Efficacy of Laparoscopic-assisted Approach for Reversal of Hartmann’s Procedure: Results From the American College of Surgeons National Surgical Quality Improvement Program

Jeanine Arkenbosch, BS, Hirochimi Miyagaki, MD, PhD, Hmc Shantha Kumara, PhD, Xiaohong Yan, PhD, Vesna Cekic, RN, Richard L Whelan, MD. Division of Colon and Rectal Surgery, Department of Surgery, St Luke’s Roosevelt Hospital Center.

INTRODUCTION: Postoperative morbidity after reversal of Hartmann’s procedure remains high. Proponents of minimally invasive methods believe the laparoscopic approach may be associated with a lower morbidity than open colostomy takedown and Hartmann’s closure. The aim of this study is to evaluate the efficacy of laparoscopic-assisted methods for reversal of Hartmann’s procedure.

METHODS AND PROCEDURES: The ACS-NSQIP database was queried from 2005 to 2011 based on Current Procedural Terminology (CPT) procedure codes 44227 (Laparoscopy, Surgical, Closure of Enterostomy, Large or Small Intestine, with Resection and Anastomosis) and 44626 (Closure of Enterostomy, Large or Small Intestine; with Resection and Colorectal Anastomosis {Eg, Closure of Hartmann Type Procedure}) as well as the ICD-9 diagnosis codes V44.3 (Colostomy Status) and V55.3 (Attention to Colostomy). Exclusion criteria included: preoperative (preop) ventilator dependence, ASA 4 and 5 classification, totally dependent functional status, SIRS, sepsis, emergency case, advanced malignancy, and current pneumonia. Patients were divided into laparoscopic-assisted approach group (LAP) and open approach group (OPEN) according to CPT codes. Demographic parameters were assessed as well as comorbidities, complications and other short term outcome measures. The statistical methods used were the Fisher’s exact test for categorical variables, the student t-test for BMI and surgery time and the Wilcoxon test for other continuous variables.

RESULTS: A total of 3312 patients underwent stoma closure and Hartmann’s reversal during the period assessed (LAP, 555 [16.8%], OPEN, 2757 [83.2%]. The mean BMI of the LAP patients (mean±SD, 27.5 ±6.6) was significantly lower than that of the OPEN group (28.2±6.6, p=0.0170). There was also a difference in the rate of ETOH ingestion (LAP, 3.2%, OPEN 2.6%,,p= 0.0476). In regards to nutritional status and other comorbidities including cardiac and pulmonary issues there were no differences between the groups. The mean surgery time was not significantly different (LAP185.9±81.6 min, OPEN, 189.8±89.1min). The length of stay (LOS) was significantly longer in the OPEN group (median LOS 6 days) vs the LAP group (median LOS 5days). The overall morbidity for the LAP procedure (18.4%) was significantly lower than the rate noted in the OPEN group (26.8%, p<0.0001). In contrast, there was no difference in the mortality results between the groups (LAP 0.2%, OPEN 0.4%; p>0.05). The incidence of the following complications were significantly lower for the LAP patients vs the OPEN group’s results: incisional SSI (LAP 11.2% vs OPEN 14.6%, p=0.0322), sepsis (LAP, 3.4%; OPEN 6.5%, p=0.0043); wound disruption (LAP, 0.5%; OPEN 2.0% (p=0.0125); urinary tract infection (LAP, 1.6%; OPEN 3.3%, p=0.0301); and re-operation (LAP, 3.2%; OPEN 5.4%, p=0.0334).

CONCLUSION: Only 17 % of Hartmann’s reversal’s were done using LAP methods. The LAP and OPEN groups were similar except for BMI and ETOH use. LAP methods were associated with a 1 day LOS benefit and significantly lower overall morbidity including lower SSI, wound disruption, and reoperation rates. Surprisingly, the length of surgery was similar between groups. The short term results of the LAP approach are superior to the OPEN results.