Prevalence and outcomes of Hartmann’s reversal following Hartmann’s procedure in a regional center, a retrospective cohort study.

Prevalence and outcomes of Hartmann’s reversal following Hartmann’s procedure in a regional center, a retrospective cohort study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence and outcomes of Hartmann’s reversal following Hartmann’s procedure in a regional center, a retrospective cohort study. William Fleischl, Kari Clifford, Deborah Wright This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4800010/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Dec, 2024 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 19 You are reading this latest preprint version Abstract Background Hartmann’s procedure (sigmoid resection with end colostomy) is a commonly performed emergency procedure for diseases of the sigmoid colon. Aim To determine the proportion of patients undergoing Hartmann’s reversal (restoration of GI continuity) following Hartmann’s procedure, the clinical and demographic factors associated with reversal, and the reasons for non-reversal. Method This is a single center, retrospective audit of patients undergoing Hartmann’s procedure between June 2011 and May 2020. Age, sex, American Society of Anesthesiologists classification (ASA), indication for Hartmann’s, surgical approach, specialty of responsible surgeon (General or Colorectal), 30-day reoperation, requirement for radiologically-guided drain, and reason for non-reversal were recorded. The association between these factors and reversal was determined with Fischer’s exact test and logistic regression. Cumulative reversal proportions were calculated with the Kaplan-Meier method. Results Data was obtained for 114/117 patients, of whom 31% (35/114) underwent Hartmann’s reversal. The median (IQR) time to reversal was 372 (188-500) days). Patients with restoration of GI continuity were younger (median 67 versus 73 years, P <0.001) with fewer co-morbidities, (ASA £2 34% versus 9% P =0.002). The estimated cumulative 24-month reversal incidence was 37%. Patients who had a Hartmann’s procedure performed for diverticulitis had an increased odds of being reversed (OR 4.1 (95% CI 1.6, 10.5) P =0.001); Hartmann’s for malignancy was associated with decreased odds of reversal (OR 0.37 (95% CI 0.12, 1) P =0.035). Conclusion Of patients who underwent Hartmann’s procedure, the majority retained a permanent stoma. Older patients, those with high ASA, and those who underwent index procedures for malignancy had lower rates of reversal. Hartmann’s procedure Hartmann’s reversal postoperative outcomes Figures Figure 1 Introduction The eponymous Hartmann’s procedure, a sigmoid colectomy with formation of an end-colostomy, was described by French surgeon Henri Albert Hartmann in 1921 and remains a common general surgical procedure [ 1 ]. Hartmann’s procedure is often performed acutely for colonic obstruction. It is performed electively when patient co-morbidity or likely poor functional outcome preclude anastomosis. For patients with peritonitis, there is an associated mortality risk of up to 30% [ 2 ]. Restoration of gastrointestinal (GI) continuity by rejoining the colon and rectum, Hartmann’s reversal, is currently performed for 35% − 47% of patients, with the remainder living with a permanent colostomy [ 3 – 6 ]. Factors influencing the decision whether to reverse include risk of complications (21–45%), risk of mortality (0.5–7.5%), the presence of metastatic disease, anticipated poor functional outcome, and patient preference [ 3 , 4 ]. Once this decision has been made, reversal may be delayed by non-clinical factors, such as lack of theatre access. End colostomy is associated with physical and psychological distress, including rectal discharge, inability to control gas, difficulties returning to work, decreased sexual activity, and difficulties in activities of travel and leisure [ 7 ]. Salem et al found time to restoration of GI continuity beyond 12 months was associated with an increased peri-operative morbidity and mortality [ 8 ]. Timely Hartmann’s reversal is important both for mental and physical wellness. Colostomies are often described to patients as “temporary” or “reversible”. There are currently no published studies in Aotearoa New Zealand or Australia on the rate of reversal, and how patients’ clinical and demographic factors influence this. Understanding these factors will help clinicians counsel patients on the likelihood of subsequent reversal. This study investigates Hartmann’s reversal following the Hartmann’s procedure at a single centre in Aotearoa New Zealand, the clinical and demographic factors associated with Hartmann’s reversal, and the reasons for non-reversal. Methods This is a single-center, retrospective, observational cohort study conducted at Dunedin Hospital, a 400-bed tertiary referral hospital located in Aotearoa New Zealand. Consecutive patients who underwent a Hartmann’s procedure between 1 June 2011 and 31 May 2020 were identified by searching procedure codes stored in the Otago Clinical Audit [ 9 ]. Data extraction was performed in June 2022 to allow a minimum of 2 years follow-up. Patients less than 18 years old or with incomplete follow-up data were excluded. Patient and procedure details were retrieved from the contemporaneous clinical record. Patient factors including age, sex, ethnicity, and ASA were recorded. Indication for Hartmann’s procedure was determined and grouped into the following categories: diverticulitis, colonic malignancy, stercoral perforation, anastomotic leak, colonic fistula, and sigmoid volvulus. “Diverticulitis” included perforated and non-perforated diverticulitis. Surgical approach, responsible surgeon, metastatic disease at time of initial surgery, reoperation within 30 days of index surgery, and radiologically-guided insertion of peritoneal drain within three months of index surgery was also collected. Time to Hartmann’s reversal, decision not to attempt reversal, or death was recorded. Reasons not to attempt reversal included excess peri-operative risk, patient choice, the patient being too unwell to attend follow-up, or anticipated poor function. Patients on a waitlist for reversal were also recorded. The primary outcomes were proportion of patients who underwent Hartmann’s reversal, and the time to Hartmann’s reversal. The secondary outcomes were demographic and clinical factors associated with Hartmann’s reversal. The Shapiro-Wilk test was used to assess the distribution of the data. Univariable general linear models were used to investigate the association of the demographic factors with Hartmann’s reversal. Results with a P < 0.05 in two-tailed testing were considered statistically significant. The cumulative proportion of patients undergoing Hartmann’s reversal was calculated from the date of surgical procedure until reversal and estimated by the Kaplan-Meier method. Patients were censored on the date of last clinical contact, death, or if there was a decision documented to not reverse. Statistical analysis was performed in R (V4.3.0) [ 10 ]. Approval was obtained from the University of Otago Humans Research Ethics Committee (HD22/088) prior to data extraction and analysis. There are no conflicts of interest. Results Between 1 June 2011 and 31 May 2020, 117 patients underwent Hartmann’s procedure at Dunedin Hospital. Three patients had incomplete data and thus were excluded from the analysis. The median (IQR) age was 71.5 (65–80) years; 4.4% (5/114) were Māori and 54% (61/114) were female. The median (IQR) follow-up time was 403 (73-1539) days. Within the study period, 35/114 patients (31%) underwent Hartmann’s reversal after having the Hartmann’s procedure. The median (IQR) time to reversal was 372 (188–500) days. After excluding patients where Hartmann’s reversal was not considered (increased peri-operative risk, anticipated poor function, patient too unwell to attend follow up, or death during index admission) the proportion of patient who underwent Hartmann’s within the study period was 52% (35/67). There was no difference in the reversal proportion between male and female patients. Patients who were reversed were younger (median 67 versus 73 years, P = 0.001). Each extra year of age was associated with a 1% decrease in the odds of reversal. A higher proportion of patients with ASA scores ≤2 was reversed compared with patients with ASA scores ≥ 3 (34% vs 9% P = 0.002) (Table 1 ). Three of the five Māori patients who had a Hartmann’s procedure were reversed. Table 1 Demographic characteristics of patients who underwent Hartmann’s procedure (sigmoid resection with end colostomy) at Dunedin Hospital 2011 – with and without reversal (restoration of GI continuity), number (%). Reversed N = 35 Not reversed N = 79 P-value Sex 0.423 Female 17(49) 45(55) Male 18(51) 34(45) Age (years) <0.001 ≤60 12 (34) 6(7) 61–70 14(40) 24(30) 71–80 8(23) 28(36) ≥81 1(3) 21(27) ASA 0.002 ≤2 12(34) 7(9) ≥3 23(66) 72(91) ASA, American Society of Anesthesiologists classification The most common indications for Hartmann’s procedure in this cohort were diverticulitis (37%), colonic malignancy (34%), stercoral perforation (13%) and anastomotic leak (10%) (Table 2 ). Hartmann’s procedure or take down of anastomosis with formation of end colostomy, was performed laparoscopically for 6/114 patients. Diverticulitis as an indication for surgery was significantly associated with an increased odds of being reversed (OR 4.1 95% (CI 1.6, 10.5) P = 0.001). In contrast, patients who had a Hartmann’s procedure for malignancy were less likely to be reversed within the study period (OR 0.37 95% CI 0.12, 1) P = 0.035) (Table 2 ). Table 2 Indications of Hartmann’s procedure (non-restorative sigmoid colectomy) at Dunedin Hospital 2011–2020 with and without reversal (restoration of GI continuity), number (%). Reversed N = 35 Not reversed N = 79 P -value Indication Diverticulitis 21 (60) 21 (27) 0.001 Malignancy 7 (20) 32 (40) 0.035 Stercoral perforation 3 (9) 12 (15) 0.547 Anastomotic leak 4 (11) 7 (9) 0.647 Fistula 0 3 (4) 0.994 Ischemia 0 2 (3) 0.994 Volvulus 0 2 (3) 0.994 This study included nine patients who had a Hartmann’s procedure in the setting of metastatic colorectal cancer. None of these patients were reversed and seven died within two years of index surgery. Responsible surgeon (colorectal versus non-colorectal) and surgical approach did not differ between the two groups. Acuity was a statistically significant factor; no patient who had a Hartmann’s performed electively had a reversal within the study period (Table 3 ). Table 3 Clinical factors of patients undergoing Hartmann’s procedure (non-restorative sigmoid colectomy) at Dunedin Hospital 2011–2020 with and without reversal (restoration of GI continuity), number (%). Responsible surgeon Reversed N = 35 Not reversed N = 79 P -value 0.834 Colorectal 12 (34) 30 (38) General 23 (76) 49 (62) Surgical approach Laparoscopic 2 (6) 3 (4) 0.642 Open 33 (94) 76 (96) Acuity 0.005 Elective 0 15 (19) Emergency 35 (100) 64 (81) Surgical complications requiring re-operation within 30 days of index surgery occurred in 11 patients, one of whom was subsequently reversed. Two patients required radiologically-guided peritoneal drains following index surgery, neither of whom were subsequently reversed. The reasons for non-reversal are shown in Table 4 . The most common reasons patients in the group did not proceed to reversal were perceived excess peri-operative risk, or the patient being too unwell to attend follow up clinic. For one quarter of patients, there was no clear documentation as to why Hartmann’s reversal did not occur or was not considered. Table 4 Reasons for non-reversal of patients who underwent sigmoid resection with end colostomy (Hartmann’s procedure) at Dunedin Hospital 2011–2020 with and without reversal (restoration of GI continuity), number (%). N (%) On wait list for reversal 2 (3) Decision not to attempt reversal Excessive peri-operative risk 23 (29) Patient choice 10 (12) Anticipated poor function 3 (4) Patient too unwell to attend follow-up 17 (22) Unknown 20 (25) Death during index admission 4 (5) Figure 1 represents the estimated cumulative incidence of Hartmann’s reversal. The estimated 6, 12, 18, 24, and 30-month reversal incidence was 9%, 21%, 34%, 37%, and 41% respectively. Discussion Our study found that 31% underwent a Hartmann’s reversal within a minimum two-year follow-up period, with the median interval to reversal being one year. While this overall rate is low, for patients who survive their emergency admission, and are later eligible for reversal, the rate is much higher; in our study 52%. This observed rate of reversal is lower than rates reported internationally. Hallam et al reported a reversal rate of 47% in a comparative health care system (UK NHS) during a similar period (2008–2014). However, their cohort was younger; median 58 years as compared with 71.5 years in this study [ 3 ]. Roig et al reported a reversal rate of 35% in a Spanish cohort which was younger (median age 57.7 years) [ 4 ]. These studies report a median length of time to reversal of 10 months, which is similar to our findings. Our cohort was older than both the Spanish and UK cohorts, despite their countries having an older median age, and similar life expectancy [ 11 ]. The older age of our cohort, despite similar population demographics, suggests differences in healthcare delivery. In our population, older patients were significantly less likely to be reversed. This is consistent with previous literature showing age less than 65 years is associated with a higher rate of Hartmann’s reversal [ 3 , 5 ]. Patients receiving a Hartmann’s procedure for diverticulitis had increased odds of being reversed, whereas malignancy was associated with decreased odds of reversal. This is in-line with a retrospective study performed by Katsura et al , who found patients receiving a Hartmann’s procedure for diverticular disease were twice as likely to be reversed compared with those with malignancy [ 12 ]. This study reported a reversal rate of 17.9% in patients with malignancy, comparable to rates reported elsewhere [ 3 , 4 ]. This low rate is likely explained by the associated risk of having, or subsequently developing, local or distant metastatic disease. Another explanation is that the Hartmann’s procedure will often be the procedure of choice for patients whose tumours have obstructed, perforated, locally invaded, or required emergent surgery. These factors are each independently associated with reduced survival, as well as subsequent reversal [ 13 – 15 ]. Our results demonstrate a negative association of baseline co-morbidity with subsequent Hartmann’s reversal. An example is the low reversal rate amongst patients who underwent a Hartmann’s procedure for stercoral perforation, a condition associated with advanced age, multiple co-morbidities, and debility [ 16 ]. This study looked at an objective measurement of patient health and co-morbidity; the American Society of Anaesthesiologist classification. We found a negative association with ASA and reversal. This is consistent with the results of Hallam et al , who also found a higher Charlson Co-morbidity index was negatively associated with reversal [ 3 ]. The cumulative incidence analysis demonstrated the extended length of time patients in this study waited for reversal. At 12 and 24 months, 21% and 37% of patients eligible underwent reversal respectively. A delay beyond 12 months from index surgery is associated with an increased risk of requiring a second stoma, bleeding complications, and in-hospital death [ 8 ]. Lengthy surgical waiting lists in Aotearoa New Zealand likely contribute to this delay. No patient who underwent a Hartmann’s procedure electively was subsequently reversed. This finding of elective surgery being negatively associated with reversal has been found in similar studies [ 17 , 4 ]. The elective patient generally has stable physiology without peritonitis. The decision to not anastomose thus reflects their co-morbidities. Given these factors are unlikely to change, permanent stoma is more likely. Limitations of this retrospective study include the population being a single center cohort; results may not be generalisable patients treated in other parts of Aotearoa New Zealand. Patients may have undergone restoration of GI continuity at another centre. A quarter of patients lacked documented reasons for non-reversal, reducing our ability to identify factors associated with the non-reversal. Conclusion This is the first study to examine the rate of Hartmann’s reversal in an Aotearoa New Zealand setting. We found that 69% of patients had not undergone Hartman’s reversal by the end of the study period. Patients undergoing Hartmann’s procedure for diverticulitis were less likely to undergo subsequent Hartmann’s reversal. Older patients, and those undergoing Hartmann’s procedure for malignancy had reduced odds of being reversed. These results will enable clinicians to provide evidence-based information to patients about their likelihood of Hartmann’s reversal. Declarations Author Contribution William Fleischl - study design, data collection, manuscript writing and revision.Kari Clifford - study design, manuscript editing and revision, data synthesis, statistical analysis. Deborah Wright - study design, data collection, manuscript editing and revision. References Hotouras A (2008) Henri Hartmann and his operation. Grand Rounds. ;8 Tridente A, Clarke GM, Walden A et al (2014) Patients with faecal peritonitis admitted to European intensive care units: An epidemiological survey of the GenOSept cohort. Intensive Care Med 40(2). 10.1007/s00134-013-3158-7 Hallam S, Mothe BS, Tirumulaju RMR (2018) Hartmann’s procedure, reversal and rate of stoma-free survival. Ann R Coll Surg Engl 100(4). 10.1308/rcsann.2018.0006 Roig JV, Cantos M, Balciscueta Z et al (2011) Hartmann’s operation: How often is it reversed and at what cost? A multicentre study. Colorectal Dis 13(12). 10.1111/j.1463-1318.2011.02738.x Yalkın Ö, Altıntoprak F, Uzunoğlu MY et al (2022) Factors Predicting the Reversal of Hartmann’s Procedure. Biomed Res Int 2022:1–7. 10.1155/2022/7831498 Salusjärvi JM, Koskenvuo LE, Mali JP, Mentula PJ, Leppäniemi AK, Sallinen VJ (2022) Stoma reversal after Hartmann’s procedure for acute diverticulitis. Surg Published online Dec. 10.1016/j.surg.2022.10.028 Sprangers MAG, Taal BG, Aaronson NK, te Velde A (1995) Quality of life in colorectal cancer. Dis Colon Rectum 38(4):361–369. 10.1007/BF02054222 Salem L, Anaya DA, Roberts KE, Flum DR (2005) Hartmann’s colectomy and reversal in diverticulitis: A population-level assessment. Dis Colon Rectum 48(5). 10.1007/s10350-004-0871-x DIVA, Otago Clinical Audit. Published online 2023 URL https://www.R-project.org/. 1. R Core Team (2023) R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria Life expectancy at birth, total (years) | Data. Accessed July 8 (2023) https://data.worldbank.org/indicator/SP.DYN.LE00.IN Katsura M, Fukuma S, Chida K et al (2022) Which factors influence the decision to perform Hartmann’s reversal in various causative disease situations? A retrospective cohort study between 2006 and 2021. Colorectal Disease . Published online October 21, 10.1111/codi.16364 Hogan J, Samaha G, Burke J et al (2015) Emergency presenting colon cancer is an independent predictor of adverse disease-free survival. Int Surg 100(1). 10.9738/INTSURG-D-13-00281.1 Abdelrazeq AS, Scott N, Thorn C et al (2008) The impact of spontaneous tumour perforation on outcome following colon cancer surgery. Colorectal Dis 10(8). 10.1111/j.1463-1318.2007.01412.x Katoh H, Yamashita K, Wang G, Sato T, Nakamura T, Watanabe M (2011) Prognostic significance of preoperative bowel obstruction in stage III colorectal cancer. Ann Surg Oncol 18(9). 10.1245/s10434-011-1625-3 Fernando S, Sarma DR (2021) Rare but relevant: a systematic review of stercoral perforation. Br J Hosp Med 82(4):1–7. 10.12968/hmed.2020.0659 Kang JH, Kang BM, Yoon SN et al (2020) Analysis of factors affecting reversal of Hartmann’s procedure and post-reversal complications. Sci Rep 10(1):16820. 10.1038/s41598-020-73791-w Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Dec, 2024 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 11 Sep, 2024 Reviews received at journal 03 Sep, 2024 Reviews received at journal 03 Sep, 2024 Reviews received at journal 27 Aug, 2024 Reviewers agreed at journal 10 Aug, 2024 Reviewers agreed at journal 10 Aug, 2024 Reviewers agreed at journal 10 Aug, 2024 Reviewers agreed at journal 09 Aug, 2024 Reviews received at journal 08 Aug, 2024 Reviewers agreed at journal 08 Aug, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviewers agreed at journal 05 Aug, 2024 Reviewers agreed at journal 05 Aug, 2024 Reviewers agreed at journal 05 Aug, 2024 Reviewers invited by journal 05 Aug, 2024 Editor assigned by journal 01 Aug, 2024 Submission checks completed at journal 31 Jul, 2024 First submitted to journal 25 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4800010","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":344609136,"identity":"3686e6b8-6607-4896-a923-2b85d97bc123","order_by":0,"name":"William Fleischl","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYFACxocHGAwYGAzYGdiYGSoOgMUOPMCrhdkAooUZpOXMAQYekJYEgloYoFoY2yBaGPBpMTjAzHDgQ0GdvDlQy+PCeXfk7MUOPwTaYien24Bby8EZBocNdzYzsBvP3PbMmEc6zQCoJdnY7AB2LWYH+A8c5gGqMTjMwCbNu+1wYo90AkjLgcRtOLUwMxz+Y1AH1TIHpCX9A2EtQL9DtTSAtOTgt8X+MNAvPUC/bDjM2CY949hhY57bOQVAd+L2i2R7M+ODH3/q5A2ONx+TLqg5LMc+O33zhw8VdnK4tDAww1mMDUjCBjiUj4JRMApGwSggCgAAF0dfJVYvtz4AAAAASUVORK5CYII=","orcid":"","institution":"Dunedin Public Hospital","correspondingAuthor":true,"prefix":"","firstName":"William","middleName":"","lastName":"Fleischl","suffix":""},{"id":344609137,"identity":"1c7b895d-2a8a-43cd-9eea-9f6142bbe403","order_by":1,"name":"Kari Clifford","email":"","orcid":"","institution":"University of Otago","correspondingAuthor":false,"prefix":"","firstName":"Kari","middleName":"","lastName":"Clifford","suffix":""},{"id":344609138,"identity":"e07746fd-5a00-4d97-818a-8d69eb76214f","order_by":2,"name":"Deborah Wright","email":"","orcid":"","institution":"University of Otago","correspondingAuthor":false,"prefix":"","firstName":"Deborah","middleName":"","lastName":"Wright","suffix":""}],"badges":[],"createdAt":"2024-07-25 07:59:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4800010/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4800010/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-024-03558-8","type":"published","date":"2024-12-03T15:56:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64005452,"identity":"f9fd0de6-5816-4ab4-9f32-3338df9e395a","added_by":"auto","created_at":"2024-09-04 21:38:17","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":183029,"visible":true,"origin":"","legend":"\u003cp\u003eCumulative incidence curve demonstrating the estimated incidence of Hartmann’s reversal (restoration of GI continuity) over time, amongst patients undergoing a Hartmann’s procedure (non-restorative sigmoid colectomy) at Dunedin Hospital between 2011-2020.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4800010/v1/6c0783dfe104023018dbbf68.jpeg"},{"id":70964676,"identity":"50e46266-365a-4be5-bb2f-7d19699d0176","added_by":"auto","created_at":"2024-12-09 16:14:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":577134,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4800010/v1/a173ba43-b363-451c-ba4b-d4197599b4c9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence and outcomes of Hartmann’s reversal following Hartmann’s procedure in a regional center, a retrospective cohort study.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe eponymous Hartmann\u0026rsquo;s procedure, a sigmoid colectomy with formation of an end-colostomy, was described by French surgeon Henri Albert Hartmann in 1921 and remains a common general surgical procedure [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHartmann\u0026rsquo;s procedure is often performed acutely for colonic obstruction. It is performed electively when patient co-morbidity or likely poor functional outcome preclude anastomosis. For patients with peritonitis, there is an associated mortality risk of up to 30% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRestoration of gastrointestinal (GI) continuity by rejoining the colon and rectum, Hartmann\u0026rsquo;s reversal, is currently performed for 35% \u0026minus;\u0026thinsp;47% of patients, with the remainder living with a permanent colostomy [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFactors influencing the decision whether to reverse include risk of complications (21\u0026ndash;45%), risk of mortality (0.5\u0026ndash;7.5%), the presence of metastatic disease, anticipated poor functional outcome, and patient preference [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Once this decision has been made, reversal may be delayed by non-clinical factors, such as lack of theatre access.\u003c/p\u003e \u003cp\u003eEnd colostomy is associated with physical and psychological distress, including rectal discharge, inability to control gas, difficulties returning to work, decreased sexual activity, and difficulties in activities of travel and leisure [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Salem \u003cem\u003eet al\u003c/em\u003e found time to restoration of GI continuity beyond 12 months was associated with an increased peri-operative morbidity and mortality [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Timely Hartmann\u0026rsquo;s reversal is important both for mental and physical wellness.\u003c/p\u003e \u003cp\u003eColostomies are often described to patients as \u0026ldquo;temporary\u0026rdquo; or \u0026ldquo;reversible\u0026rdquo;. There are currently no published studies in Aotearoa New Zealand or Australia on the rate of reversal, and how patients\u0026rsquo; clinical and demographic factors influence this. Understanding these factors will help clinicians counsel patients on the likelihood of subsequent reversal.\u003c/p\u003e \u003cp\u003eThis study investigates Hartmann\u0026rsquo;s reversal following the Hartmann\u0026rsquo;s procedure at a single centre in Aotearoa New Zealand, the clinical and demographic factors associated with Hartmann\u0026rsquo;s reversal, and the reasons for non-reversal.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a single-center, retrospective, observational cohort study conducted at Dunedin Hospital, a 400-bed tertiary referral hospital located in Aotearoa New Zealand. Consecutive patients who underwent a Hartmann\u0026rsquo;s procedure between 1 June 2011 and 31 May 2020 were identified by searching procedure codes stored in the Otago Clinical Audit [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eData extraction was performed in June 2022 to allow a minimum of 2 years follow-up. Patients less than 18 years old or with incomplete follow-up data were excluded.\u003c/p\u003e \u003cp\u003ePatient and procedure details were retrieved from the contemporaneous clinical record. Patient factors including age, sex, ethnicity, and ASA were recorded. Indication for Hartmann\u0026rsquo;s procedure was determined and grouped into the following categories: diverticulitis, colonic malignancy, stercoral perforation, anastomotic leak, colonic fistula, and sigmoid volvulus. \u0026ldquo;Diverticulitis\u0026rdquo; included perforated and non-perforated diverticulitis. Surgical approach, responsible surgeon, metastatic disease at time of initial surgery, reoperation within 30 days of index surgery, and radiologically-guided insertion of peritoneal drain within three months of index surgery was also collected.\u003c/p\u003e \u003cp\u003eTime to Hartmann\u0026rsquo;s reversal, decision not to attempt reversal, or death was recorded. Reasons not to attempt reversal included excess peri-operative risk, patient choice, the patient being too unwell to attend follow-up, or anticipated poor function. Patients on a waitlist for reversal were also recorded.\u003c/p\u003e \u003cp\u003eThe primary outcomes were proportion of patients who underwent Hartmann\u0026rsquo;s reversal, and the time to Hartmann\u0026rsquo;s reversal. The secondary outcomes were demographic and clinical factors associated with Hartmann\u0026rsquo;s reversal.\u003c/p\u003e \u003cp\u003eThe Shapiro-Wilk test was used to assess the distribution of the data. Univariable general linear models were used to investigate the association of the demographic factors with Hartmann\u0026rsquo;s reversal. Results with a \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in two-tailed testing were considered statistically significant. The cumulative proportion of patients undergoing Hartmann\u0026rsquo;s reversal was calculated from the date of surgical procedure until reversal and estimated by the Kaplan-Meier method. Patients were censored on the date of last clinical contact, death, or if there was a decision documented to not reverse. Statistical analysis was performed in R (V4.3.0) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eApproval was obtained from the University of Otago Humans Research Ethics Committee (HD22/088) prior to data extraction and analysis. There are no conflicts of interest.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween 1 June 2011 and 31 May 2020, 117 patients underwent Hartmann\u0026rsquo;s procedure at Dunedin Hospital. Three patients had incomplete data and thus were excluded from the analysis. The median (IQR) age was 71.5 (65\u0026ndash;80) years; 4.4% (5/114) were Māori and 54% (61/114) were female. The median (IQR) follow-up time was 403 (73-1539) days.\u003c/p\u003e \u003cp\u003eWithin the study period, 35/114 patients (31%) underwent Hartmann\u0026rsquo;s reversal after having the Hartmann\u0026rsquo;s procedure. The median (IQR) time to reversal was 372 (188\u0026ndash;500) days. After excluding patients where Hartmann\u0026rsquo;s reversal was not considered (increased peri-operative risk, anticipated poor function, patient too unwell to attend follow up, or death during index admission) the proportion of patient who underwent Hartmann\u0026rsquo;s within the study period was 52% (35/67).\u003c/p\u003e \u003cp\u003eThere was no difference in the reversal proportion between male and female patients. Patients who were reversed were younger (median 67 versus 73 years, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). Each extra year of age was associated with a 1% decrease in the odds of reversal. A higher proportion of patients with ASA scores \u0026le;2 was reversed compared with patients with ASA scores \u0026ge; 3 (34% vs 9% \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Three of the five Māori patients who had a Hartmann\u0026rsquo;s procedure were reversed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of patients who underwent Hartmann\u0026rsquo;s procedure (sigmoid resection with end colostomy) at Dunedin Hospital 2011 \u0026ndash; with and without reversal (restoration of GI continuity), number (%).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReversed\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot reversed\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;79\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.423\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45(55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18(51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e61\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e71\u0026ndash;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72(91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eASA, American Society of Anesthesiologists classification\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe most common indications for Hartmann\u0026rsquo;s procedure in this cohort were diverticulitis (37%), colonic malignancy (34%), stercoral perforation (13%) and anastomotic leak (10%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Hartmann\u0026rsquo;s procedure or take down of anastomosis with formation of end colostomy, was performed laparoscopically for 6/114 patients.\u003c/p\u003e \u003cp\u003eDiverticulitis as an indication for surgery was significantly associated with an increased odds of being reversed (OR 4.1 95% (CI 1.6, 10.5) \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). In contrast, patients who had a Hartmann\u0026rsquo;s procedure for malignancy were less likely to be reversed within the study period (OR 0.37 95% CI 0.12, 1) \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.035) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndications of Hartmann\u0026rsquo;s procedure (non-restorative sigmoid colectomy) at Dunedin Hospital 2011\u0026ndash;2020 with and without reversal (restoration of GI continuity), number (%).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReversed\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot reversed\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;79\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiverticulitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStercoral perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.547\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.647\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIschemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolvulus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThis study included nine patients who had a Hartmann\u0026rsquo;s procedure in the setting of metastatic colorectal cancer. None of these patients were reversed and seven died within two years of index surgery.\u003c/p\u003e \u003cp\u003eResponsible surgeon (colorectal versus non-colorectal) and surgical approach did not differ between the two groups. Acuity was a statistically significant factor; no patient who had a Hartmann\u0026rsquo;s performed electively had a reversal within the study period (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical factors of patients undergoing Hartmann\u0026rsquo;s procedure (non-restorative sigmoid colectomy) at Dunedin Hospital 2011\u0026ndash;2020 with and without reversal (restoration of GI continuity), number (%).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponsible surgeon\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReversed\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot reversed\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;79\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003cp\u003e0.834\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColorectal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical approach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.642\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcuity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSurgical complications requiring re-operation within 30 days of index surgery occurred in 11 patients, one of whom was subsequently reversed. Two patients required radiologically-guided peritoneal drains following index surgery, neither of whom were subsequently reversed.\u003c/p\u003e \u003cp\u003eThe reasons for non-reversal are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The most common reasons patients in the group did not proceed to reversal were perceived excess peri-operative risk, or the patient being too unwell to attend follow up clinic. For one quarter of patients, there was no clear documentation as to why Hartmann\u0026rsquo;s reversal did not occur or was not considered.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReasons for non-reversal of patients who underwent sigmoid resection with end colostomy (Hartmann\u0026rsquo;s procedure) at Dunedin Hospital 2011\u0026ndash;2020 with and without reversal (restoration of GI continuity), number (%).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOn wait list for reversal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDecision not to attempt reversal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcessive peri-operative risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient choice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnticipated poor function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient too unwell to attend follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnknown\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDeath during index admission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e represents the estimated cumulative incidence of Hartmann\u0026rsquo;s reversal. The estimated 6, 12, 18, 24, and 30-month reversal incidence was 9%, 21%, 34%, 37%, and 41% respectively.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study found that 31% underwent a Hartmann\u0026rsquo;s reversal within a minimum two-year follow-up period, with the median interval to reversal being one year. While this overall rate is low, for patients who survive their emergency admission, and are later eligible for reversal, the rate is much higher; in our study 52%.\u003c/p\u003e \u003cp\u003eThis observed rate of reversal is lower than rates reported internationally. Hallam \u003cem\u003eet al\u003c/em\u003e reported a reversal rate of 47% in a comparative health care system (UK NHS) during a similar period (2008\u0026ndash;2014). However, their cohort was younger; median 58 years as compared with 71.5 years in this study [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Roig \u003cem\u003eet al\u003c/em\u003e reported a reversal rate of 35% in a Spanish cohort which was younger (median age 57.7 years) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These studies report a median length of time to reversal of 10 months, which is similar to our findings. Our cohort was older than both the Spanish and UK cohorts, despite their countries having an older median age, and similar life expectancy [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The older age of our cohort, despite similar population demographics, suggests differences in healthcare delivery.\u003c/p\u003e \u003cp\u003eIn our population, older patients were significantly less likely to be reversed. This is consistent with previous literature showing age less than 65 years is associated with a higher rate of Hartmann\u0026rsquo;s reversal [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients receiving a Hartmann\u0026rsquo;s procedure for diverticulitis had increased odds of being reversed, whereas malignancy was associated with decreased odds of reversal. This is in-line with a retrospective study performed by Katsura \u003cem\u003eet al\u003c/em\u003e, who found patients receiving a Hartmann\u0026rsquo;s procedure for diverticular disease were twice as likely to be reversed compared with those with malignancy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study reported a reversal rate of 17.9% in patients with malignancy, comparable to rates reported elsewhere [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This low rate is likely explained by the associated risk of having, or subsequently developing, local or distant metastatic disease. Another explanation is that the Hartmann\u0026rsquo;s procedure will often be the procedure of choice for patients whose tumours have obstructed, perforated, locally invaded, or required emergent surgery. These factors are each independently associated with reduced survival, as well as subsequent reversal [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur results demonstrate a negative association of baseline co-morbidity with subsequent Hartmann\u0026rsquo;s reversal. An example is the low reversal rate amongst patients who underwent a Hartmann\u0026rsquo;s procedure for stercoral perforation, a condition associated with advanced age, multiple co-morbidities, and debility [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study looked at an objective measurement of patient health and co-morbidity; the American Society of Anaesthesiologist classification. We found a negative association with ASA and reversal. This is consistent with the results of Hallam \u003cem\u003eet al\u003c/em\u003e, who also found a higher Charlson Co-morbidity index was negatively associated with reversal [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe cumulative incidence analysis demonstrated the extended length of time patients in this study waited for reversal. At 12 and 24 months, 21% and 37% of patients eligible underwent reversal respectively. A delay beyond 12 months from index surgery is associated with an increased risk of requiring a second stoma, bleeding complications, and in-hospital death [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Lengthy surgical waiting lists in Aotearoa New Zealand likely contribute to this delay.\u003c/p\u003e \u003cp\u003eNo patient who underwent a Hartmann\u0026rsquo;s procedure electively was subsequently reversed. This finding of elective surgery being negatively associated with reversal has been found in similar studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The elective patient generally has stable physiology without peritonitis. The decision to not anastomose thus reflects their co-morbidities. Given these factors are unlikely to change, permanent stoma is more likely.\u003c/p\u003e \u003cp\u003eLimitations of this retrospective study include the population being a single center cohort; results may not be generalisable patients treated in other parts of Aotearoa New Zealand. Patients may have undergone restoration of GI continuity at another centre. A quarter of patients lacked documented reasons for non-reversal, reducing our ability to identify factors associated with the non-reversal.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis is the first study to examine the rate of Hartmann\u0026rsquo;s reversal in an Aotearoa New Zealand setting. We found that 69% of patients had not undergone Hartman\u0026rsquo;s reversal by the end of the study period. Patients undergoing Hartmann\u0026rsquo;s procedure for diverticulitis were less likely to undergo subsequent Hartmann\u0026rsquo;s reversal. Older patients, and those undergoing Hartmann\u0026rsquo;s procedure for malignancy had reduced odds of being reversed. These results will enable clinicians to provide evidence-based information to patients about their likelihood of Hartmann\u0026rsquo;s reversal.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWilliam Fleischl - study design, data collection, manuscript writing and revision.Kari Clifford - study design, manuscript editing and revision, data synthesis, statistical analysis. Deborah Wright - study design, data collection, manuscript editing and revision.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHotouras A (2008) Henri Hartmann and his operation. Grand Rounds. ;8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTridente A, Clarke GM, Walden A et al (2014) Patients with faecal peritonitis admitted to European intensive care units: An epidemiological survey of the GenOSept cohort. Intensive Care Med 40(2). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00134-013-3158-7\u003c/span\u003e\u003cspan address=\"10.1007/s00134-013-3158-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHallam S, Mothe BS, Tirumulaju RMR (2018) Hartmann\u0026rsquo;s procedure, reversal and rate of stoma-free survival. Ann R Coll Surg Engl 100(4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1308/rcsann.2018.0006\u003c/span\u003e\u003cspan address=\"10.1308/rcsann.2018.0006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoig JV, Cantos M, Balciscueta Z et al (2011) Hartmann\u0026rsquo;s operation: How often is it reversed and at what cost? A multicentre study. Colorectal Dis 13(12). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1463-1318.2011.02738.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1463-1318.2011.02738.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYalkın \u0026Ouml;, Altıntoprak F, Uzunoğlu MY et al (2022) Factors Predicting the Reversal of Hartmann\u0026rsquo;s Procedure. Biomed Res Int 2022:1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1155/2022/7831498\u003c/span\u003e\u003cspan address=\"10.1155/2022/7831498\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalusj\u0026auml;rvi JM, Koskenvuo LE, Mali JP, Mentula PJ, Lepp\u0026auml;niemi AK, Sallinen VJ (2022) Stoma reversal after Hartmann\u0026rsquo;s procedure for acute diverticulitis. Surg Published online Dec. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.surg.2022.10.028\u003c/span\u003e\u003cspan address=\"10.1016/j.surg.2022.10.028\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSprangers MAG, Taal BG, Aaronson NK, te Velde A (1995) Quality of life in colorectal cancer. Dis Colon Rectum 38(4):361\u0026ndash;369. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/BF02054222\u003c/span\u003e\u003cspan address=\"10.1007/BF02054222\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalem L, Anaya DA, Roberts KE, Flum DR (2005) Hartmann\u0026rsquo;s colectomy and reversal in diverticulitis: A population-level assessment. Dis Colon Rectum 48(5). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10350-004-0871-x\u003c/span\u003e\u003cspan address=\"10.1007/s10350-004-0871-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDIVA, Otago Clinical Audit. Published online 2023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eURL https://www.R-project.org/. 1. R Core Team (2023) R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLife expectancy at birth, total (years) | Data. Accessed July 8 (2023) \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.worldbank.org/indicator/SP.DYN.LE00.IN\u003c/span\u003e\u003cspan address=\"https://data.worldbank.org/indicator/SP.DYN.LE00.IN\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatsura M, Fukuma S, Chida K et al (2022) Which factors influence the decision to perform Hartmann\u0026rsquo;s reversal in various causative disease situations? A retrospective cohort study between 2006 and 2021. \u003cem\u003eColorectal Disease\u003c/em\u003e. Published online October 21, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/codi.16364\u003c/span\u003e\u003cspan address=\"10.1111/codi.16364\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHogan J, Samaha G, Burke J et al (2015) Emergency presenting colon cancer is an independent predictor of adverse disease-free survival. Int Surg 100(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.9738/INTSURG-D-13-00281.1\u003c/span\u003e\u003cspan address=\"10.9738/INTSURG-D-13-00281.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdelrazeq AS, Scott N, Thorn C et al (2008) The impact of spontaneous tumour perforation on outcome following colon cancer surgery. 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Br J Hosp Med 82(4):1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12968/hmed.2020.0659\u003c/span\u003e\u003cspan address=\"10.12968/hmed.2020.0659\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang JH, Kang BM, Yoon SN et al (2020) Analysis of factors affecting reversal of Hartmann\u0026rsquo;s procedure and post-reversal complications. Sci Rep 10(1):16820. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41598-020-73791-w\u003c/span\u003e\u003cspan address=\"10.1038/s41598-020-73791-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Hartmann’s procedure, Hartmann’s reversal, postoperative outcomes","lastPublishedDoi":"10.21203/rs.3.rs-4800010/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4800010/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHartmann’s procedure (sigmoid resection with end colostomy) is a commonly performed emergency procedure for diseases of the sigmoid colon.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAim\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo determine the proportion of patients undergoing Hartmann’s reversal (restoration of GI continuity) following Hartmann’s procedure, the clinical and demographic factors associated with reversal, and the reasons for non-reversal.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMethod\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis is a single center, retrospective audit of patients undergoing Hartmann’s procedure between June 2011 and May 2020. Age, sex, American Society of Anesthesiologists classification (ASA), indication for Hartmann’s, surgical approach, specialty of responsible surgeon (General or Colorectal), 30-day reoperation, requirement for radiologically-guided drain, and reason for non-reversal were recorded. The association between these factors and reversal was determined with Fischer’s exact test and logistic regression. Cumulative reversal proportions were calculated with the Kaplan-Meier method.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData was obtained for 114/117 patients, of whom 31% (35/114) underwent Hartmann’s reversal. The median (IQR) time to reversal was 372 (188-500) days). Patients with restoration of GI continuity were younger (median 67 versus 73 years, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) with fewer co-morbidities, (ASA £2 34% versus 9% \u003cem\u003eP\u003c/em\u003e=0.002). \u0026nbsp;The estimated cumulative 24-month reversal incidence was 37%.\u003c/p\u003e\n\u003cp\u003ePatients who had a Hartmann’s procedure performed for diverticulitis had an increased odds of being reversed (OR 4.1 (95% CI 1.6, 10.5) \u003cem\u003eP\u003c/em\u003e=0.001); Hartmann’s for malignancy was associated with decreased odds of reversal (OR 0.37 (95% CI 0.12, 1) \u003cem\u003eP\u003c/em\u003e=0.035).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOf patients who underwent Hartmann’s procedure, the majority retained a permanent stoma. Older patients, those with high ASA, and those who underwent index procedures for malignancy had lower rates of reversal.\u003c/p\u003e","manuscriptTitle":"Prevalence and outcomes of Hartmann’s reversal following Hartmann’s procedure in a regional center, a retrospective cohort study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-04 21:38:12","doi":"10.21203/rs.3.rs-4800010/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-12T03:56:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-03T08:58:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-03T07:00:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-27T16:29:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102315987536627834692503254641065653539","date":"2024-08-10T16:21:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58255401654945096907359101715532975625","date":"2024-08-10T11:12:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202858510840391109474010587128623273224","date":"2024-08-10T10:38:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96941512831535182499066355871151972349","date":"2024-08-09T21:45:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-08T22:11:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203822040861328933611906606001994946137","date":"2024-08-08T05:02:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2726380510692248756455541983774865407","date":"2024-08-07T00:01:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315696139608436887467735120141217550573","date":"2024-08-06T20:42:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138587934843678342758061844538309129431","date":"2024-08-05T19:10:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168199565998419510589011584648223006584","date":"2024-08-05T12:11:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329215025197577765536709002828189900365","date":"2024-08-05T11:18:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-05T08:37:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-01T07:47:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-31T10:27:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2024-07-25T07:57:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3fb08c1a-7ce0-4b93-bf19-b6e1c40af938","owner":[],"postedDate":"September 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-09T16:00:50+00:00","versionOfRecord":{"articleIdentity":"rs-4800010","link":"https://doi.org/10.1007/s00423-024-03558-8","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2024-12-03 15:56:52","publishedOnDateReadable":"December 3rd, 2024"},"versionCreatedAt":"2024-09-04 21:38:12","video":"","vorDoi":"10.1007/s00423-024-03558-8","vorDoiUrl":"https://doi.org/10.1007/s00423-024-03558-8","workflowStages":[]},"version":"v1","identity":"rs-4800010","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4800010","identity":"rs-4800010","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}