Acute Diverticulitis & Hartmann’s Procedure

Nigel A. Scott MD FRCS

Hope Hospital, Salford

CT diagnosis/ CT intervention

Illness and Optimisation

A randomised clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high risk patients. Boyd O et al JAMA 1993;270:2699-2707

Hospital death

Morbidity

Routine Care 22% 1.35+/- 0.2

O2 delivery targeted towards 600ml/min/m2

5.7% 0.68 +/- 0.6

Emergency Admission for Acute Diverticulitis

• CT diagnosis/ CT intervention

• illness /optimisation

What’s the best operation in acute complicated diverticulitis ?

Acute Complicated Diverticulitis – Which Operation ?

• death

• illness

• permanent stoma

Defunctioning Colostomy

Hartmann’s Procedure (HP)

Primary Anastomosis (PA)

Emergency Admission for Acute Diverticulitis

Hinchey stage III & IV – colostomy alone ?

Primary Resection Proximal Colostomy

Anastomosis

Hartmann’s

Lateral Colostomy

3

520

0

0

48

Early re-operation

2 9 <0.02

Death 13 9 ns

Post-op Peritonitis

1 10 <0.01

Length of stay 15d 24d <0.05

Zeitoun et al Br J Surg 2000;87:1366-1374

Emergency Admission for Acute Diverticulitis

Acute Complicated Diverticulitis – Which Operation ?

• death

• illness

• permanent stoma

Defunctioning Colostomy

Hartmann’s

Primary Anastomosis

Emergency Admission for Acute Diverticulitis

Q – Primary Anastomosis (PA) or Hartmann’s Procedure (HP)

• 15 papers (1997 – 2003)

Emergency Admission for Acute Diverticulitis

Primary Anastomosis (stoma)

Hartmanns Other Mortality

Elliott 1997 14 (?) 51 18 20/113 (17%)

Wedell 1997 183 (35) 31 10 13/224 (6%)

Hoemke 1999 113 (0) 0 0 2/113 (2%)

Umbach 1999 28 (0) 0 5 0

Blair 2000 33 (5) 64 0 16/96 (16%)

Schilling 2001 13 (0) 42 0 5/55 (9%)

Gooszen 2001 32 (32) 28 0 12/60 (20%)

Maggard 2001 33 (0) 32 9 0

Biondo 2000 55(0) 60 8 4/124 (3%)

Makela 2002 46 (?) 75 22 4/101 (4%)

Somasekar 2002

4 (?) 98 2 34/102 (33%)

Gooszen 2002 45(0) 0 0 3/45 (6%)

Landen 2002 20(20) 0 0 3/20 (15%)

Regenet 2003 27 (0) 33 0 7/60 (12%)

Zorcollo 2003 ~70(?) ~92 ~6 22/168 (13%)

PAPA+ stomaHPOther

Resection for Acute Diverticular Sepsis n=1620

1 HP:1 PA

Emergency Admission for Acute Diverticulitis

• 18 studies comparing HP and PA in 884 patients with acute diverticulitis

• mortality same• morbidity same (sepsis, wound infection,

antibiotic use)• duration of procedure the same

Emergency Admission for Acute Diverticulitis

Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis. 2006 Jan 7;:1-7 [

Might as well do PA as HP –

but are we comparing like with like ?

0%

20%

40%

60%

80%

100%

<50yrs 51-70yrs >70yrs

HPPA

Hartmann’s Procedure is used in Elderly

Makela et al Dis Colon Rectum 1998;1523-1528

Emergency Admission for Acute Diverticulitis

• ASA I - Normal healthy individual

• ASA II - Mild systemic disease that does not limit activity

• ASA III - Severe systemic disease that limits activity but is not incapacitating

• ASA IV - Incapacitating systemic disease which is constantly life threatening

• ASA V - Moribund, not expected to survive 24 hours with or without surgery

Emergency Admission for Acute Diverticulitis

0%

20%

40%

60%

80%

100%

I II III IV DEATHS

HPPA

Blair et al Am J Surg 2002:183:525-528

Emergency Admission for Acute Diverticulitis

Hartmann’s Procedure is used in ASA >III

0%10%20%30%40%50%60%70%80%90%

100%

I II III IV DEATHS

HPPA

Biondo et al J Am Coll Surg 2000;191:635-642

• Hinchey I – pericolic abscess confined to mesentery of colon

• Hinchey II – walled off pelvic abscess

• Hinchey III – generalised peritonitis

• Hinchey IV – faecal peritonitis

Emergency Admission for Acute Diverticulitis

Hinchey I

Hinchey II Hinchey III Hinchey IV Deaths

**Wedell 1997

PA

HP

149(1)

17(3)

14(1)

15(4)

2

7

Blair 2000

PA

HP

12

6

12

25

7

25

2

7

3

13

**Gooszen 2001

PA

HP

28

0

9

0

3

Somasekar 2002

PA

HP

0

3

0

6

0

59

0

27 34

Makela 2002

PA

HP

8

2

3

1

1

7

0

19

4(total)

** adapted from Hughes staging

Emergency Admission for Acute Diverticulitis

0%

20%

40%

60%

80%

100%

I & II III & IV

HPPA

6 papers n = 454

Emergency Admission for Acute Diverticulitis

Hartmann’s Procedure is used in Hinchey III and IV

age

sepsis

ASA

What’s the best operation in acute complicated diverticulitis ?

CT

HPPA

Hinchey I and II

If adequate bowel preparation is possible and substantial contamination is not present, a primary anastomosis may be performed, with or without a proximal stoma. Alternatively, Hartmann’s resection is the most appropriate procedure.

Hinchey III and IV

The procedure of choice in this situation is immediate segmental resection with colostomy.

Hartmann’s Procedure

• elderly

• >ASA III

• Hinchey III and IV

What are the chances of reversal ?

Hartmann’s Reversal

• general patient fitness• leave for 6 months - adhesions

1- negligible filmy

2- moderate

3 – dense, difficult

4 – inadvertent enterotomy

Reversal of Hartmann's procedure: Effect of timing and technique on ease and safety DCR 1994;37:243-248

Hartmann’s Reversal

• general patient fitness• leave for 6 months - adhesions

Reversal of Hartmann's procedure: Effect of timing and technique on ease and safety DCR 1994;37:243-248

Early reversal (mean 11 weeks)

4 – inadvertent enterotomy

Late reversal (mean 34 weeks)

4 – inadvertent enterotomy

5/13 (38%) 3/37 (8%)

Hartmann’s Reversal

• general patient fitness• leave for 6 months• informed – autonomic

injury, death, morbidity, failure, loop stoma

• image/ visualise rectal stump

• lose weight

Hartmann’s Reversal - Open• Lloyd Davies• ureteric stents• mobilise splenic flexure• TV colon to rectum

anastomosis• ? loop stoma

Hartmann’s Reversal – Laparoscopic

• 38 patients – 70% with diverticular disease

• reversal at average of 4 -5 months

• adhesions; low 13; moderate 15; dense 10;

• 15% conversion – adhesions

• los 10 days +/- 4

• 1 death from anastomotic leak

Laparoscopic reversal of the Hartmann's procedure Vacher C.; Zaghloul R.; Borie F.; Laporte S.; Callafe R.; Skawinski P.; Leynau G.; Domergue J. Annales de Chirugie Volume 127, Number 3, March 2002, pp. 189-192(4)

Hartmann’s Reversal – LaparoscopicH Gallagher

109 reversal HP

1 ileorectal

7 laparoscopic 3 converted

All 3 needed conversions for large incisional herniae

Laparoscopic reversal of Hartmann’s can certainly be performed with a significantly low morbidity but incisional herniation from the previous laparotomy is an important rate limiting factor-necessitating conversion when the hernia itself demands repair on its own merit

Hartmann’s Reversal Rate – 63%

Hartmanns ReversalsElliott 1997 51 86%Wedell 1997 31 31%Hoemke 1999 0 -Umbach 1999 0 -Blair 2000 64 naSchilling 2001 42 76%Gooszen 2001 28 57%Maggard 2001 32 100%Biondo 2000 60 naMakela 2002 75 45%Somasekar 2002 98 naGooszen 2002 0 -Landen 2002 0 -Regenet 2003 33 69%Zorcollo 2003 ~92 39%

Reversal of Hartmann's Procedure after Surgery for Complications of Diverticular Disease of the Sigmoid Colon Is Safe and Possible in Most Patients. Dig Surg. 2006 Feb 10;22(6):419-425

91 HP for Diverticulitis in 12mths

72 survivors 19 deaths

65 attempted reversal

63 success3% died

38% morbidity

63/65 = 96.9% reversal63/91 = 69% reversal

• Common and increasing presentation associated with 30% chance of resection and 10% chance of death after surgery

• Hartmanns is used for elderly; >ASA III and Hinchey III and IV

• Reversal is possible in 60% - laparoscopic or open

Surgery and Acute Diverticulitis

Summary

The End