Factors influencing postoperative adverse events after Hartmann's reversal
Department of Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA. Colorectal Disease
(Impact Factor: 2.35).
03/2011; 14(3):369-73. DOI: 10.1111/j.1463-1318.2011.02629.x
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.
Available from: Andrea Sebastiano Cavallaro
- "In open Hartmann's procedure, the mean operative time reported in literature is 167 min . In laparoscopic Hartmann's procedure, the mean operative time was 171.1 min. "
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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.
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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.
Available from: Mike Liang
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ABSTRACT: IMPORTANCE Surgical site infection following stoma reversal (SR) poses a substantial burden to the patient and health care system. Its overall incidence is likely underreported and poorly characterized. Improving our understanding of surgical site infection following stoma reversal may help us identify methods to decrease this complication. OBJECTIVE To evaluate the incidence of surgical site infection (SSI) and identify predictors of SSI following SR. DESIGN A review of computerized hospital records on SR performed from January 1, 2005, until February 27, 2011. SETTING An integrated medical system at the Michael E. DeBakey Veterans Affairs Medical Center. PARTICIPANTS AND INTERVENTION All adults undergoing SR during the study period. MAIN OUTCOME MEASURES Rates of SSI and characteristics of patients with and without SSI were compared. A logistic regression model was developed to identify predictors of SSI. RESULTS One hundred twenty-eight patients underwent SR; 46 patients (36.0%) had an SSI. In comparison with no SSI, the infection was associated with seromas (17.4% vs 2.4%, P = .004), fascial dehiscence (15.2% vs 2.4%, P = .01), intensive care unit admission (34.8% vs 17.1%, P = .03), increased hospital length of stay (20 vs 9 days, P = .02), readmission (32.6% vs 13.4%, P = .01), delayed wound healing (91 vs 66 days, P = .02), and reoperation (32.6% vs 13.4%, P = .01). On multivariate analysis, history of fascial dehiscence (odds ratio, 16.9; 95% CI, 1.94-387), colostomy (5.07; 2.12-13.0), thicker subcutaneous fat (2.02; 1.33-3.21), and black race (0.35; 0.13-0.86) were associated with incisional SSI. There was no significant difference in patient satisfaction or functional status in late follow-up (1-73 months). CONCLUSIONS AND RELEVANCE Surgical site infection is common following SR and is associated with significant morbidity. Four factors are strongly associated with increased risk of SSI in SR: history of fascial dehiscence, thicker subcutaneous fat, colostomy, and white race. Patients with none of these risk factors had a 0% SSI risk; patients with all 4 risk factors had a 100% risk of SSI.
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