Complications of Hartmann takedown in a decade of preferred primary anastomosis.
BACKGROUND
Primary anastomosis with or without proximal diversion is increasingly applied to patients requiring urgent colectomy for complicated disease of the left colon. As such, the Hartmann procedure is now often restricted to patients who are unstable or otherwise poor candidates for primary anastomosis. We sought to define the complication rate of Hartmann takedown in a contemporary setting.


METHODS
Consecutive adult patients undergoing colostomy takedown with colorectal anastomosis at an academic teaching hospital from January 1, 2001, to December 31, 2010, were included in the study. Complications were captured prospectively by a single trained nurse practitioner. Demographics, body mass index, American Society of Anesthesiologists (ASA) classification, interval between Hartmann procedure and subsequent takedown, surgical indication, duration of surgery, surgeon volume and specialty, length of stay, and complications were recorded.


RESULTS
One hundred three patients underwent Hartmann reversal by 16 different surgeons; 7 of these surgeons performed 4 or fewer procedures during the study period. During the same time period, 334 patients underwent a Hartmann procedure at our institution. Seventy-seven of 104 patients (74%) had their index resection for complicated diverticulitis; an anastomotic leak was the second most common indication. The median age was 61 years (range 31 to 84 years), and the interval from Hartmann procedure to reversal ranged from 87 to 1,489 days. Only 8 patients (7.7%) had an ASA of 1. Thirty patients (29.1%) had postoperative complications, and 12 (11%) had 2 or more complications. There were 2 deaths and 4 anastomotic leaks, and 7 patients had inadvertent enterotomies. Only ASA status predicted postoperative complications (P = .01).


CONCLUSIONS
Hartmann takedown is a morbid operation with a substantial risk of inadvertent enterotomy and serious complications. Excluding cases referred from elsewhere, there were more than 5-fold the number of Hartmann procedures than takedowns performed during the study period. This suggests that Hartmann procedures are typically restricted to patients who are also poor candidates for takedown and that their colostomy is likely to be permanent.
Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA.
Ari
A
Garber
Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA. Electronic address: neil.hyman@uvm.edu.
Neil
N
Hyman
Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA.
Turner
T
Osler
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D057868:Anastomotic Leak / Q000453:epidemiology / Q000209:etiology*; D001145:Arrhythmias, Cardiac / Q000453:epidemiology / Q000209:etiology; D001803:Blood Transfusion / Q000706:statistics & numerical data; D015992:Body Mass Index; D003082:Colectomy / Q000379:methods* / Q000401:mortality; D003106:Colon / Q000601:surgery*; D003108:Colonic Diseases / Q000601:surgery*; D003125:Colostomy; D016208:Databases, Factual; D013505:Digestive System Surgical Procedures / Q000009:adverse effects*; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007422:Intestines / Q000293:injuries*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D010538:Peritonitis / Q000209:etiology; D014481:United States
Anastomosis; Colostomy; Diverticulitis; Surgery