Factors influencing postoperative adverse events after Hartmann's reversal
ABSTRACT The study was performed to evaluate factors influencing postoperative adverse events after Hartmann's reversal (HR).
This was a retrospective study of unselected patients who underwent HR after the Hartmann's procedure (HP) for left colonic perforation with peritonitis at a single institution. Data were retrieved from an Institutional Review Board-approved database. The study end-point was postoperative adverse events, which included mortality, complications, reoperations and 30-day readmission. Lag time was defined as the time from HP to HR. The results are expressed as mean±SD.
From 1997 to 2007, 204 (39.1%) of all patients who underwent the HP [60±16 years of age; 58% men; body mass index (BMI) 27.6±5.7; 2% were American Society of Anesthesiology (ASA) 1, 50.2% were ASA 2, 39.9% were ASA 3 and 7.9% were ASA 4) underwent HR at an interval of 158±107 days. There were 24 laparoscopic and 180 open HRs, with no deaths. The operating time was 167±64 min, estimated blood loss was 245±283 ml and the 30-day readmission rate was 4.9%. Eleven (5.4%) patients developed 14 (6.8%) complications and five (2.4%) of these patients required a new stoma at the time of HR or later. On multivariate analysis controlling for confounders, chronic renal failure requiring dialysis (OR=21.0; 95% CI: 1.5-284; P=0.02) was significantly associated with increased adverse events.
The study showed that chronic renal failure requiring dialysis was the only independent predictor of postoperative adverse event rates following HR.
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ABSTRACT: BACKGROUND:: Comprehensive analyses are lacking to identify predictors of postoperative complications in patients who undergo a Hartmann reversal. OBJECTIVE:: The aim of this study is to identify predictive factors for morbidity after reversal. DESIGN:: This study is a retrospective review of prospectively collected data. SETTINGS:: The study was conducted at Cleveland Clinic Florida. PATIENTS:: Consecutive patients from January 2004 to July 2011 who underwent reversal were included. MAIN OUTCOME MEASURES:: Variables pertaining to Hartmann procedure and reversal were obtained for analyses in patients with and without postoperative complications. Univariate and multivariate analyses were performed. RESULTS:: A total of 95 patients (mean age 61 years, 56% male) underwent reversal, with an overall morbidity of 46%. Patients with and without complications had similar demographics, comorbidities, diagnoses, and Hartmann procedure intraoperative findings. Patients with complications after reversal were more likely to have prophylactic ureteral stents (61% vs 41%, p < 0.05) and an open approach (91% vs 75%, p < 0.04). Complications were associated with longer hospital stay (8.8 vs 6.9 days,p < 0.006) and higher rates of reintervention (9% vs 0%, p < 0.03) and readmission (16% vs 2%, p < 0.02). Predictors of morbidity after reversal included BMI (29 vs 26 kg/m, p < 0.04), hospital stay for Hartmann procedure (15 vs 10 days, p < 0.03), and short distal stump (50% vs 31%, p < 0.05). BMI was the only independent predictor of morbidity (p < 0.04). Obesity was associated with significantly greater overall morbidity (64% vs 40%, p < 0.04), wound infections (56% vs 31%, p < 0.04), diverting ileostomy at reversal (24% vs 13%, p < 0.05), and time between procedures (399 vs 269 days, p < 0.02). LIMITATIONS:: This study was limited by its retrospective design. CONCLUSIONS:: Hartmann reversal is associated with significant morbidity; BMI independently predicts complications. Therefore, patients who are obese should be encouraged or even potentially required to lose weight before reversal.Diseases of the Colon & Rectum 01/2013; 56(1):83-90. DOI:10.1097/DCR.0b013e318270a1a3 · 3.20 Impact Factor
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ABSTRACT: Readmission rates after intestinal surgery have been notably high, ranging from 10 % for elective surgery to 21 % for urgent/emergent surgery. Other than adherence to established strategies for decreasing individual postoperative complications, there is little guidance available for providers to work toward reducing their postoperative readmission rates. Processes of care that may affect postoperative readmissions were identified through a systematic literature review, assessment of existing guidelines, and semi-structured interviews with individuals who have expertise in hospital readmissions and surgical quality improvement. Eleven experts ranked potential process measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology. Of 49 proposed process measures, 34 (69 %) were rated as valid. Of the 34 valid measures, two measures addressed care in the preoperative period. These included evaluation of patient's comorbidities, providing written instruction detailing the anticipated perioperative course, and communication with the patient's referring or primary care doctor. A measure addressing perioperative care stated that institutions should have a standardized perioperative care protocol. Additional measures focused on discharge instructions and communication. An expert panel identified several aspects of care that are considered essential to quality patient care and important to reducing postoperative readmissions.Journal of Gastrointestinal Surgery 06/2014; 18(8). DOI:10.1007/s11605-013-2429-5 · 2.39 Impact Factor
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ABSTRACT: Introduction. Aim of the present work is to review the literature to point out the role of laparoscopic reversal of Hartmann procedure. Material and Methods. Number of patients, age, sex, etiology, Hinchey classification, interval between procedure and reversal, position of the first trocars, mean operative time (min), number and causes of conversion, length of stay, mortality, complications, and quality of life were considered. Results. 238 males (52.4%) and 216 females (47.6%) between 38 and 67 years were analyzed. The etiology was diverticulitis in 292 patients (72.1%), carcinoma in 43 patients (10.6%), and other in 70 patients (17.3%). Only 7 articles (22.6%) reported Hinchey classification. The interval between initial procedure and reversal was between 50 and 330 days. The initial trocar was open positioned in 182 patients (43.2%) through umbilical incision, in 177 patients (41.9%) in right upper quadrant, and in 63 patients (14.9%) in colostomy site. The operative time was between 69 and 285 minutes. A total of 83 patients (12.1%) were converted and the causes were reported in 67.4%. The length of stay was between 3 and 12 days. 5 patients (0.7%) died. The complications concern 112 cases (16.4%). Conclusion. The laparoscopic Hartmann's reversal is safer and achieves faster positive results.Gastroenterology Research and Practice 08/2014; 2014:530140. DOI:10.1155/2014/530140 · 1.75 Impact Factor