Complications During and After Restoration of Intestinal Continuity

After Colostomy. Is it Worth it?Gustavo Plasencia, MD, FACS, FASCRS

Hartmann’s reversal: high risk procedure

• Only 50-60% of all Hartmann’s are eventually reversed

• Many patients are elderly with significant comorbidities

• Anastomotic leak rates up to 15%• Morbidity rates range 30-40%• Mortality rates up to 10%

Laparoscopic Hartmann’s Reversal

• Conversion usually dictated by extent of adhesions and difficulty finding rectal stump

• Intraoperative and postoperative complications also dictated by surgeon experienceBennett Ch, et al. Arch Surg 1997.– Surgeons with > 40 cases have lower rates of

intraoperative and postoperative complications than surgeons with < 40 cases.

• 114 surgeons• 1194 patients • Intraoperative – 3.7% vs. 6.3%, Postoperative - 10% vs. 19%,

Laparoscopic Hartmann’s Reversal

• Technique variations– Take down colostomy site, resection of stump,

placement of circular stapler anvil, reduction into abdomen, and placement of intial trocar into ostomy site

– Establishment of pneumoperitoneum with port site remote from colostomy site/previous incision

• Continue with adhesiolysis and identification of rectal stump

Hartmann’s reversal: high risk procedure

• Schmelzer, et al, Surgery 2007– 113 pts.– 15% performed laparoscopically– 25% postop complication rate, no mortality

• 16% wound infection, 5% bleeding, 1.5% pneumonia, 1.5% abscess, 1% anastomotic leak

– Albumin <3.5 only significant predictor of postop complications

Laparoscopic vs. Open Reversal

• Mazeh, et al, 2009, retrospective analysis– 41 pts lap, 41 open– Conversion rate 19.5%

– Lap Morbidities: Ileus, SSI, blood transfusion, EC fistula– Open: Ileus, SSI, pneumonia, atelectasis, urinary rtn,

arrythmia, blood trx, ICU admit, Cdiff colitis, DVT, reoperation

Laparoscopic Open

OR time (min) 193 209

Hospital stay (days)

6.4 8.0

Morbidity 26.8% 48.7%

Laparoscopic vs. Open Reversal• Rosen, et al, 2006

– 22 total lap cases at single institution compared to 22 randomly selected open cases

– 9% conversion rate

– Lap Morbidities: Wound infection (3)– Open: Wound infx (6), ileus (4)anast. leak, resp.

failure, SBO, pnuemonia, transfusion, UTI

Laparoscopic Open

OR time 158 189

Hospital stay 4.2 7.3

Morbidity 14% 59%

Laparoscopic vs. Open Reversal

• Faure, et al, 2007– 14 lap, 20 open– 14.2% conversion rate

– Lap Morbidities: 1 abscess, 1 anast. stenosis– Open: 1 anast. leak, 5 incisional hernias

Laparoscopic Open

OR time 143 180

Hospital stay 9.5 18

Morbidity 14% 30%

Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann’s procedure

be considered a one-stage procedure?

• Reversal 139 Hartmann’s Procedure for diverticulitis• Reversal-rate 63/139 (45%) • Delay to reversal 9.1 months• Post reversal morbidity was 44%• Anastomotic leakage was observed in 10 patients• Three patients died 4.7 %

Closure 19 Primary Anastomosis with Diverting Ileostomy• Reversal-rate 14/19 (74%)• Delay to reversal 3.9 months• Post reversal morbidity was 15%• No leaks or mortality

Vermeulen,Colorectal Disease.July 2009

Laparoscopic vs. Conventional Reversal of HP

• A total of 396 patients had a laparoscopic HR vs. 5,853 patients with conventional HR.

• Hospital stay appeared to be notably shorter after laparoscopic HR

• patients treated laparoscopically appeared to have a reduced mean overall morbidity rate (wound infections mainly)

• Reoperations occurred more often in conventional HR• operating time was comparable (mean 153 min, range 30–

356• Conversion from laparoscopy to conventional surgery ranged

from 7% to 22%Bryan Joost Marinus van de Wall et al, Conventional and Laparoscopic Reversal of the Hartmann Procedure: a Review of Literature. J Gastrointest Surg. 2010 April; 14(4): 743–752. Published online 2009 November 21

Laparoscopic vs. Conventional Reversal of HP

Laparoscopic HR Conventional HR

Hospital Stay mean 6.9 range 3–11 days mean 10.7 range 3–18 days

Morbidity rate 12.2% 20.3%

Leak rate 1.2% 5.1%

Reoperation rate 3.6% 6.9%

Mortality 0.9% 1.1%

Operative time mean 153Range 30-356 min

mean 170 , range 57–500 min

Bryan Joost Marinus van de Wall et al, Conventional and Laparoscopic Reversal of the Hartmann Procedure: a Review of Literature. J Gastrointest Surg. 2010 April; 14(4): 743–752. Published online 2009 November 21

Best treatment for complications Best treatment for complications

Prevent themPrevent them

LearningLearning

Complications of laparoscopic colorectal surgery

Long-term Experience with the Laparoscopic Approach to Perforated Diverticulitis plus generalized peritonitis

• Antibiotics started in ER. Endoscopic peritoneal lavage, if a perforation was seen, it was closed with 2-0 vicryl. 2 JP drains were placed. No sigmoid resection.

• 40 patients included. • Mean operative time 62 min (40-150)

M.E. Franklin Jr., G. Portillo., J.M. Treviño., J.J. González., J. L. Glass. Long Term Experience with the Laparoscopic Approach to Perforated Diverticulitis plus Generalized Peritonitis. World J Surg (2008) 32: 1507-1511

Results• Patients became afebrile and WBC returned to

normal on the second post-op day.• Oral feeding started post-op day 2.• Drains removed post-op day 6.• Average in-hospital stay 3 days.• 50% of the patients had a planned colectomy

afterwards.• Mean follow-up 96 months. No recurrences or

admissions related to diverticular disease.• No conversion to open.M.E. Franklin Jr., G. Portillo., J.M. Treviño., J.J. González., J. L. Glass. Long Term Experience with the Laparoscopic Approach to Perforated Diverticulitis plus Generalized Peritonitis. World J Surg (2008) 32: 1507-1511

Conclusions

• Laparoscopic lavage is a safe alternative to the management of perforated diverticulitis. – Decrease cost of treatment– Colostomy avoided– Immediate improvement– Reduction of morbidity and mortality– Low rate of wound complications

• Should be considered for every patient presenting with perforated diverticulitis.

M.E. Franklin Jr., G. Portillo., J.M. Treviño., J.J. González., J. L. Glass. Long Term Experience with the Laparoscopic Approach to Perforated Diverticulitis plus Generalized Peritonitis. World J Surg (2008) 32: 1507-1511

PERFORATED DIVERTICULITIS MANAGED BY LAPAROSCOPIC LAVAGE• Fourteen patients with a mean age of 57.2 years• Sigmoid diverticulitis was confirmed in all cases

– Hinchey grade 3 purulent peritonitis in 10 patients– grade 2 contamination in 2 patients – grade 4 feculent peritonitis in 2 patients

• Three patients (2 feculent peritonitis, 1 purulent) did not improve and underwent acute resection with stoma

• Eleven patients (79%) improved and were discharged following a median of 6.5 days (range, 5–32 days)

• Eight patients have subsequently undergone elective resection without a stoma at a mean interval of 6 weeks

• Conclusion: Acute resection should still be carried out in patients found to have fecal peritonitis

Taylor,ANZ Journal of Surgery,November 2006