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Hartmann’s procedure, reversal and rate of
stoma-free survival
S Hallam
1
, BS Mothe
2
, RMR Tirumulaju
1
1
Department of Colorectal Surgery, Good Hope Hospital, Sutton Coldfield, Birmingham, UK
2
Royal Liverpool Hospital, Liverpool, UK
ABSTRACT
BACKGROUND Hartmann’s procedure is a commonly performed operation for complicated left colon diverticulitis or malignancy.
The timing for reversal of Hartmann’s is not well defined as it is technically challenging and carries a high complication rate.
METHODS This study is a retrospective audit of all patients who underwent Hartmann’s procedure between 2008 and 2014.
Reversal of Hartmann’s rate, timing, American Society of Anesthesiologists grade, length of stay and complications (Clavien–Dindo)
including 30-day mortality were recorded.
RESULTS Hartmann’s procedure (n= 228) indications were complicated diverticular disease 44% (n= 100), malignancy 32%
(n= 74) and other causes 24%, (n= 56). Reversal of Hartmann’s rate was 47% (n= 108). Median age of patients was 58 years
(range 21–84 years), American Society of Anesthesiologists grade 2 (range 1–4), length of stay was eight days (range 2–42 days).
Median time to reversal of Hartmann’s was 11 months (range 4–96 months). The overall complication rate from reversal of Hart-
mann’s was 21%; 3.7% had a major complication of IIIa or above including three anastomotic leaks and one deep wound dehis-
cence. Failure of reversal and permanent stoma was less than 1% (n= 2). Thirty-day mortality following Hartmann’s procedure was
7% (n= 15). Where Hartmann’s procedure wass not reversed, for 30% (n= 31) this was the patient’s choice and 70% (n= 74)
were either high risk or unfit.
CONCLUSIONS Hartmann’s procedure is reversed less frequently than thought and consented for. Only 46% of Hartmann’s proce-
dures were stoma free at the end of the audit period. The anastomotic complication rate of 1% is also low for reversal of Hartmann’s
procedure in this study.
KEYWORDS
Colonic diverticulosis –Colorectal neoplasms –Colorectal surgery –Colostomies
Accepted 6 November 2017
CORRESPONDENCE TO
Sally Hallam, E: sally84hallam@gmail.com
Introduction
Hartmann’s procedure consists of a rectosigmoid resection,
closure of the rectal stump and formation of an end colos-
tomy. It was first described by Henri Hartmann in 1921 as a
novel solution to high rates of anastomotic dehiscence and
mortality following resection and primary anastomosis of
obstructing left-sided colonic carcinoma.
1
Indications for
Hartmann’s procedure have expanded to include a range of
pathologies resulting in obstruction or perforation of the left
colon including malignancy, diverticulitis, ischemia, volvu-
lus or trauma.
Ideally, Hartmann’s procedure is followed by reversal of
Hartmann’s, restoring intestinal continuity. However, this is
considered a major operation associated with high morbidity
rates of up to 58% and mortality of up to 3.6%.
2–14
Hart-
mann’s procedure is commonly performed in older, comor-
bid patients and may preclude subsequent reversal.
Technical challenges particular to reversal include dense
pelvic adhesions, chronic pelvic infection, difficulty in
identification of and anastomosis to a short rectal stump. As
a result, large numbers of patients are left with a permanent
stoma following Hartmann’s procedure, either due to inabil-
ity to perform reversal or due to anastomotic leak and stoma
restoration.
15
According to the National Bowel Cancer Audit
in 2015, 95% of patients undergoing Hartmann’s still have a
stoma at 18 months.
16
The identification of factors predicting successful rever-
sal, as well as factors predicting morbidity and mortality
following reversal, will allow patient selection, optimisa-
tion of risk factors and realistic preoperative counselling
before Hartmann’s procedure in those unlikely to proceed
reversal.
This study aimed to answer three main questions:
> What are the factors that can be used to predict rever-
sal of Hartmann’s procedure?
> What are the factors that can predict complications
following reversal and did the procedure involve a
stapled or handsewn anastomosis?
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COLORECTAL SURGERY
Ann R Coll Surg Engl 2018; 100: 301–307
doi 10.1308/rcsann.2018.0006
> What were the rates of stoma-free survival following
Hartmann’s procedure and the reasons for not pro-
ceeding to reversal?
Materials and methods
This was a retrospective observational study. Consecutive
patients aged 18 years and above undergoing Hartmann’s
procedure with or without reversal from 2008 to 2015 at the
Heart of England NHS Trust were identified and included.
Cases were retrieved using the Hospital Episode Statistic
procedure codes H33.4, (Hartmann’s procedure) and H15.4
(reversal of Hartmann’s procedure). Notes were reviewed
and incorrectly coded cases excluded.
Patients were divided into two groups: those undergoing
Hartmann’s procedure (group 1) and those proceeding to
reversal following Hartmann’s procedure (group 2). The fol-
lowing parameters were collected for all patients: demo-
graphic details, smoking status, Charlston comorbidity
index and American Society of Anesthesiologists grade
(ASA). Pertaining to the initial Hartmann’s procedure, the
following were recorded: indication for Hartmann’s proce-
dure (malignant or benign), emergency or elective, 30-day
postoperative mortality and length of stay. For group 1, the
indication not to proceed to reversal was categorised as
patient choice or surgeon recommendation due to advanced
age, comorbidity, recurrence of malignancy or anticipated
technical difficulties. For group 2, further parameters were
collected relating to the reversal including preoperative
albumin </> 35g/l, time to reversal, handsewn or stapled
anastomosis, technical difficulties, formation of diverting
ileostomy, subsequent reversal of ileostomy, and postopera-
tive morbidity (Clavien–Dindo grading).
Definition of parameters
ASA grading is a widely used and accepted tool to assess a
patients anaesthetic risk. It is based on five classes (I–V) and
is calculated and recorded preoperatively. In this study, stat-
istical analysis an ASA of greater than II was graded as high
risk and I–II as low risk.
The Charlston comorbidity index is a method of categoris-
ing patient’s comorbidities. Each comorbidity has an associ-
ated score of 1–6 based on the adjusted risk of mortality.
Scores are summed to give a single comorbidity score. In
this studies statistical analysis, a Charlston comorbidity
score of 0–1 was regarded as low risk and greater than 1 as
high risk.
Clavien–Dindo is a validated method of classifying surgi-
cal complications according to the treatment needed from
no intervention to reoperation, graded from I to V.
Outcomes
Primary outcome measures were factors predicting reversal,
factors predicting complication following reversal. Secon-
dary outcome measures included rates of stoma-free sur-
vival, the reasons for non-reversal of Hartmann’s procedure
and time to reversal.
Ethics
This study was approved by the Audit and Clinical Gover-
nance Committee of the Heart of England NHS Foundation
Hospitals Trust.
Statistical analysis
Statistical analysis was performed using SPSS software (SPSS
for Windows release 19.0). Univariate analysis was per-
formed using Chi squared for categorical variables and the
Mann–Whitney U for continuous variables. Risk factors iden-
tified with a significance value of Pless than 0.05 on univari-
ate analysis were entered into multivariate logistic
regression analysis, and odds ratios (OR) with 95% confi-
dence intervals (CI) are presented.
Results
A total of 228 patients undergoing Hartmann’s procedure
during the study period were identified. The group com-
prised 111 women and 117 men with a median age of 66
years (range 21–91 years). The most common indications for
Hartmann’s procedure (Table 1) were complicated divertic-
ular disease, (n= 100, 44%), sigmoid cancer (n= 44, 19%),
rectal cancer (n= 24, 10.5%) and stercoral perforation
(n= 11, 5%). Patients had numerous comorbidities with a
mean Charlston comorbidity score of 2.3. A substantial pro-
portion of patients were ASA grade III–V(n= 92, 40%), One
hundred and ninety patients were admitted acutely for Hart-
mann’s procedure (83%). Fifteen patients died within thirty
days of Hartmann’s procedure (7%).
Hartmann’s procedure not reversed
One hundred and five of the surviving patients did not pro-
ceed to reversal (46%). Seventy-four patients were consid-
ered unsuitable for reversal because of recurrent
malignancy (n= 26, 35%), high risk comorbidity (n= 41,
Table 1 Indications for Hartmann’s procedure in the 228
patients in the study.
Indication Incidence
(n) (%)
Diverticular complication 100 44
Rectal cancer 24 10.5
Sigmoid cancer 44 19
Rectosigmoid cancer 6 2.5
Stercoral perforation 11 5
Anastomotic leak 9 4
Ischaemia 8 3.5
Trauma 8 3.5
Other 18 8
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HALLAM MOTHE TIRUMULAJU HARTMANN’S PROCEDURE, REVERSAL AND RATE OF STOMA-FREE
SURVIVAL
55%) or anticipated technical difficulties such as dense pel-
vic adhesions or a short rectal stump (n= 7, 10%). Thirty-
one patients (30%) declined reversal for a mixture of satis-
faction with current stoma and not wanting further admis-
sion or surgery.
Hartmann’s procedure reversed
Barium enema or sigmoidoscopy was performed in all
patients prior to reversal to rule out residual pathology in
the proximal colon and to assess the rectal segment. One
hundred and eight of the surviving patients underwent a
successful reversal (47%). The median time interval to
reversal was 11 months (range 4–96 months). Anastomosis
was stapled in 85 patients, (79%) and handsewn in 23
(21%). Ten patients had a defunctioning ileostomy, of which
90% had been reversed at a median of five months (range 1–
16 months). There were no postoperative mortalities follow-
ing reversal. Twenty-three patients experienced a postoper-
ative complication (21%), of which wound infection was the
most common (n= 9, 8%). Anastomotic leaks occurred in
five patients, (5%) of whom 1% (n= 2) were left with perma-
nent ileostomy as they did not want to proceed with reversal
following their initial complications. Median length of stay
following reversal was eight days (range 2–42 days).
Factors predicting reversal of Hartmann procedure
On univariate analysis (Table 2), patients had an increased
likelihood of reversal if they were of younger age
(P< 0.0001), ASA less than or equal to 2 (P< 0.0001), emer-
gency Hartmann’s procedure (P= 0.012), benign indication
for Hartmann’s procedure (P= 0.003) and a Charlston
comorbidity score of less than or equal to 1 (P< 0.001; Table
1). Sex and smoking status were not significantly associated
with reversal. On multivariate analysis (Table 3), the follow-
ing factors retained significance: age (OR 0.95, range 0.92–
0.98; P= 0.001), ASA less than or equal to 2 (OR 0.38, range
0.02–0.09; P< 0.001) and emergency Hartmann’s procedure
(OR 5.5, range 2.13–14.16, P< 0.001).
Factors predicting complication following reversal
On univariate analysis, the following factors were signifi-
cantly associated with complication following reversal:
smoking status (P< 0.001), length of stay over 11 days
(P< 0.001). Sex, age, preoperative albumin, benign or
Table 2 Univariate analysis of factors predicting reversal of Hartmann’s procedure.
Factor Hartmann’s procedure
alone (n= 120)
Hartmann’s procedure +
reversal (n= 108)
P-value
(n) (%) (n) (%)
Sex: 0.52
Male 60 50 50 46
Female 60 50 58 54
Median age (years) 71
a
58
b
< 0.0001
ASA score: < 0.0001
Low risk (I–II) 36 30 100 93
High risk (≥III) 84 70 8 7
Smoking status: 0.15
Non-smoker 82 68 83 77
Smoker 38 32 25 23
Emergency procedure: 0.012
Yes 93 78 97 90
No 27 22 11 10
Malignancy: 0.003
Malignant 51 43 26 24
Benign 69 58 82 76
Charlston comorbidity index: < 0.001
Low risk (0–1) 30 25 65 60
High risk (≥2) 90 75 43 40
ASA, American Anesthesiologists Association.
a
Range 30–91 years.
b
Range 21–84 years.
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HALLAM MOTHE TIRUMULAJU HARTMANN’S PROCEDURE, REVERSAL AND RATE OF STOMA-FREE
SURVIVAL
malignant indication for Hartmann’s procedure, Charlston
comorbidity index, time to reversal and stapled or handsewn
anastomosis were not significantly associated with compli-
cation following reversal (Table 4). On multivariate analysis
(Table 5), the following factors retained significance in pre-
dicting complication following reversal: smoking status (OR
6.08, 95% CI 1.77–20.9; P= 0.003) and length of stay (OR
15.45, 95% CI 4.7–50.5; P< 0.001).
Discussion
To our knowledge, this is the single largest series attempting
to identify factors predicting reversal of Hartmann’s proce-
dure. One hundred and eight patients (47%) underwent suc-
cessful reversal, which compares favourably with rates
reported in the literature of 33.5% (range 19.2–69%).
2,6–
8,11,14,15,17,18
A large proportion of patients in our series declined rever-
sal (30%), which is higher than figures reported in the liter-
ature we reviewed (18%).
6
Patients declining reversal were
older (median age 71 years), had higher ASA grade,
increased malignant pathology and underwent elective
Hartmann’s procedure more commonly. Patients reasons for
refusal of reversal is multifactorial and beyond the scope of
our study but review of the notes suggested that patients
refusing reversal perceived surgery to be of higher risk and
that they expressed higher rates of satisfaction with perma-
nent stoma.
A literature review of a similar study involving quality of
life questionnaires for Hartmann’s procedure in perforated
diverticular disease showed significantly reduced quality of
life, which was strongly related to patient’s stoma and body
image. Of note is that the study population was notably
younger than our study group (median age 61 years vs. 71
years).
19
A further 73 patients were documented as unsuitable for
reversal due to recurrent malignancy (35%), high-risk
comorbidity (55%) or anticipated technical difficulties fol-
lowing the primary surgery such as dense pelvic adhesions
or short rectal stump (10%). Currently, no guidelines exist to
help clinicians in selecting patients for reversal following
Hartmann’s procedure. This means that clinicians must use
Table 4 Univariate analysis factors predicting complication
following reversal of Hartmann’s procedure.
Factor No compli-
cations
(n= 85)
Complica-
tions
(n= 23)
P-value
(n) (%) (n) (%)
Sex: 0.085
Male 43 86 7 14
Female 42 72.4 16 27.6
Age (years) 56
a
63
b
0.348
Pre-albumin: 0.118
≤35 g/l 73 82 16 18
> 35 g/l 12 63.2 7 36.8
Malignancy: 0.163
Benign 62 75.6 20 24.4
Malignant 23 88.5 3 11.5
Smoking status: < 0.001
Non-smoker 72 86.7 11 13.3
Smoker 13 52 12 48
Length of stay (days): < 0.001
< 11 74 91.4 7 8.6
≥11 11 40.7 16) 59.3
ASA score: 0.363
I–II 80 80 20 20
≥III 5 62.5 3 37.5
Charlston comorbidity
index:
0.172
0–1 54 83.1 11 16.9
≥2 31 72.1 12 27.9
Time to reversal
(months):
0.471
< 12 55 80.9 13 19.1
≥12 30 75 10 25
Anastomoses: 0.57
Hand-sewn 17 73.9 6 26.1
Stapled 68 80 17 20
ASA, American Anesthesiologists Association.
a
Range 4–67 years.
b
Range 50–71 years.
Table 3 Multivariate multiple logistic regression of factors
predicting reversal of Hartmann’s procedure.
Factor Adjusted OR
(95% CI)
P-value
Age 0.948
(0.919–0.978)
0.001
ASA score: < 0.001
Low risk (1 or 2) –
High risk (3 or higher) 0.038
(0.016–0.092)
Emergency: < 0.001
No –
Yes 5.496
(2.133–14.164)
Malignancy Not significant
Charlston comorbidity index Not significant
CI, confidence interval; OR, odds ratio.
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HALLAM MOTHE TIRUMULAJU HARTMANN’S PROCEDURE, REVERSAL AND RATE OF STOMA-FREE
SURVIVAL
a range of measures including disease pathology, perform-
ance status, comorbidity, professional experience and
patient factors that may affect wound healing such as nutri-
tion and smoking status. With increasing patient autonomy
and complaints, all decisions must be clearly documented
after carefully assessing the impact of comorbidity and other
prohibitory factors and seeking appropriate specialist
opinions.
Prior to elective or emergency sigmoid resection
•
Stoma nurse review and counselling
•
Counsel regarding the high risk of permanent
stoma following Hartmann’s resection
•
What are the patient’s initial feelings about
reversal if a stoma is needed?
•
Explain the importance of smoking cessation
and nutrition in successful reversal
Hartmann’s procedure
Or
Sigmoid resection and
primary anastomosis
Following primary surgery
• Maximise post-operative nutrition
• Support continued smoking cessation
• Arrange outpatient review with imaging as
required
Outpatient review
• What are the patient’s wishes regarding reversal?
• Are adjuvant treatments complete and staging free of
recurrence if malignancy was the indication for resection?
• Sigmoidoscopy: are the anal canal & rectal stump adequate
for reversal?
•
Anaesthetic assessment, is the patient fit for further
surgery?
• Do you anticipate any technical difficulties? plan strategies
to deal with these
Reversal of Hartmann’s
Figure 1 Flow diagram of decision making for reversal of Hartmann’s procedure
Ann R Coll Surg Engl 2018; 100: 301–307 305
HALLAM MOTHE TIRUMULAJU HARTMANN’S PROCEDURE, REVERSAL AND RATE OF STOMA-FREE
SURVIVAL
Time to the reversal of Hartmann’s varied widely in this
series from 4months to 96 months, occurring at a median of
11 months after Hartmann’s procedure, which is slightly lon-
ger than the literature median of 7.63 months (range 5.6–
13.3 months). A prolonged time to reversal of 12 months or
more, however, was not associated with increased postoper-
ative complication (P= 0.471).
The timing of reversal remains a contentious issue. Some
studies
7,17,20,21
report increased complications with longer
time to reversal, which they postulate relates to atrophy of
the distal stump and hence enhance the difficulty of per-
forming the anastomosis. Selection bias, however, must be
considered, since surgeons who experienced a tough Hart-
mann’s procedure initially may be keen to avoid early rever-
sal and so delay it in the hope that the patient may change
their mind. Conversely, several studies support delayed
reversal and postulate that the improved clinical and nutri-
tional state of the patient leads to fewer complications.
2,20
Postoperative complications occurred in 23 patients
(21%). Wound infection was the most common surgical
complication (n= 9, 8%). Grade III or above Clavien–Dindo
complications occurred in five patients (5%) of which all
were anastomotic leaks. The complication rate in this study
is noted to be lower when compared with those reported in
the literature, at 27% (range 5.4–54.8%).
2,6–11,13–15,17,18,21
The lower complication rate might, however, reflect the
limitation of this study, which is retrospective in nature and
potentially fails to capture the inadequately documented
minor grade I–II complications in the notes or which may
have been dealt with in the community.
Over the first decade if the 21st century, there has been a
change in approach and primary anastomosis is preferred to
Hartmann’s procedure with permanent stoma where possi-
ble.
22
A systematic review by Salem et al. found no difference
in the mortality and morbidity rates for patients with perfo-
rated diverticulitis, whether aprimary anastamosis or Hart-
mann’s procedure with stoma is performed.
23
A further
study looking at obstructed colorectal cancer patients
showed improved or equivalent morbidity and mortality for
primary anastomosis than Hartmann’s procedure.
24
Alterna-
tives include colonic stenting to relieve obstruction as a
bridge to definitive surgery.
25
The primary anastomosis may
be a longer operation than Hartmann’s procedure for those
not performing it on a regular basis in the elective setting.
For high-risk comorbid patients, therefore, Hartmann’s pro-
cedure is still a safe approach and viable option.
26
In the UK, emergency surgery is covered by a broad range
of subspecialties in general surgery, which include upper
gastrointestinal, hepatobiliary and vascular surgeons.
Because of this there is a huge difference in the day to day
practice adopted for colonic resections, with some surgeons
preferring a straightforward procedure such as Hartmann’s
procedure over primary anastomosis. A move towards cen-
tralisation of services with 24-hour-a-day access to colorec-
tal surgeons may reduce the number of Hartmann’s
procedure performed overall, as is suggested from recent
data from the USA, which found that colorectal surgeons
were more likely to perform primary anastomosis than gen-
eral surgeons, had shorter operating times and length of
stay and equivalent morbidity and mortality to their general
surgical colleagues.
26
Conclusion
In conclusion, Hartmann’s procedure is still a commonly
performed emergency colorectal operation. Reversal of the
procedure in our series was a relatively safe operation with
a low risk of major morbidity and no mortality. Reversal,
however, occurs in less than 50% of patients who undergo
Hartmann’s procedure, who must be adequately counselled
and consented before the initial procedure. Future NHS
changes to the delivery of emergency surgery with the deliv-
ery of surgical emergency surgery with centralisation of sub-
specialty services may lead to a reduction in Hartmann’s
procedures and overall improved morbidity and mortality.
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