REVERSAL OF HARTMANNS PROCEDURE - EFFECT OF TIMING AND TECHNIQUE ON EASE AND SAFETY

PURPOSE: The optimal time for reversal of Hartmann's procedure is cont roversial. Significant operative difficulty and morbidity have been re ported for Hartmann's reversal. The purpose of this study was to exami ne 11 years' experience with Hartmann's reversal, with particular atte ntion to rate of reversibility, operative difficulty, and timing of re versal. METHODS: Case records of all patients undergoing either Hartma nn's procedure or Hartmann's reversal at St. Vincent's Hospital betwee n 1981 and 1991 were examined. Patients having Hartmann's reversal wer e divided into an early group (before 15 weeks) and a late group (afte r 15 weeks). These groups were compared in terms of morbidity and mort ality, bed stay, and operative difficulty. RESULTS: Hartmann's procedu re was performed on 111 patients, mostly for advanced cancer and compl icated diverticular disease. Of 96 patients who survived, 50 (52 perce nt) underwent reversal. Of those with diverticular disease, 40 of 48 ( 83 percent) underwent reversal. Mortality for Hartmann reversal was 2 percent; anastomotic leak rate 4 percent; and overall complication rat e 26 percent. Early reversal was performed in 13 patients and late rev ersal in 37 patients. There was no difference between these groups in mortality, morbidity, or anastomotic leakage. However, bed stay was lo nger in the early group and graded operative difficulty greater. In pa rticular, cases in which adhesion density was most severe and in which accidental enterotomy occurred were more common in the early group (P = 0.02, Miettinen's modification of Fisher's exact test). CONCLUSIONS : Hartmann's reversal can be performed with an acceptable morbidity an d mortality in most survivors of complicated diverticular disease. Ope rative difficulty appears to be less after a delay of 15 weeks.