Considerations for Hartmann's reversal and Hartmann's reversal outcomes-a multicenter study.

Abstract

Hartmann's procedure is commonly practiced in emergent cases with the restoration of bowel continuity planned at a second stage. This study assessed the rate of restorations following Hartmann's procedure and evaluated factors affecting decision-making. Data on patient demographics, comorbidities, causes for Hartmann's procedure, reversal rate, and complications were collected in a multicenter retrospective cohort study of patients who underwent Hartmann's procedure in five medical centers. Six hundred forty patients underwent Hartmann's procedure for diverticular disease (36.1%), obstructing malignancy (31.8%), benign obstruction (5%), and other reasons (23.1%). Overall, 260 (40.6%) patients underwent subsequent restoration of bowel continuity. One hundred twenty-one (46.5%) patients had post-reversal complications, with an average Clavien-Dindo score of 1.4 and a mortality rate of 0.77%. Decision to avoid reversal was mostly related to comorbidities (49.7%) and metastatic disease (21.6%). Factors associated with the decision to restore bowel continuity included male gender (P=0.02), patient age (62.3years in Hartmann's reversal patients vs 73.5years in non-reversal patients; P<0.0001), number of comorbidities (1.1 vs 1.58; P<0.001), average Charlson score (1.93 vs 3.44; P<0.001), and a neoplastic etiology (P<0.0001). A sub-analysis excluding all patients who died in the 30days following Hartmann's procedure showed similar factors associated with ostomy closure. Many patients do not have restoration of bowel continuity after undergoing Hartmann's procedure. Hartmann's reversal is associated with a significant postoperative morbidity. Surgeons and patients should be aware of the possibility that the colostomy might become permanent.