed to fix colonic obstruction and perforation. It should ideally be followed by a reversal to restore bowel continuity. Reversal of Hartmann’s procedure was traditionally performed using an open technique. However, in recent days, the use of a laparoscopic approach has become increasingly popular. In our retrospective observational study, we aim to investigate the outcomes of laparoscopic versus open reversal of Hartmann’s procedure in a UK tertiary centre.

Methods

All patients who underwent reversal of their Hartmann’s procedure between January 2017 and December 2019 were included in the study. Data including demographics, days between primary operation and reversal, laparoscopic or open reversal, length of hospital stay following reversal procedure, 30-day readmission, mortality, and complication rate were collected. Statistical analysis was performed using t-test and chi-squared test.

Results

Forty-nine patients underwent reversal of Hartmann’s procedure from January 2017 to December 2019. The mean age of our cohort was 59.6 ± 13.2 years. There was no significant difference in baseline demographics of both groups, apart from the number of days between the primary operation and reversal procedure. There was also no statistical difference in length of stay, 30-day readmission, and mortality between laparoscopic and open reversal techniques. However, there was a higher incidence of wound complications in patients who underwent open reversal of Hartmann’s procedure.

Conclusion

The reversal of Hartmann’s procedure is a challenging operation. We found no significant difference between both open and laparoscopic approaches, but our study might be confounded by various factors including small sample size and selection bias. A larger, randomised study with greater statistical power is needed to confirm our findings.

• colostomy
• hartmann procedure
• laparoscopic reversal hartmann's procedure
• minimally invasive laparoscopy
• reversal of hartmann's procedure

The Hartmann procedure is currently recognized as a common, safe, and feasible surgical procedure. However, its reversal rate is low, and the optimal timing for Hartmann reversal surgery is controversial.

A 65-year-old man came to our hospital with a complaint of an intestinal fistula next to the stoma. The patient had undergone a Hartmann procedure 13 years prior. We performed colonoscopy, computed tomography, and other diagnostics before successfully reversing the stoma.

Although the optimal time for Hartmann procedure reversal is controversial, time may ultimately not be a factor in the success of reversal.

• Hartmann
• Hartmann's procedure
• Reversal
• Time
• Complications
• Case study
• Case report

• Damage control surgery
• Diverticular perforation
• Diverticular peritonitis

• Adult
• Anastomosis, Surgical
• Diverticulitis/surgery
• Diverticulitis, Colonic/complications
• Diverticulitis, Colonic/surgery
• Humans
• Intestinal Perforation/etiology
• Intestinal Perforation/surgery
• Laparoscopy
• Peritonitis/surgery
• Treatment Outcome

• Università degli Studi di Perugia

• musculoskeletal system
• digestive signs and symptoms
• colonic diseases
• colon

• Aged
• Colostomy/adverse effects
• Female
• Follow-Up Studies
• Hernia, Ventral/epidemiology
• Hernia, Ventral/surgery
• Herniorrhaphy/adverse effects
• Humans
• Incisional Hernia/epidemiology
• Incisional Hernia/surgery
• Male
• Middle Aged
• Postoperative Complications/epidemiology
• Retrospective Studies

Although Hartmann’s procedure (HP) is commonly used as emergency treatment for colorectal disease, the reversal of HP (HR) is infrequently performed. The aims were to evaluate the rate of HR and determine the factors predictive of achieving HR. We retrospectively reviewed the medical records of patients who underwent HP between January 2007 and June 2019 at six Hallym University-affiliated hospitals. Multivariable analysis was performed to identify which factors were independently associated with HR. In the study period, 437 patients underwent HP, and 127 (29.0%) subsequently underwent HR. Of these, 46 (35.9%) patients experienced post-HR complications. In multivariable analysis, an interval between HP and HR of > 6 months was associated with the only lower rate of post-HR complications. Multivariate analysis showed that HR was less likely in patients aged > 70 years, those with American Society of Anesthesiologists (ASA) class III or IV, elective surgery, those experiencing more than two HP-related complications, and those with a malignancy (an indication for HP). One-third of the patients underwent HR. Age > 70 years, ASA class III or IV, elective surgery, more than two HP-related complications, and malignancy were associated with a non-HR rate.

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

• Age Factors
• Colonoscopy
• Diagnostic Imaging
• Digestive System Surgical Procedures
• Disease Management
• Diverticulitis, Colonic/diagnosis
• Diverticulitis, Colonic/therapy
• Humans
• Risk Factors

• K23 DK118192 NIDDK NIH HHS

• Benign disease
• Colon
• Colorectal
• Colorectal cancer
• Hartmann
• Ostomy

• Colorectal Surgery
• Colostomy
• Hartmann's Reversal
• Post-operative complications

• Acute Disease
• Adult
• Aged
• Aged, 80 and over
• Colostomy/methods
• Diverticulitis, Colonic/surgery
• Female
• Humans
• Intestinal Perforation/surgery
• Length of Stay
• Male
• Middle Aged
• Outcome Assessment, Health Care
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Propensity Score
• ROC Curve
• Retrospective Studies
• Time Factors

• Anastomotic Leak/epidemiology
• Anastomotic Leak/etiology
• Laparoscopy/adverse effects
• Laparoscopy/methods
• Postoperative Hemorrhage/epidemiology
• Postoperative Hemorrhage/etiology
• Rectal Neoplasms/surgery
• Reoperation/statistics & numerical data
• Robotic Surgical Procedures/adverse effects
• Robotic Surgical Procedures/methods
• Wound Infection/epidemiology
• Wound Infection/etiology

• National Natural Science Foundation of China

• colorectal anastomotic leak
• colorectal surgery
• complications
• endoluminal negative pressure therapy
• endosponge treatment

• Hartmann's procedure
• Hartmann's reversal
• laparoscopy

• Adult
• Aged
• Aged, 80 and over
• Anastomosis, Surgical
• Colostomy/methods
• Female
• Humans
• Intestinal Diseases/surgery
• Laparoscopy/methods
• Male
• Middle Aged
• Reoperation
• Retrospective Studies

• Hartmann's procedure
• Hartmann's reversal
• Morbi-mortality

: The restoration of intestinal continuity is an elective procedure that is not free of complications; on the contrary, many studies have proven a high level of morbidity and mortality. It is multifactorial, and has factors inherent to the patients and to the surgical technique.

: To identify epidemiological features of patients that underwent ostomy closure analyzing the information about the surgical procedure and its arising complications.

: It was realized a retrospective analysis of medical records of patients who underwent ostomy closure over a period of seven years (2009-2015).

: A total of 39 patients were included, 53.8% male and 46.2% female, with mean age of 52.4 years. Hartmann´s procedure and ileostomy were the mainly reasons for restoration of intestinal continuity, representing together 87%. Termino-terminal anastomosis was performed in 71.8% of cases, by using mainly the manual technique. 25.6% developed complications, highlighting anastomotic leakage; there were three deaths (7.6%). The surgical time, the necessity of ICU and blood transfusion significantly related to post-operative complications.

: It was found that the majority of the patients were male, with an average age of 52 years. It was observed that the surgical time, the necessity of blood transfusion and ICU were factors significantly associated with complications.

• Hartmann's procedure
• Hartmann's reversal

• Colorectal surgery
• Colostomy
• Hartmann’s reversal
• Morbidity

• Colonic diverticulosis
• Colorectal neoplasms
• Colorectal surgery
• Colostomies

• Adult
• Aged
• Aged, 80 and over
• Anastomosis, Surgical/adverse effects
• Anastomosis, Surgical/methods
• Anastomosis, Surgical/statistics & numerical data
• Colectomy/adverse effects
• Colectomy/methods
• Colectomy/statistics & numerical data
• Colon, Sigmoid/surgery
• Colostomy/adverse effects
• Colostomy/methods
• Colostomy/statistics & numerical data
• Diverticulitis, Colonic/complications
• Diverticulitis, Colonic/mortality
• Diverticulitis, Colonic/surgery
• Female
• Humans
• Male
• Medical Audit/statistics & numerical data
• Middle Aged
• Operative Time
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Rectum/surgery
• Reoperation/adverse effects
• Reoperation/mortality
• Reoperation/statistics & numerical data
• Retrospective Studies
• Surgical Stomas/statistics & numerical data
• Treatment Outcome
• Young Adult

• acute abdomen
• diverticular peritonitis
• laparoscopic Hartmann’s procedure
• laparoscopic reversal

• Adult
• Aged
• Aged, 80 and over
• Cohort Studies
• Colectomy
• Colon, Sigmoid/surgery
• Colostomy
• Diverticulitis/surgery
• Female
• Humans
• Laparoscopy
• Length of Stay
• Male
• Middle Aged
• Peritonitis/surgery
• Postoperative Complications/epidemiology
• Recovery of Function
• Reoperation
• Treatment Outcome

• Bowel continuity
• Hartmann’s reversal
• Ostomy closure

• Adult
• Aged
• Anastomosis, Surgical/adverse effects
• Anastomosis, Surgical/methods
• Cohort Studies
• Colectomy/adverse effects
• Colectomy/methods
• Colon, Sigmoid/pathology
• Colon, Sigmoid/physiopathology
• Colon, Sigmoid/surgery
• Colonic Diseases/surgery
• Colostomy/adverse effects
• Colostomy/methods
• Female
• Humans
• Israel
• Male
• Middle Aged
• Postoperative Complications/diagnosis
• Postoperative Complications/etiology
• Postoperative Complications/surgery
• Plastic Surgery Procedures/adverse effects
• Plastic Surgery Procedures/methods
• Plastic Surgery Procedures/statistics & numerical data
• Rectum/surgery
• Reoperation/adverse effects
• Reoperation/methods
• Reoperation/statistics & numerical data
• Retrospective Studies
• Treatment Outcome

• Acute care surgery
• Acute diverticulitis
• Colorectal surgery
• Emergency surgery
• Hartmann resection
• Laparoscopic lavage
• Perforated diverticulitis

• Diverticulitis, Colonic/complications
• Diverticulitis, Colonic/surgery
• Evidence-Based Medicine/methods
• General Surgery/history
• History, 20th Century
• Humans
• Peritonitis/etiology
• Peritonitis/surgery
• Therapeutic Irrigation/history
• Therapeutic Irrigation/methods

• Hartmanns procedure
• anastomotic leak
• diverticular disease
• laparoscopic surgery
• reversal

• Age
• Co-morbidities
• Colorectal
• Hartmann's procedure
• Regional centre
• Stoma reversal
• Surgery

• Diverticulitis
• Hartmann’s procedure
• Hartmann’s reversal
• Robotic surgery

Aims: The present study aimed to compare the surgical outcomes of patients receiving laparoscopic reversal of Hartmann’s procedure (RHP) with those receiving open surgery.

Methods: Records of all patients with RHP performed in our unit (including laparoscopic and open surgery) between 2000 and 2012 were retrieved. Data were retrospectively reviewed and compared.

Results: Eighty-two RHPs were performed between 2000 and 2012. Thirty-five were performed with an open approach and 47 with a laparoscopic approach. Conversion rate was 28% in the laparoscopic group. There was no difference, between the two groups, in operation time or blood loss. The median length of stay was significantly shorter in the laparoscopic group (12 vs 14 days, P = 0.002) and fewer patients in the laparoscopic group had complications with post-operative paralytic ileus (2 vs 17%, P = 0.038). None of the patients in the laparoscopic group developed incisional hernia at the conclusion of follow-up, as opposed to five in the open group (0 vs 14%, P = 0.012).

Conclusion: Laparoscopic RHP is safe and feasible, with more favorable surgical outcomes, when compared with open surgery. Conversion rate is acceptable. It should be the technique of choice for patients undergoing RHP.

• Hartmann’s procedure
• laparoscopy
• reversal