CIRUGIA Y CIRUJANOS

ORIGINAL ARTICLE

Surgical results of Hartmann procedure in emergency cases

with left-sided colorectal cancer
Resultados quirúrgicos del procedimiento de Hartmann en casos de emergencia con
cáncer colorrectal izquierdo
Onder Altin, Selcuk Kaya, Ramazan Sari, Yunus E. Altuntas, Baver Baris, and Hasan F. Kucuk
Department of General Surgery, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey

Abstract

Objective: We aimed to define indication of Hartmann procedure (HP) under emergency conditions, analyze, and present in
which cases this procedure should be used. Methods: The patients who underwent emergency surgery for colorectal cancer
were analyzed. Rates of mortality, overall, and disease-free survival of the patients were evaluated. The colostomy closure
rate, operative mortality, and surgical complications of the secondary operation performed after the HP were also assessed.
Results: Fifty-seven patients who underwent HP were included in the study. The indications were obstruction (n = 37) or
perforation (n = 20). The post-operative mortality and morbidity rates were 21.1% and 63.2%, respectively. The 1-, 3-, and
5-year survival rates for all patients were 54%, 49%, and 45%. Conclusion: HP can be a life-saving procedure in cases of
high risk, emergency colorectal disease. Surgeons create a temporary stoma as a part of this procedure that is generally closed
with a second operation. However, it is not possible to close the stoma in some cases, and the potential physical and emo-
tional issues related to the stoma should be a part of the surgeon’s considerations.

Key words: Colorectal cancer. Hartmann procedure. Obstruction. Perforation. Colostomy.

Resumen

Objetivo: Definir la indicación del procedimiento de Hartmann en condiciones de emergencia y en qué casos debe utilizarse.
Método: Se analizaron los pacientes sometidos a cirugía colorrectal de emergencia. Se evaluaron las tasas de mortalidad y de
supervivencia global y libre de enfermedad. También se evaluaron la tasa de cierre de la colostomía, la mortalidad operatoria y
las complicaciones quirúrgicas de la operación secundaria. Resultados: Fueron incluidos en el estudio 57 pacientes sometidos
a un procedimiento de Hartmann. Las indicaciones fueron obstrucción (n = 37) o perforación (n = 20). Las tasas de mortalidad
y de morbilidad posoperatorias fueron del 21,1% y el 63,2%, respectivamente. Las tasas de supervivencia a 1, 3 y 5 años para
todos los pacientes fueron del 54%, el 49% y el 45%. Conclusión: El procedimiento de Hartmann puede salvar vidas en casos
de enfermedad colorrectal de emergencia de alto riesgo. Los cirujanos crean un estoma temporal como parte de este proced-
imiento, que generalmente se cierra con una segunda operación. Sin embargo, en algunos casos no es posible cerrar la estoma,
y los posibles problemas físicos y emocionales relacionados con este deberían ser parte de las consideraciones del cirujano.

Palabras clave: Cáncer colorrectal. Procedimiento de Hartmann. Obstrucción. Perforación. Colostomía.

Correspondence:
*Ramazan Sari
Şemsi Denizer caddesi E-5
Karayolu Cevizli mevkii 34890 Date of reception: 25-02-2020 Cir Cir. 2021;89(2):150-155
Kartal, Istanbul, Turkey Date of acceptance: 18-04-2020 Contents available at PubMed
E-mail: [email protected] DOI: 10.24875/CIRU.20000140 www.cirugiaycirujanos.com
0009-7411/© 2020 Academia Mexicana de Cirugía. Published by Permanyer. This is an open access article under the terms of the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Introduction The aim of this study was to evaluate the surgical

results of left-sided CRC patients who underwent HP
under emergency conditions for mechanical intestinal
Almost 10-28% of patients with colorectal cancer
obstruction or perforation.
(CRC) present with mechanical intestinal obstruction
or perforation. This situation usually requires emer-
Materials and Methods
gency surgical intervention. In the literature, the mor-
tality rate after emergency colorectal surgery has
The data of patients with left-sided CRC who under-
been reported as 15-22.5% with a morbidity rate of went an emergency HP with a mechanical bowel ob-
40-50%1,2. Particularly in cases of colon cancer with struction or perforation between January 2012 and
a mechanical bowel obstruction, gastrointestinal con- December 2017 were analyzed retrospectively. This
tinuity can now be provided with the help of new tech- study was approved by ethics committee of University
nological methods, such as stenting and laser therapy. of Health Science Kartal Training and Research Hos-
Thus, patients presenting with emergency status can pital (Project No: 2018/514/125/3). Informed consent
be converted to elective or semi-elective status, re- was obtained from all patients before operation.
ducing both mortality and morbidity and allowing for Patients who were operated on for non-oncological
a one-stage operation3. reasons, elective surgeries, and cases with unavail-
However, in elderly patients, who are often dehy- able or incomplete data were excluded from the study.
drated with poor hemodynamic status and sepsis, Furthermore, the patients who placed endoscopic
these procedures are difficult and time consuming4. stent before surgery were not included in this study.
Under these conditions, many surgeons avoid the risk Demographic characteristics, perioperative risks, tu-
of performing anastomosis. Therefore, the procedure mor localization, surgical indication (obstructive or
of closure of the rectum following resection of the tu- perforated), stage according to the TNM Classification
mor and anastomosing the proximal part of the colon of Malignant Tumors, and the type of resection (cura-
to the skin (end colostomy) in a patient with a recto- tive or palliative) were analyzed in this study. No evi-
sigmoid tumor first described in 1921 by French sur- dence of residual or metastatic disease detected
geon Henri Hartmann is still widely used. This during the procedure and margins of the resected
procedure also saves both surgeons and patients from specimen that was determined to be devoid of tumor
many potentially troublesome situations5. In 1950, cells in the pathological examination was considered
Boyden reported on the application of the Hartmann a curative resection. Operative mortality was defined
procedure (HP) in cases with acute diverticulitis and as mortality occurring within 30 days of the procedure.
closure of the colostomy6. Emergency cases with a The surgical reports indicated the presence of a pre-
decompensated ileus due to tumor-induced obstruc- operative comorbidity, hemodynamic instability, local-
tion, perforation, or bleeding; secondary interventions ized or widespread peritonitis, and suspicion about
due to anastomotic leak; and unstable patients with the healthy circulation of the proximal colon as rea-
high-risk hemodynamics are the main indications for sons for not performing anastomosis during the pri-
HP7. This method has been preferred in cases of sig- mary resection.
moid volvulus, trauma-induced colon perforation, ra- The rates of mortality, overall survival (OS), and
diation injury, and anastomosis leak after anterior disease-free survival (DFS) of the patients undergoing
resection8. The creation of a stoma as a part of HP is HP were evaluated. The colostomy closure rate, op-
technically reversible with a second operation, and erative mortality, and surgical complications of the
surgeons often think of it as temporary. However, secondary operation performed after the HP were
stoma closure will not be possible in some HP pa- also assessed.
tients9. In studies evaluating the outcome of HP, the
stoma closure rate has been as low as 24-35% and Statistical analysis
the 5-year survival rate has been reported to be
31%9,10. Despite this, many surgeons still point to the The age variable was defined using the mean ±
fact that HP provides the opportunity to shorten op- standard deviation (SD) and analyzed with a t-test.
eration time and reduce surgical trauma, particularly The OS variable was defined according to the median
in high-risk patients, while allowing for R0 resection ± SD and analyzed using the Mann–Whitney U-test.
in CRC patients11. A Chi-square test was calculated using the Statistical
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Package for the Social Sciences program for other Table 1. Age distribution of patients
variables. Normally distributed data were analyzed Patient’s age n (%)
with t-tests. Data with a non-normal distribution were
<40 y/o 1 (1.8)
defined by the median and interval and analyzed us-
ing the Mann–Whitney U-test. Relationships between Between 40 and 65 y/o 22 (38.6)
cross-tabulated variables were analyzed using a Chi- More than 65 y/o 34 (59.6)
square test or Fisher’s test, as necessary. The nor-
mality of the data was analyzed using the
Kolmogorov–Smirnov test. Values of p < 0.05 were
considered statistically significant. Table 2. Mortality and morbidity rates

Obstruction Perforation Total

Results (n:37) (n:20) (n:57)

Complication: 20 16 36 (63%)
A total of 57 patients who underwent HP under Wound related 11 9 20 (35%)
emergency conditions were included in the study. All Ostomy related 3 2 5 (9%)
of the operations performed by general surgeons in Intra-abdominal abscess 4 3 7 (12%)
Respiratory or other 2 2 4 (7%)
the colorectal department. Thirty-one (54.4%) patients
were male and 26 (45.6%) were female. The median Mortality: 19 12 31 (54%)
Early 8 4 12 (21%)
age was 67 years (31-89 years) and distribution of Delay 11 8 19 (33%)
patients by age groups presented in table 1. Concomi-
tant diseases were observed in 40 (70%) patients. The
indication for HP was obstruction (n = 37) or perfora-
tion (n = 20). The early post-operative mortality and significantly less than in Stages II-III (p<0.05). The
morbidity rates were 21.1% (n = 12) and 63.2% (n = 36),
5-year survival time of the study group is illustrated in
respectively. Detailed mortality and morbidity rates by
figures 1 and 2.
groups are presented in table 2. The median follow-up
The stomas of 12 (26.6%) patients were closed in
period for remaining 45 patients was 16 months
an average of 237 days (180-360 days) (Fig. 3). No
(2-67 months). During the follow-up period, 23 (40.3%)
death or anastomotic leakage was observed after sto-
patients presented with metastatic disease (19 cases
ma closure. In one patient, the procedure was not
with liver metastasis, 2 cases with lung metastasis,
completed as a result of the peroperative discovery of
and 2 patients with carcinomatosis), and 19 (33.3%)
peritonitis carcinomatosa. Two patients in this group
of these patients died. Of the 26 (45.6%) surviving
developed distant metastasis; however, no mortality
patients, 21 (36.8%) had DFS, while 5 (8.7%) patients
had distant organ metastasis. The 1-, 3-, and 5-year was observed during the follow-up period.
survival rates for all patients were 54%, 49%, and
45%, respectively. Discussion
Comparison of the patients who underwent HP for
obstruction with those who experienced a perforation HP was initially used as a treatment modality for
did not reveal any significant difference in survival rate left-sided colonic obstruction, perforated diverticulitis,
(p > 0.05). However, the presence of extramural peri- and emergency cases of colorectal disease with a
neural invasion (n:31) was significant in terms of poor high risk for anastomosis. The procedure is largely
prognosis (p < 0.05). Curative resection was per- successful in achieving resolution of an emergency
formed in 34 patients (60%). In this group, the overall situation12,13. However, with the increase in application
1-, 3-, and 5-year survival rates were 79%, 67%, and of HP, new challenges emerged, and the deterioration
64%, respectively. The average DFS for Stage II and in the quality of life of these emergency patients drew
III patients was 30.7 months and 35.8 months, respec- more attention. It has been reported in various studies
tively, while the OS was 32.4 months and 35.9 months, that patients with an ostomy face psychological and
respectively. For Stage IV patients, the average DFS physical difficulties14,15. The ideal treatment approach
was 3.7 months and the OS was 7.5 months. There in emergency cases of left-sided CRC is still contro-
was no significant difference in DFS and OS between versial and it is closely related to the surgeon’s experi-
Stages II and III. The average survival in Stage IV was ence as well as the general condition of the patient.
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 O. Altin, et al.: Hartmann procedure in emergency cases

has ranged between 39% and 44%, while the rate of

anastomotic leakage and mortality has ranged be-
tween 4% and 11% and 9% and 11%, respectively19.
In HP patients, the mortality rate can be 28% and the
morbidity rate can be 60-70%20. In our study, the op-
erative mortality and morbidity rates were 21% and
63%, respectively. Higher mortality and morbidity
rates in patients undergoing HP compared with pa-
tients who underwent a single-session primary resec-
tion and anastomosis may be explained by the fact
that HP is often performed for older patients with poor
nutritional status, comorbid diseases, higher Ameri-
can Society of Anesthesiologists (ASA) scores, un-
stable hemodynamic status, or obesity. In the present
study, the mean age of the patients for whom HP was
performed was 67.1 ± 13.3 years. Furthermore, 70%
of those patients had comorbidities and the majority
Figure 1. Overall survival (OS) in all stages (months).
had an ASA III score with high existing morbidity.
The negative effect of emergency surgery on onco-
logical outcomes in cases of CRC is limited to the
initial postoperative period21. There is little difference
in the length of post-operative OS in emergency pa-
tients when compared with elective surgery among
patients with Stages II-III CRC22. In our study, the me-
dian survival in Stage II and III patients was 32.4 months
and 35.9 months, respectively, while it was 7.5 months
in Stage IV patients who received palliative treatment.
Therefore, surgery has two goals in high-risk patients
with obstructive or perforated CRC. The first is effec-
tive relief of symptoms in patients undergoing R1-R2
resection. The second is to lengthen survival with a
minimization of surgical mortality and morbidity in pa-
tients undergoing R0 resection.
In some cases of CRC patients who undergo HP,
the colostomy may be permanent. HP is technically
reversible and surgeons often think of the colostomy
as a temporary measure until they close the stoma
Figure 2. Disease-free survival (DFS) in all stages (months).
with a second operation; however, closure of the sto-
ma is not always possible9. Studies evaluating HP
outcomes have reported stoma closure rates as low
The main factor in the mortality and morbidity of these as 24-35%9,10. Although the decision to perform a
patients is comorbidities16. The incidence of primary stoma closure and the timing of the procedure depend
resection and anastomosis is increasing in selected on many factors, the oncological condition of the pa-
cases of emergency left-sided CRC surgery. However, tient is the primary determining factor. There are con-
if primary anastomosis is performed in patients who tradictory studies in the literature about the timing of
are not suitable candidates, dehiscence of the anas- a stoma closure. In a study of 69 cases, they divided
tomosis, intra-abdominal abscess, wound infection, study patients into two groups: those with a stoma
and mortality can occur17,18. closure performed within 4 months of the procedure
HP can be an ideal surgical treatment. The post- or later 23. Pearce et al. categorized 80 patients ac-
operative complication rate in patients undergoing pri- cording to a stoma closure time of within 3 months,
mary resection and anastomosis due to urgent CRC 3-6 months, and 6 months after the first operation,
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40 36.8
35
30
25
21.1
20
15
10
5.3
5
0
Tumor Stage
II III IV
Figure 3. Colostomy reversal rates according to the tumor stages.

and found lower anastomotic leakage and mortality patients was 36% and 21.1%, respectively. However,
rates in patients whose stomas were closed 6 months the rate was 5.3% in Stage IV patients, and patients
after the first operation24. In another study, it was re- in this group were likely to have permanent colosto-
ported that the number of post-operative complica- mies (Fig. 3). Many factors may contribute to a low
tions was greater in patients whose stomas were stoma closure rate: patients may not want a second
closed 3-9 months after HP compared with those operation, there may be significant risk factors associ-
whose stomas were closed more than 9 months lat- ated with an additional operation, or the presence of
er 25. These contradictory results suggest that larger an advanced stage tumor can preclude performing the
scale studies on stoma closure are needed. Horesh closure procedure.
et al. reported morbidity and mortality rates related to
stoma closure of 46.5% and 0.7%, respectively26. Conclusion
In our series, the colostomies of only 12 patients
[26.6%] were closed in an average of 237 days (180- The main disadvantages of HP are need for a sec-
360 days). Although our rate of colostomy closure is ond major operation to reverse the colostomy, which
within the range described in the literature, we attri- will be also associated with a risk of morbidity and
bute this low rate to the large number of Stage IV mortality like anastomotic dehiscence. In addition,
patients. We did not observe death or anastomotic ostomy has some psychological and physical difficul-
leak after colostomy closure. In one patient, the pro- ties for patients, so the 1-time surgery is superior in
cedure was discontinued because the presence of terms of patient’s quality of life with a chance to live
peritonitis carcinomatosa was detected peroperative- without ostomy. HP can be an ideal surgical treat-
ly. Two patients in this group developed distant me- ment for these cases; anastomosis is risky due to
tastasis; however, no mortality was observed during poor condition and resection mandatory due to per-
the follow-up period. González et al. reported a stoma foration. HP can be a life-saving procedure in high
closure rate of 21.73%. Similarly, other lower stoma risk, emergency cases of colorectal diseases. Sur-
closure rates have also been reported in the litera- geons create a temporary stoma as a part of this
ture27-29. In our study, the stomas of the patients who procedure that can be reversed with a second opera-
underwent HP were closed in a period of 6-12 months. tion. However, it is not possible to close the stoma
It has been reported that if the existing stoma is not in some HP patients.
closed within the 1st year, it will probably become per-
manent30. The time between HP and stoma closure Funding source
allows for the identification of appropriate, low-risk
patients for stoma closure. In our study, the stoma The authors declared that this study received no
closure rate among socially active, Stage II and III financial support.
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 O. Altin, et al.: Hartmann procedure in emergency cases

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