EP2024 - Determinants Influencing the Successful Restoration of Bowel Continuity Following Hartmann’s Procedure

Purpose/Background: Hartmann's procedure remains a prevalent approach for managing acute colorectal pathology. Despite its utility, the procedure has historically been associated with a substantial rate of permanent stoma formation. This study aims to evaluate factors that contribute to unsuccessful restoration of bowel continuity following Hartmann's procedure.

Methods/Interventions: Following institutional review board approval, a retrospective study was conducted on all adult patients (age > 18) who underwent a Hartmann's procedure from 2010 to 2025 at a single academic institution. The patients were stratified into those who subsequently underwent reversal and those who did not. Demographic, perioperative, and long-term data were collected and compared between the two groups. The primary outcome described factors associated with reversal.

Results/Outcomes: A total of 107 patients met the inclusion criteria between January 2010 to April 2025. The average age at index surgery was 61.4 (± 15.53) years, with 71 patients (66.4%) being male. Indications for surgery included malignancy in 44 patients (41.1%), followed by diverticular disease in 36 patients (33.6%), ischemia in 10 patients (9.3%) and volvulus in 7 patients (6.5%). Other causes comprised of 10 cases (9.3%), which included trauma, Crohn's disease, anastomotic strictures, and leak. Reasons for non-reversal included postoperative mortality in 47.6%, palliative intent of the initial surgery in 17.5%, comorbidities precluding reversal in 11.1%, patients declining reversal surgery in 4.8%, and 19% were lost to follow-up. Table 1 compares the demographic and perioperative characteristics of the reversal group and the non-reversal group. When stratified by subsequent stoma reversal, the reversal group were younger (53.2 vs 67.2, p,0.001) with significantly different indications for the primary surgery (p < 0.001). Diverticular disease was more common among those who underwent reversal (54.5% vs 19.0%), whereas malignancy was less common (44.4% vs. 36.4%) and ischemia and volvulus occurred exclusively in the non-reversal group. Additionally, the burden of comorbidity differed significantly between the two groups, with the reversal group exhibiting lower Charlson Comorbidity Index (CCI) scores compared to the non-reversal group (CCI=0: 59.1% vs 33.3%, p< 0.001). Moreover, differences in the complication profiles were observed between the two groups, with more patients in the reversal group experiencing an uncomplicated postoperative course (47.7% vs 28.6%, p< 0.001). Forty-four patients (41.1%) underwent reversal and the median time to reversal was 174.5 days (IQR 111.8 - 347.8). Following reversal, 38.6% experienced postoperative complications. There were two patients who experienced a postoperative leak, and no mortalities reported.

Conclusion/Discussion: Underlying etiology for Hartmann's procedure and comorbidity burden are important determinants of reversal, with benign indications and lower comorbidity burden favoring restoration of bowel continuity.

Table 1. comparison of perioperative characteristics of the patients who underwent reversal and those who did not