Hartmann's procedure for obstructive carcinoma of the left colon and rectum: a comparative study with one-stage surgery

Abstract

Introduction and objectives: Despite the criticisms from prestigious expert committees, a high percentage of surgeons continue to use, as the technique-of-choice, Hartmann's procedure for acute malignant intestinal obstruction of the distal colon and rectum, without faecal peritonitis. We have reviewed our results with this technique and compared them with other series of patients in the literature undergoing one-stage surgery (resection with primary anastomosis or sub-total colectomy).

Material and methods: A retrospective and descriptive study using clinical histories and, from which, the variables studied were: median hospitalisation stay, morbido-mortality and reconstruction index.

Results: Included in the analysis were 44 patients (24 male; 20 female) with an age range between 37 and 87 years (median age: 67.04 years). The median hospitalisation stay was 15.59 days (range: 8-39). In the 10 patients undergoing reconstruction this was 12.8 days (range: 10-17). The overall stay, therefore, was 28.39 days. The median stay in the series of patients having one-stage surgery was 13.9 days. The morbidity using Hartmann's procedure was 43.18% (19/44) and, in the patients with reconstruction, 40% (4/10). The morbidity in the literature series with one-stage surgery was 22.53%. Mortality in our study was 0%. The mortality in the 16 cases from the literature was close to 5%, although in 3 of the studies this was also 0%. The percentage undergoing reconstruction was 22.72% (10 cases). The median age in the non-reconstructed patients was 71.42 years (range: 46-87) compared to a median age of 52.6 (range 37-67) in the group with reconstruction (p < 0.001). The percentages undergoing reconstruction, according to tumour stage, were Dukes B: 36.84%; Dukes C: 23.07%; Dukes D: 0% (p < 0.001). The median waiting-time for a reconstruction was 15.73 months (range: 8-33).

Conclusions: Comparisons of our results with the outcomes in the series of patients in the literature with one-stage surgery indicate that "one-stage surgery" is the more suitable but, however, with two conditions: a sufficient command of the technique so as to minimise complications and a strict patient selection, with the Hartmann's procedure being retained for patients with high anaesthesia risk.