Acute Diverticulitis & Hartmann’s Procedure
Nigel A. Scott MD FRCS
Hope Hospital, Salford
CT diagnosis/ CT intervention
Illness and Optimisation
Hospital
death
Morbidity
Routine Care
22%
1.35+/- 0.2
O2 delivery
targeted
towards
600ml/min/m2
5.7%
0.68 +/0.6
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
Emergency Admission for Acute Diverticulitis
• CT diagnosis/ CT intervention
• illness /optimisation
What’s the best operation in acute
complicated diverticulitis ?
Emergency Admission for Acute Diverticulitis
Acute Complicated Diverticulitis – Which Operation ?
Defunctioning Colostomy
• death
Hartmann’s Procedure (HP)
• illness
Primary Anastomosis (PA)
• permanent stoma
Emergency Admission for Acute Diverticulitis
Hinchey stage III & IV – colostomy alone ?
Primary Resection
Anastomosis
Hartmann’s
Lateral Colostomy
52
0
0
0
48
Early reoperation
2
9
<0.02
Death
13
9
ns
Post-op
Peritonitis
1
10
<0.01
15d
24d
<0.05
Length of stay
3
Proximal Colostomy
Zeitoun et al Br J Surg 2000;87:1366-1374
Emergency Admission for Acute Diverticulitis
Acute Complicated Diverticulitis – Which Operation ?
Defunctioning Colostomy
• death
Hartmann’s
• illness
Primary Anastomosis
• permanent stoma
Emergency Admission for Acute Diverticulitis
Q – Primary Anastomosis (PA) or
Hartmann’s Procedure (HP)
• 15 papers (1997 – 2003)
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%)
Emergency Admission for Acute Diverticulitis
Resection for Acute Diverticular Sepsis n=1620
PA
PA+ stoma
HP
Other
1 HP:1 PA
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 [
• 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
Might as well do PA as HP –
but are we comparing like with like ?
Emergency Admission for Acute Diverticulitis
Makela et al Dis Colon Rectum 1998;1523-1528
100%
80%
60%
HP
PA
40%
20%
0%
<50yrs
51-70yrs
>70yrs
Hartmann’s Procedure is used in Elderly
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
Blair et al Am J Surg 2002:183:525-528
100%
80%
60%
HP
PA
40%
20%
0%
I
II
III
IV
DEATHS
Biondo et al J Am Coll Surg 2000;191:635-642
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
HP
PA
I
II
III
Hartmann’s Procedure is used in ASA >III
IV
DEATHS
Emergency Admission for Acute Diverticulitis
• 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
**Wedell 1997
PA 149(1)
HP 17(3)
Hinchey III
Hinchey IV
14(1)
15(4)
Deaths
2
7
Blair 2000
PA 12
HP 6
**Gooszen
2001
Somasekar
2002
12
25
28
PA 0
HP
0
PA 3
HP
7
25
2
7
9
0
0
6
0
59
3
13
3
0
27
Makela 2002
34
4(total)
PA 8
HP 2
3
1
1
7
0
19
** adapted from Hughes staging
Emergency Admission for Acute Diverticulitis
6 papers n = 454
100%
80%
60%
HP
PA
40%
20%
0%
I & II
III & IV
Hartmann’s Procedure is used in Hinchey III and IV
What’s the best operation in acute complicated diverticulitis ?
age
CT
PA
HP
sepsis
ASA
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
Early reversal (mean 11 weeks)
Late reversal (mean 34 weeks)
4 – inadvertent enterotomy
4 – inadvertent enterotomy
5/13 (38%)
3/37 (8%)
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
• 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 – Laparoscopic
H Gallagher
10
9 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
Reversals
Elliott 1997
51
86%
Wedell 1997
31
31%
Hoemke 1999
0
-
Umbach 1999
0
-
Blair 2000
64
na
Schilling 2001
42
76%
Gooszen 2001
28
57%
Maggard 2001
32
100%
Biondo 2000
60
na
Makela 2002
75
45%
Somasekar 2002
98
na
Gooszen 2002
0
-
Landen 2002
0
-
Regenet 2003
33
69%
Zorcollo 2003
~92
39%
91
HP for Diverticulitis in 12mths
72 survivors
19 deaths
65 attempted reversal
63 success
3% died
38% morbidity
63/65 = 96.9% reversal
63/91 = 69% reversal
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
Surgery and Acute Diverticulitis
Summary
• 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
The End