title: Hartmann's procedure and laparoscopic reversal versus primary anastomosis and ileostomy closure for left colonic perforation.
abstract: OBJECTIVE
  Emergency surgical strategies for acute left-sided colonic perforation are evolving preferring primary anastomosis (PA) with ileostomy to Hartmann's procedure (HP) based on the morbidity and reversal rates. However, HP is still commonly performed. Hartmann's reversal is associated with considerable morbidity. It is of interest whether laparoscopic reversal results in a lower morbidity as retrospective data suggest. Here, we compared the combined morbidity rates for two surgical strategies: strategy A, HP followed by laparoscopic reversal, and strategy B, sigmoid resection with PA followed by ileostomy closure.
  
  
  METHODS
  Prospectively collected data of all consecutive patients undergoing HP for benign left-sided colonic perforation between 2010 and 2014 were retrospectively compared to data of patients undergoing PA. Groups were matched for age and Charlson comorbidity index. Additionally, patients were analyzed for American Society of Anesthesiologists score, body mass index, and peritonitis stage. End points were morbidity, operation time, reversal rate, time to reversal, and length of hospital stay.
  
  
  RESULTS
  The study included 32 patients for whom Hartmann's reversal was planned, along with 32 matched patients who underwent PA and diverting ileostomy. Median age was 75 and 72 years, Charlson score was 6 (4-9) and 6 (5-7), and patients classified by the American Society of Anesthesiologists (ASA) higher than III were 81 % in both groups. Combined major morbidity rates were 21 % for strategy A and 20 % for strategy B (p = 1.0). Combined comprehensive complication index was 16.4 ± 14.1 and 12.3 ± 19.1 (p = 0.08). HP reversal by laparoscopy was achieved in 71 %. The colostomy reversal rate was 75 % compared to ileostomy closure rate of 88 % (p = 0.34).
  
  
  CONCLUSIONS
  Laparoscopic Hartmann's reversal is achievable in a high proportion of patients. Strategy B tends to have lower overall morbidity; meanwhile, major morbidity seems to be similar. Yet, in critically ill patients and in the absence of expertise of the surgeon on call, HP followed by elective laparoscopic reversal represents a viable alternative.
authors.affiliation: Department of Surgery, Cantonal Hospital Baselland, Bruderholz, CH-4101, Bruderholz, Switzerland, daniel.steinemann@ksbl.ch.
authors.forename: D C
authors.initials: DC
authors.lastname: Steinemann
authors.forename: T
authors.initials: T
authors.lastname: Stierle
authors.forename: A
authors.initials: A
authors.lastname: Zerz
authors.forename: S H
authors.initials: SH
authors.lastname: Lamm
authors.forename: P
authors.initials: P
authors.lastname: Limani
authors.forename: A
authors.initials: A
authors.lastname: Nocito
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods*; D003082:Colectomy / Q000379:methods*; D003108:Colonic Diseases / Q000601:surgery*; D003125:Colostomy / Q000379:methods*; D015897:Comorbidity; D023381:Endpoint Determination; D005260:Female; D006801:Humans; D007081:Ileostomy / Q000379:methods*; D007416:Intestinal Perforation / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D011183:Postoperative Complications / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors