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 experience Bennett Ch, et al. Arch Surg – 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 LaparoscopicOpen OR time (min) Hospital stay (days) Morbidity26.8%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 LaparoscopicOpen OR time Hospital stay Morbidity14%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 LaparoscopicOpen OR time Hospital stay9.518 Morbidity14%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 April; 14(4): 743–752. Published online 2009 November 21

Laparoscopic vs. Conventional Reversal of HP Laparoscopic HRConventional HR Hospital Staymean 6.9 range 3–11 daysmean 10.7 range 3–18 days Morbidity rate12.2%20.3% Leak rate1.2%5.1% Reoperation rate3.6%6.9% Mortality0.9%1.1% Operative timemean 153 Range 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 April; 14(4): 743–752. Published online 2009 November 21

Best treatment for complications Prevent them Learning 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:

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:

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:

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