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Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure?
Colorectal Dis 2009; 11(6):619-24CD

Abstract

OBJECTIVE

Hartmann's procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis.

METHOD

All 158 patients who had survived emergency surgery for acute perforated diverticulitis in five teaching hospitals in The Netherlands between 1995 and 2005 and underwent HP or PA with DI were retrospectively studied. Age, gender, ASA-classification, severity of primary disease, delay of stoma reversal, surgeon's experience, surgical procedure and type of anastomosis were analysed in relation to outcome after stoma reversal.

RESULTS

Of the 158 patients, 139 had undergone HP and 19 PA with DI. The reversal-rate was higher in patients with DI (14/19; 74%) compared to HP (63/139; 45%) (P = 0.027) Delay between primary surgery and stoma reversal was shorter after PA with DI compared with HP (3.9 vs 9.1 months; P < 0.001). Cumulative postreversal morbidity after HP was 44%. Early surgical complications occurred in 22 of 63 patients. Morbidity after DI reversal was 15% (P < 0.001). Three patients died after HP reversal, none died after DI reversal. Anastomotic leakage was observed in 10 patients after HP reversal. This was less frequently observed when the operation was performed by a specialist colorectal surgeon (10%vs 33%; P = 0.049) and when a stapled anastomosis was performed (4%vs 24%; P = 0.037).

CONCLUSIONS

Reversal of HP should only be performed by an experienced colorectal surgeon, preferably performing a stapled anastomosis, or probably not be performed at all, as it is accompanied by high postoperative morbidity and even mortality. It is important that these findings are taken in account for when performing primary emergency surgery for acute perforated diverticulitis.

Authors+Show Affiliations

Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands. j.vermeulen.1@erasmusmc.nlNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

18727727

Citation

Vermeulen, J, et al. "Restoration of Bowel Continuity After Surgery for Acute Perforated Diverticulitis: Should Hartmann's Procedure Be Considered a One-stage Procedure?" Colorectal Disease : the Official Journal of the Association of Coloproctology of Great Britain and Ireland, vol. 11, no. 6, 2009, pp. 619-24.
Vermeulen J, Coene PP, Van Hout NM, et al. Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure? Colorectal Dis. 2009;11(6):619-24.
Vermeulen, J., Coene, P. P., Van Hout, N. M., van der Harst, E., Gosselink, M. P., Mannaerts, G. H., ... Lange, J. F. (2009). Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure? Colorectal Disease : the Official Journal of the Association of Coloproctology of Great Britain and Ireland, 11(6), pp. 619-24. doi:10.1111/j.1463-1318.2008.01667.x.
Vermeulen J, et al. Restoration of Bowel Continuity After Surgery for Acute Perforated Diverticulitis: Should Hartmann's Procedure Be Considered a One-stage Procedure. Colorectal Dis. 2009;11(6):619-24. PubMed PMID: 18727727.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure? AU - Vermeulen,J, AU - Coene,P P L O, AU - Van Hout,N M, AU - van der Harst,E, AU - Gosselink,M P, AU - Mannaerts,G H H, AU - Weidema,W F, AU - Lange,J F, Y1 - 2008/08/21/ PY - 2008/8/30/pubmed PY - 2009/10/9/medline PY - 2008/8/30/entrez SP - 619 EP - 24 JF - Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland JO - Colorectal Dis VL - 11 IS - 6 N2 - OBJECTIVE: Hartmann's procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis. METHOD: All 158 patients who had survived emergency surgery for acute perforated diverticulitis in five teaching hospitals in The Netherlands between 1995 and 2005 and underwent HP or PA with DI were retrospectively studied. Age, gender, ASA-classification, severity of primary disease, delay of stoma reversal, surgeon's experience, surgical procedure and type of anastomosis were analysed in relation to outcome after stoma reversal. RESULTS: Of the 158 patients, 139 had undergone HP and 19 PA with DI. The reversal-rate was higher in patients with DI (14/19; 74%) compared to HP (63/139; 45%) (P = 0.027) Delay between primary surgery and stoma reversal was shorter after PA with DI compared with HP (3.9 vs 9.1 months; P < 0.001). Cumulative postreversal morbidity after HP was 44%. Early surgical complications occurred in 22 of 63 patients. Morbidity after DI reversal was 15% (P < 0.001). Three patients died after HP reversal, none died after DI reversal. Anastomotic leakage was observed in 10 patients after HP reversal. This was less frequently observed when the operation was performed by a specialist colorectal surgeon (10%vs 33%; P = 0.049) and when a stapled anastomosis was performed (4%vs 24%; P = 0.037). CONCLUSIONS: Reversal of HP should only be performed by an experienced colorectal surgeon, preferably performing a stapled anastomosis, or probably not be performed at all, as it is accompanied by high postoperative morbidity and even mortality. It is important that these findings are taken in account for when performing primary emergency surgery for acute perforated diverticulitis. SN - 1463-1318 UR - https://www.unboundmedicine.com/medline/citation/18727727/Restoration_of_bowel_continuity_after_surgery_for_acute_perforated_diverticulitis:_should_Hartmann's_procedure_be_considered_a_one_stage_procedure L2 - https://doi.org/10.1111/j.1463-1318.2008.01667.x DB - PRIME DP - Unbound Medicine ER -