Prevalence and outcomes of Hartmann's reversal following Hartmann's procedure in a regional center, a retrospective cohort study.

Abstract

Background: Hartmann's procedure (sigmoid resection with end colostomy) is a commonly performed emergency procedure for diseases of the sigmoid colon.

Aim: To determine the proportion of patients undergoing Hartmann's reversal (restoration of GI continuity) following Hartmann's procedure, the clinical and demographic factors associated with reversal, and the reasons for non-reversal.

Method: This is a single center, retrospective audit of patients undergoing Hartmann's procedure between June 2011 and May 2020. Age, sex, American Society of Anesthesiologists classification (ASA), indication for Hartmann's, surgical approach, specialty of responsible surgeon (General or Colorectal), 30-day reoperation, requirement for radiologically-guided drain, and reason for non-reversal were recorded. The association between these factors and reversal was determined with Fischer's exact test and logistic regression. Cumulative reversal proportions were calculated with the Kaplan-Meier method.

Results: Data was obtained for 114/117 patients, of whom 31% (35/114) underwent Hartmann's reversal. The median (IQR) time to reversal was 372 (188-500) days. Patients with restoration of GI continuity were younger (median 67 versus 73 years, P < 0.001) with fewer co-morbidities, (ASA ≤ 2 34% versus 9% P = 0.002). The estimated cumulative 24-month reversal incidence was 37%. Patients who had a Hartmann's procedure performed for diverticulitis had an increased odds of being reversed (OR 4.1 (95% CI 1.6, 10.5) P = 0.001); Hartmann's for malignancy was associated with decreased odds of reversal (OR 0.37 (95% CI 0.12, 1) P = 0.035).

Conclusion: Of patients who underwent Hartmann's procedure, the majority retained a permanent stoma. Older patients, those with high ASA, and those who underwent index procedures for malignancy had lower rates of reversal.