Nonreversal of Hartmann's Procedure for Diverticulitis: Derivation of a Scoring System to Predict Nonreversal

Abstract

More than 30% of patients undergoing a Hartmann's procedure for diverticulitis will not have their stoma reversed within a year. If this scoring system can be validated in an independent group of patients, it will be useful in allowing surgeons to strategize accurately and to counsel patients realistically.

Reversal of Hartmann's procedure: a single‐centre experience of 533 consecutive cases

“…Postoperative blood transfusion was another independent predictor of non-restoration of intestinal continuity in our series. A similar result was reported by Riansuwan et al [7] and Vaid et al [8]. We suggest that patients who did not require blood transfusion had fewer comorbidities or a benign pathology, or a technically easier procedure.…”

Who gets Hartmann's reversed in a regional centre?

“…3,5,14 Riansuwan et al studied patients undergoing a Hartmann's procedure for diverticulitis only and multivariate analysis demonstrated significance for POSSUM score, preoperative transfusion, pulmonary co-morbidity, pneumaturia, perforation and anticoagulation as independent predictors for reversal within 12 months. 7 While we found benign disease to be a significant factor on univariate analysis, it was not significant on multivariate analysis. We performed 96 Hartmann's for diverticulitis from a total of 707 admissions for diverticulitis (unpublished data) but subgroup analysis of this cohort did not produce any other significant findings.…”

“…7 There is some debate regarding the optimum timing for reversal of Hartmann's, with Pearce et al making a convincing argument for waiting 6 months suggesting that improvements in the patient's fitness, fatigability, nutrition, as well as less adhesions. 12 However Wigmore et al demonstrated an acceptable morbidity and mortality with 50% and 80% of patients reversed within 3 and 6 months respectively, thus restoring bowel continuity earlier.…”

“…2 There is interest in predicting those patients who are likely to undergo reversal in order to better counsel patients as well as decision making in regards to length of colonic dissection and stoma creation. 7 A study by Riansuwan et al has found the pre-operative factors of increased age, pre-operative transfusion, pulmonary co-morbidity, pre-operative classification grading developed by the American Society of Anaesthesiologists (ASA), anticoagulation and diverticular perforation as significant predictors, albeit in patients with diverticulitis only. 7 We retrospectively analysed our prospective colorectal database between 2002 and 2010 at Barwon Health, a regional centre in Victoria, to determine the reversal rates of Hartmann's procedures at our institution and factors influencing this decision.…”

Surgical Access Through the Stoma for Laparoscopic Reversal of Hartmann Procedures

“…[3][4][5] Once performed it is possible to restore intestinal continuity at a later date with a reversal of Hartmann procedure (RHP), but this is in itself associated with not inconsiderable perioperative risk. 2,7,8 If complication rates after RHP could potentially be reduced, then it is likely that the number of reversal procedures will increase and the percentage of patients left with a permanent stoma will decline as a result. A recent study that reviewed nationwide trends in the use of Hartmann procedure and RHP in the United Kingdom showed that only 23% of patients had their stoma reversed in a 4-year period after their primary operation.…”