Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study

E G M van Geffen^{1

2}, F S Verheij^{1

3}, S M J A Hazen^{1

2}, T C Sluckin^{1

2}, E C J Consten⁴, J-W T Dekker⁵, J Nederend⁶, K C M J Peeters⁷, J H W de Wilt⁸, S van Dieren¹, R Hompes¹, J B Tuynman¹, C A M Marijnen^{9

10}, P J Tanis^{11

12}, M Kusters¹; Dutch Snapshot Research Group

Collaborators, Affiliations

Collaborators

Dutch Snapshot Research Group:
A G J Aalbers, S M van Aalten, F J Amelung, M Ankersmit, I E Antonisse, J F Ashruf, T S Aukema, H Avenarius, R R Bahadoer, F C H Bakers, I S Bakker, F Bangert, R M Barendse, H M D Beekhuis, G L Beets, R G H Beets-Tan, W A Bemelman, M Berbée, S H de Bie, R H C Bisschops, R D Blok, L W van Bockel, A H Boer, F C den Boer, E-J G Boerma, L S F Boogerd, J Borstlap, W A A Borstlap, J E Bouwman, S J Braak, M N G J A Braat, J Bradshaw, A T A Brandsma, V van Breest Smallenburg, W T van den Broek, S W van der Burg, J W A Burger, T A Burghgraef, D W G Ten Cate, H M Ceha, J S Cnossen, R R J Coebergh van den Braak, M Corver, R M P H Crolla, S Curutchet, A W Daniëls-Gooszen, P H P Davids, E N Dekker, J W T Dekker, A Demirkiran, T Derksen, A L Diederik, A M Dinaux, K Dogan, I M van Dop, K E Droogh-de Greve, H M H Duijsens, M S Dunker, J Duyck, E B van Duyn, L S E van Egdom, B Eijlers, Y El-Massoudi, S van Elderen, A M L H Emmen, M Engelbrecht, A C van Erp, J A van Essen, H F J Fabry, T Fassaert, E A Feitsma, S S Feshtali, B Frietman, E J B Furnée, A M van Geel, E D Geijsen, A A W van Geloven, M F Gerhards, H Gielkens, R A H van Gils, L Goense, M J P M Govaert, W M U van Grevenstein, E J de Groof, I de Groot, R J de Haas, N A G Hakkenbrak, M D den Hartogh, V Heesink, J T Heikens, E M Hendriksen, S van den Hoek, E J R J van der Hoeven, C Hoff, A Hogewoning, C R C Hogewoning, S Hoogendoorn, F van Hoorn, K Horsthuis, R L van der Hul, R van Hulst, F Imani, B Inberg, M P W Intven, P Janssen, C E J de Jong, J Jonkers, D Jou-Valencia, B Keizers, S H J Ketelaers, E Knöps, S van Koeverden, S Kok, S E M Kolderman, F I de Korte, R T J Kortekaas, J C Korving, I M Koster, J Krdzalic, P Krielen, L F Kroese, E J T Krul, D H H Lahuis, B Lamme, A A G van Landeghem, J W A Leijtens, M M Leseman-Hoogenboom, M S de Lijster, C A M Marijnen, M S Marsman, M H Martens, I Masselink, W van der Meij, P Meijnen, J Melenhorst, D J L de Mey, J Moelker-Galuzina, L Morsink, E J Mulder, K Muller, G D Musters, P A Neijenhuis, L C F de Nes, M Nielen, J B J van den Nieuwboer, J F Nieuwenhuis, J Nonner, B J Noordman, S Nordkamp, P B Olthof, S J Oosterling, D Ootes, V Oppedijk, P Ott, I Paulusma, I T A Pereboom, J Peringa, Z Pironet, J D J Plate, F Polat, I G M Poodt, L A E Posma, J F Prette, B B Pultrum, S M Qaderi, J M van Rees, R-J Renger, A J M Rombouts, L J Roosen, E A Roskott-Ten Brinke, J Rothbarth, D B Rouw, T Rozema, H Rütten, H J T Rutten, M E van der Sande, B E Schaafsma, R A Schasfoort, M M Scheurkogel, A P Schouten van der Velden, W H Schreurs, P M E Schuivens, C Sietses, P C G Simons, M J Slob, G D Slooter, M van der Sluis, B P Smalbroek, A B Smits, E J Spillenaar-Bilgen, P H Spruit, T C Stam, J Stoker, A K Talsma, S J D Temmink, G Y Mireille, J A W Tielbeek, A A J M van Tilborg, F van Tilborg, D van Trier, M J M van der Valk, I J S Vanhooymissen, G Boudewijn, C Vasbinder, C J Veeken, L A Velema, A W H van de Ven, E G G Verdaasdonk, W M Verduin, T Verhagen, P M Verheijen, M Vermaas, A-S E Verrijssen, A V D Verschuur, H Verwoerd-van Schaik, R F A Vliegen, S Voets, F Jeroen Vogelaar, C L A Vogelij, J Vos-Westerman, M de Vries, J C Vroemen, B S T van Vugt, J A Wegdam, B J van Wely, M Westerterp, P P van Westerveld, H L van Westreenen, A G Wijma, B W K de Wit, F Wit, K Woensdregt, V van Woerden, F S W van der Wolf, S van der Wolk, J M Wybenga, E S van der Zaag, B Zamaray, H J A Zandvoort, D van der Zee, A P Zeilstra, K J Zheng, D D E Zimmerman, M Zorgdrager

Affiliations

¹ Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC Location Vrije Universiteit Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
² Treatment and Quality of Life and Imaging and Biomarkers, Cancer Centre Amsterdam, Amsterdam, The Netherlands.
³ Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
⁴ Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.
⁵ Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands.
⁶ Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands.
⁷ Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
⁸ Department of Surgical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
⁹ Department of Radiotherapy, Leiden University Medical Centre, Leiden, The Netherlands.
¹⁰ Department of Radiotherapy, Netherlands Cancer Institute, Amsterdam, The Netherlands.
¹¹ Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands. p.tanis@erasmusmc.nl.
¹² Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, The Netherlands. p.tanis@erasmusmc.nl.

PMID: 41276685
DOI: 10.1007/s10151-025-03169-5

Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study

E G M van Geffen et al. Tech Coloproctol. 2025.

. 2025 Nov 23.

doi: 10.1007/s10151-025-03169-5. Online ahead of print.

Authors

Collaborators

Dutch Snapshot Research Group:
A G J Aalbers, S M van Aalten, F J Amelung, M Ankersmit, I E Antonisse, J F Ashruf, T S Aukema, H Avenarius, R R Bahadoer, F C H Bakers, I S Bakker, F Bangert, R M Barendse, H M D Beekhuis, G L Beets, R G H Beets-Tan, W A Bemelman, M Berbée, S H de Bie, R H C Bisschops, R D Blok, L W van Bockel, A H Boer, F C den Boer, E-J G Boerma, L S F Boogerd, J Borstlap, W A A Borstlap, J E Bouwman, S J Braak, M N G J A Braat, J Bradshaw, A T A Brandsma, V van Breest Smallenburg, W T van den Broek, S W van der Burg, J W A Burger, T A Burghgraef, D W G Ten Cate, H M Ceha, J S Cnossen, R R J Coebergh van den Braak, M Corver, R M P H Crolla, S Curutchet, A W Daniëls-Gooszen, P H P Davids, E N Dekker, J W T Dekker, A Demirkiran, T Derksen, A L Diederik, A M Dinaux, K Dogan, I M van Dop, K E Droogh-de Greve, H M H Duijsens, M S Dunker, J Duyck, E B van Duyn, L S E van Egdom, B Eijlers, Y El-Massoudi, S van Elderen, A M L H Emmen, M Engelbrecht, A C van Erp, J A van Essen, H F J Fabry, T Fassaert, E A Feitsma, S S Feshtali, B Frietman, E J B Furnée, A M van Geel, E D Geijsen, A A W van Geloven, M F Gerhards, H Gielkens, R A H van Gils, L Goense, M J P M Govaert, W M U van Grevenstein, E J de Groof, I de Groot, R J de Haas, N A G Hakkenbrak, M D den Hartogh, V Heesink, J T Heikens, E M Hendriksen, S van den Hoek, E J R J van der Hoeven, C Hoff, A Hogewoning, C R C Hogewoning, S Hoogendoorn, F van Hoorn, K Horsthuis, R L van der Hul, R van Hulst, F Imani, B Inberg, M P W Intven, P Janssen, C E J de Jong, J Jonkers, D Jou-Valencia, B Keizers, S H J Ketelaers, E Knöps, S van Koeverden, S Kok, S E M Kolderman, F I de Korte, R T J Kortekaas, J C Korving, I M Koster, J Krdzalic, P Krielen, L F Kroese, E J T Krul, D H H Lahuis, B Lamme, A A G van Landeghem, J W A Leijtens, M M Leseman-Hoogenboom, M S de Lijster, C A M Marijnen, M S Marsman, M H Martens, I Masselink, W van der Meij, P Meijnen, J Melenhorst, D J L de Mey, J Moelker-Galuzina, L Morsink, E J Mulder, K Muller, G D Musters, P A Neijenhuis, L C F de Nes, M Nielen, J B J van den Nieuwboer, J F Nieuwenhuis, J Nonner, B J Noordman, S Nordkamp, P B Olthof, S J Oosterling, D Ootes, V Oppedijk, P Ott, I Paulusma, I T A Pereboom, J Peringa, Z Pironet, J D J Plate, F Polat, I G M Poodt, L A E Posma, J F Prette, B B Pultrum, S M Qaderi, J M van Rees, R-J Renger, A J M Rombouts, L J Roosen, E A Roskott-Ten Brinke, J Rothbarth, D B Rouw, T Rozema, H Rütten, H J T Rutten, M E van der Sande, B E Schaafsma, R A Schasfoort, M M Scheurkogel, A P Schouten van der Velden, W H Schreurs, P M E Schuivens, C Sietses, P C G Simons, M J Slob, G D Slooter, M van der Sluis, B P Smalbroek, A B Smits, E J Spillenaar-Bilgen, P H Spruit, T C Stam, J Stoker, A K Talsma, S J D Temmink, G Y Mireille, J A W Tielbeek, A A J M van Tilborg, F van Tilborg, D van Trier, M J M van der Valk, I J S Vanhooymissen, G Boudewijn, C Vasbinder, C J Veeken, L A Velema, A W H van de Ven, E G G Verdaasdonk, W M Verduin, T Verhagen, P M Verheijen, M Vermaas, A-S E Verrijssen, A V D Verschuur, H Verwoerd-van Schaik, R F A Vliegen, S Voets, F Jeroen Vogelaar, C L A Vogelij, J Vos-Westerman, M de Vries, J C Vroemen, B S T van Vugt, J A Wegdam, B J van Wely, M Westerterp, P P van Westerveld, H L van Westreenen, A G Wijma, B W K de Wit, F Wit, K Woensdregt, V van Woerden, F S W van der Wolf, S van der Wolk, J M Wybenga, E S van der Zaag, B Zamaray, H J A Zandvoort, D van der Zee, A P Zeilstra, K J Zheng, D D E Zimmerman, M Zorgdrager

Affiliations

¹ Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC Location Vrije Universiteit Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
² Treatment and Quality of Life and Imaging and Biomarkers, Cancer Centre Amsterdam, Amsterdam, The Netherlands.
³ Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
⁴ Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.
⁵ Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands.
⁶ Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands.
⁷ Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
⁸ Department of Surgical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
⁹ Department of Radiotherapy, Leiden University Medical Centre, Leiden, The Netherlands.
¹⁰ Department of Radiotherapy, Netherlands Cancer Institute, Amsterdam, The Netherlands.
¹¹ Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands. p.tanis@erasmusmc.nl.
¹² Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, The Netherlands. p.tanis@erasmusmc.nl.

PMID: 41276685
DOI: 10.1007/s10151-025-03169-5

Abstract

Background: In the Netherlands, approximately 15% of patients with rectal cancer undergo a low Hartmann's procedure (low-HP). This is often preoperatively planned to avoid poor functional outcome or complications, but might be unplanned as a result of intraoperative difficulties. Low-HPs seem to be associated with worse oncological outcomes.

Methods: All patients who underwent either restorative low anterior resection (rLAR), planned low-HP, or unplanned low-HP for primary rectal cancer in 2016 were included from a nationwide cohort. Main outcomes were 4-year local recurrence (LR) rate and disease-free survival (DFS).

Results: Of 2043 patients, 1704 underwent rLAR (83.4%), 253 planned low-HP (12.4%), and 86 unplanned low-HP (4.2%). Among intended rLAR patients (n = 1790), independent risk factors for unplanned low-HP were older age, higher body mass index (BMI), higher American Society of Anesthesiologists (ASA) score, and more distal tumor location. Oncological outcomes after low-HPs were worse than after rLARs (LR 13.7% vs 5.6%, DFS 54.7% vs 71.8%, both p < 0.001), but similar for unplanned and planned low-HP. In multivariable analysis, unplanned and planned low-HP were not associated with LR or DFS, but R1 resection was (HR 6.6 (4.1-10.6), HR 3.0 (2.2-4.0), respectively). In R1 resections, the distal margin was more often involved after low-HP (70.0% vs 28.6%, p = 0.013) compared to rLAR.

Conclusion: Poor outcomes in univariable analysis after low-HP appear to be associated with more challenging procedures and increased risk of involved resection margin rather than the low-HP itself. In case of expected difficulties, an extralevator abdominoperineal excision or referral to an expert center might be an alternative to improve resection margins.

Trial registration: ClinicalTrials.gov, identifier NCT05539417, retrospectively registered on September 16, 2022.

Keywords: Conversion to open surgery; Minimally invasive surgical procedures; Rectal cancer; Resection margins.

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Conflict of interest statement

Declarations. Conflicts of interest: The authors declare no competing interests. Ethics approval: The Medical Ethics Committee of the Amsterdam UMC approved this study and determined it to be exempt from the Dutch Medical Research Involving Human Subjects Act. Local institutional review boards approved the study execution and determined patient consent procedures.

References

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1. Anderin C, Martling A, Hellborg H, Holm T (2010) A population-based study on outcome in relation to the type of resection in low rectal cancer. Dis Colon Rectum 53(5):753–760
1. Ortiz H, Wibe A, Ciga MA et al (2014) Multicenter study of outcome in relation to the type of resection in rectal cancer. Dis Colon Rectum 57(7):811–822
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Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study

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Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study

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