SURGICAL CONSIDERATIONS IN THE HARTMANNS PROCEDURE

Background: The present study examines the surgical outcome of the Har tmann's and Hartmann-type procedures, the problems with the remnant re ctal stump and the issues related to the colorectal anastomosis as wel l as the differences in patient outcome. Methods: One hundred and five consecutive patients (mean age 66) were evaluated. Surgical morbidity and mortality were analysed with regard to the colorectal pathology a nd the type of octal stump remnant. The surviving patients were review ed according to whether they had second-stage anastomosis. Results: In 65% of cases there were obstructed or perforated malignancies and in 16% complicated diverticular diseases. The peri-operative mortality an d morbidity were 11.4% and 24%, respectively. Seventy-two patients had intraperitoneal rectal stumps and stump blowout occurred in three int raperitoneal and one extraperitoneal remnant stumps. Local tumour recu rrence (four) and diversion proctitis (three) were diagnosed in the re ctal stump among asymptomatic patients. When the second-stage reversal of Hartmann's procedure was considered (35 cases), twice as many were performed for diverticular and other benign conditions as for tumour cases. Conclusions: Although there is a good anatomical basis for advo cating extraperitoneal rather than intraperitoneal stumps, in practice the stump blowout rate is not statistically significant (3% vs 4.1%). However, the chances of regaining normal rectal function are much bet ter for benign disease (68% vs 32%-Fisher's exact test, P = 0.004). Co mplications from second-stage re-anastomosis are not determined by tim ing of the closure, provided the septic episode has subsided.