1. Acute Diverticulitis & Hartmann’s Procedure
Nigel A. Scott MD FRCS
Hope Hospital, Salford

2. CT diagnosis/ CT intervention

3. Illness and Optimisation
Hospital death
Morbidity
Routine Care
22%
1.35+/- 0.2
O2 delivery targeted towards 600ml/min/m2
5.7%
0.68 +/- 0.6
A randomised clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high risk patients. Boyd O et al JAMA 1993;270:

4. Emergency Admission for Acute Diverticulitis
CT diagnosis/ CT intervention
illness /optimisation
What’s the best operation in acute complicated diverticulitis ?

5. Emergency Admission for Acute Diverticulitis
Acute Complicated Diverticulitis – Which Operation ?
Defunctioning Colostomy
Hartmann’s Procedure (HP)
Primary Anastomosis (PA)
death
illness
permanent stoma

6. Emergency Admission for Acute Diverticulitis
Hinchey stage III & IV – colostomy alone ?
Primary Resection
Proximal Colostomy
Anastomosis
Hartmann’s
Lateral Colostomy 3 52 48
Early re-operation 2 9
<0.02
Death 13 ns
Post-op Peritonitis 1 10
<0.01
Length of stay
15d
24d
<0.05
Zeitoun et al Br J Surg 2000;87:

7. Emergency Admission for Acute Diverticulitis
Acute Complicated Diverticulitis – Which Operation ?
Defunctioning Colostomy
Hartmann’s
Primary Anastomosis
death
illness
permanent stoma

8. Q – Primary Anastomosis (PA) or Hartmann’s Procedure (HP)
Emergency Admission for Acute Diverticulitis
Q – Primary Anastomosis (PA) or Hartmann’s Procedure (HP)
15 papers (1997 – 2003)

9. Primary Anastomosis (stoma)
Hartmanns
Other
Mortality
Elliott 1997
14 (?) 51 18
20/113 (17%)
Wedell 1997
183 (35) 31 10
13/224 (6%)
Hoemke 1999
113 (0)
2/113 (2%)
Umbach 1999
28 (0) 5
Blair 2000
33 (5) 64
16/96 (16%)
Schilling 2001
13 (0) 42
5/55 (9%)
Gooszen 2001
32 (32) 28
12/60 (20%)
Maggard 2001
33 (0) 32 9
Biondo 2000
55(0) 60 8
4/124 (3%)
Makela 2002
46 (?) 75 22
4/101 (4%)
Somasekar 2002
4 (?) 98 2
34/102 (33%)
Gooszen 2002
45(0)
3/45 (6%)
Landen 2002
20(20)
3/20 (15%)
Regenet 2003
27 (0) 33
7/60 (12%)
Zorcollo 2003
~70(?)
~92 ~6
22/168 (13%)

10. Emergency Admission for Acute Diverticulitis
Resection for Acute Diverticular Sepsis n=1620
1 HP:1 PA

11. Emergency Admission for Acute Diverticulitis
Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis Jan 7;:1-7 [
18 studies comparing HP and PA in 884 patients with acute diverticulitis
mortality same
morbidity same (sepsis, wound infection, antibiotic use)
duration of procedure the same
Might as well do PA as HP –
but are we comparing like with like ?

12. Emergency Admission for Acute Diverticulitis
Makela et al Dis Colon Rectum 1998;
Hartmann’s Procedure is used in Elderly

13. Emergency Admission for Acute Diverticulitis
ASA I - Normal healthy individual
ASA II - Mild systemic disease that does not limit activity
ASA III - Severe systemic disease that limits activity but is not incapacitating
ASA IV - Incapacitating systemic disease which is constantly life threatening
ASA V - Moribund, not expected to survive 24 hours with or without surgery

14. Emergency Admission for Acute Diverticulitis
Blair et al Am J Surg 2002:183:
Biondo et al J Am Coll Surg 2000;191:
Hartmann’s Procedure is used in ASA >III

15. Emergency Admission for Acute Diverticulitis
Hinchey I – pericolic abscess confined to mesentery of colon
Hinchey II – walled off pelvic abscess
Hinchey III – generalised peritonitis
Hinchey IV – faecal peritonitis

16. Emergency Admission for Acute Diverticulitis
Hinchey I
Hinchey II
Hinchey III
Hinchey IV
Deaths
**Wedell 1997 PA HP
149(1)
17(3)
14(1)
15(4) 2 7
Blair 2000 12 6 25 3 13
**Gooszen 2001 28 9
Somasekar 2002 59 27 34
Makela 2002 8 1 19
4(total)
** adapted from Hughes staging

17. Emergency Admission for Acute Diverticulitis
6 papers n = 454
Hartmann’s Procedure is used in Hinchey III and IV

18. What’s the best operation in acute complicated diverticulitis ?
age
sepsis
ASA

19. Hinchey I and II
If adequate bowel preparation is possible and substantial contamination is not present, a primary anastomosis may be performed, with or without a proximal stoma. Alternatively, Hartmann’s resection is the most appropriate procedure.
Hinchey III and IV
The procedure of choice in this situation is immediate segmental resection with colostomy.

20. What are the chances of reversal ?
Hartmann’s Procedure
elderly
>ASA III
Hinchey III and IV
What are the chances of reversal ?

21. Hartmann’s Reversal general patient fitness
leave for 6 months - adhesions
1- negligible filmy
2- moderate
3 – dense, difficult
4 – inadvertent enterotomy
Reversal of Hartmann's procedure: Effect of timing and technique on ease and safety DCR 1994;37:

22. Hartmann’s Reversal general patient fitness
leave for 6 months - adhesions
Early reversal (mean 11 weeks)
4 – inadvertent enterotomy
Late reversal (mean 34 weeks)
5/13 (38%)
3/37 (8%)
Reversal of Hartmann's procedure: Effect of timing and technique on ease and safety DCR 1994;37:

23. Hartmann’s Reversal general patient fitness leave for 6 months
informed – autonomic injury, death, morbidity, failure, loop stoma
image/ visualise rectal stump
lose weight

24. Hartmann’s Reversal - Open
Lloyd Davies
ureteric stents
mobilise splenic flexure
TV colon to rectum anastomosis
? loop stoma

25. Hartmann’s Reversal – Laparoscopic
38 patients – 70% with diverticular disease
reversal at average of 4 -5 months
adhesions; low 13; moderate 15; dense 10;
15% conversion – adhesions
los 10 days +/- 4
1 death from anastomotic leak
Laparoscopic reversal of the Hartmann's procedure Vacher C.; Zaghloul R.; Borie F.; Laporte S.; Callafe R.; Skawinski P.; Leynau G.; Domergue J. Annales de Chirugie Volume 127, Number 3, March 2002, pp (4)

26. Hartmann’s Reversal – Laparoscopic H Gallagher
Laparoscopic reversal of Hartmann’s can certainly be performed with a significantly low morbidity but incisional herniation from the previous laparotomy is an important rate limiting factor-necessitating conversion when the hernia itself demands repair on its own merit

27. Hartmann’s Reversal Rate – 63%
Reversals
Elliott 1997 51
86%
Wedell 1997 31
31%
Hoemke 1999 -
Umbach 1999
Blair 2000 64 na
Schilling 2001 42
76%
Gooszen 2001 28
57%
Maggard 2001 32
100%
Biondo 2000 60
Makela 2002 75
45%
Somasekar 2002 98
Gooszen 2002
Landen 2002
Regenet 2003 33
69%
Zorcollo 2003
~92
39%

28. Reversal of Hartmann's Procedure after Surgery for Complications of Diverticular Disease of the Sigmoid Colon Is Safe and Possible in Most Patients. Dig Surg Feb 10;22(6):

29. Surgery and Acute Diverticulitis
Summary
Common and increasing presentation associated with 30% chance of resection and 10% chance of death after surgery
Hartmanns is used for elderly; >ASA III and Hinchey III and IV
Reversal is possible in 60% - laparoscopic or open

30. The End