|Year : 2020 | Volume
| Issue : 4 | Page : 57-63
Is Laparoscopic Hartmann's Reversal a Safe Option? A Systematic Review and Meta-Analysis
Joseph C Kong1, Glen R Guerra1, Swetha Prabhakaran2, Satish K Warrier3, Alexander G Heriot1
1 Division of Cancer Surgery; Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, 3000, Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, 3010; Department of Surgery, The University of Melbourne, Parkville, Victoria, 3010, Australia
2 Department of Colorectal Surgery, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, 3004, Australia
3 Division of Cancer Surgery; Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, 3000, Department of Surgery, The University of Melbourne, Parkville, Victoria, 3010, Australia
|Date of Submission||14-May-2020|
|Date of Decision||29-May-2020|
|Date of Acceptance||14-Jun-2020|
|Date of Web Publication||31-Dec-2020|
Joseph C Kong
Division of Cancer Surgery, Peter MacCallum Cancer Centre,Melbourne, 305 Grattan Street, VIC 3000
Source of Support: None, Conflict of Interest: None
Background: Hartmann's reversal is a major operation to restore colorectal continuity. Traditionally, an open Hartmann's reversal (OHR) has been performed but there is a trend toward performing laparoscopic Hartmann's reversal (LHR). With the increasing number of publications comparing these two, it is important to ascertain whether the benefits of LHR outweigh the risks. Objective: To compare LHR and OHR with respect to morbidity and mortality rates. Design: A systematic review and meta-analysis. Setting: The study was conducted at the Peter MacCallum Cancer Centre in Melbourne, Australia. Patients and Methods: A detailed systematic search was performed through PubMed, SCOPUS, TRIP, EMBASE, and ClinicalKey from 1990 to October 26, 2016. A review was undertaken in accordance with PRISMA guidelines. Main Outcome Measures: The primary outcome measure was 30-day morbidity. Secondary outcome measures included estimated intraoperative blood loss, conversion from laparoscopic to open approach, length of hospital stay, and 30-day mortality. Sample Size: Eighteen eligible studies were identified, comprising a total of 7824 patients: 1586 in the laparoscopic group and 6238 in the open group. Results: There was no statistical difference in mean operative time between the two groups. Overall morbidity was lower in the LHR group (16.8% vs 23.7%, P < 0.0001). Subgroup-analysis showed a higher risk of sepsis (6.5% vs 3.2%; P < 0.0001), wound infection (22.5% vs 12.6%; P < 0.0001), and ileus (13.4% vs 5.5%; P = 0.001) in the OHR group. Conclusion: LHR was associated with a lower morbidity rate and shorter hospital stay with an equivalent operative time. There is a moderate rate of conversion and appropriate case selection is important. Limitations: An absence of prospective or randomized trials comparing the two approaches for Hartmann's reversal, contributing to selection bias in our study. It was difficult to combine patient characteristics data due to the heterogeneity in the reported parameters. Conflict of Interest: None.
Keywords: Keywords: Hartmann′s reversal, laparoscopic surgery, outcome
|How to cite this article:|
Kong JC, Guerra GR, Prabhakaran S, Warrier SK, Heriot AG. Is Laparoscopic Hartmann's Reversal a Safe Option? A Systematic Review and Meta-Analysis. World J Colorectal Surg 2020;9:57-63
|How to cite this URL:|
Kong JC, Guerra GR, Prabhakaran S, Warrier SK, Heriot AG. Is Laparoscopic Hartmann's Reversal a Safe Option? A Systematic Review and Meta-Analysis. World J Colorectal Surg [serial online] 2020 [cited 2021 May 8];9:57-63. Available from: https://www.wjcs.us.com/text.asp?2020/9/4/57/305888
| Introduction|| |
A Hartmann's procedure is commonly performed in an emergency setting to reduce the morbidity and mortality rates associated with an anastomotic leak. Patient undergoing an emergency Hartmann's procedure usually present with hemodynamic compromise from the disease process leading to severe tissue inflammation, peritoneal contamination, and compromised blood supply to the intestine. Hartmann's procedures have an estimated reversal rate ranging from 19% to 71%.
Restoration of bowel continuity is traditionally performed using the open Hartmann's reversal (OHR) approach. Adverse consequences of this surgery include a morbidity rate of more than 50% and mortality rate as high as 6%. Advances have allowed for the adoption of laparoscopic Hartmann's reversal (LHR), which was first described in 1993. The estimated rate from LHR to OHR is reported to be between 4% and 20%,,, making patient selection critical.
Despite the technical challenges, the benefits of laparoscopic surgery include shorter stay, minimal postoperative pain, early return to normal activity, and a lower morbidity rate. Since the first description of LHR, many studies have assessed its safety; however, due to the fact that OHR is more widely performed than LHR, it is difficult to ascertain the relative risk, morbidity, and mortality rates comparing the two approaches. Therefore, this study aimed to perform a systematic review and meta-analysis of the current evidence surrounding the safety of LHR as compared to OHR.
| Patients and Methods|| |
A detailed systematic search was performed through PubMed, SCOPUS, TRIP, EMBASE, and ClinicalKey from 1990 to October 26, 2016. The words used were a reversal of Hartmann's, open surgery, laparoscopic surgery, minimally invasive procedure, bowel restoration, and Hartmann's. Two reviewers, JCH and GRG performed the search and data extraction independently. The consensus was achieved between the reviewers regarding all studies.
Studies were deemed eligible if both groups were analyzed with an intention to treat and the comparative study reported the appropriate outcome of interest. The exclusion criteria were studies with less than 15 patients and written in languages other than English.
Author, year of publication, study period, number of patients, sex, age, body mass index (BMI), comorbidities, type of morbidity, and overall mortality and morbidity details were collected. To assess the quality of each study, the Newcastle-Ottawa Scale (NOS) was used and a score of ≥ 6 was deemed good quality.
Statistical analysis and main outcome measure
The primary outcome measure was 30-day morbidity and secondary outcome measures were estimated intra-operative blood loss, conversion from a laparoscopic to open approach, reoperation rate, length of stay (LOS) in hospital, days to flatus, covering ileostomy formation, and 30-day mortality. Categorical data for the outcome measured were retrieved and the odds ratio and 95% confidence interval (95% CI) were calculated in each study.
Pooled odds ratios were performed using the random-effect DerSimonian and Laird model. Study heterogeneity was calculated using I2 statistics and can be interpreted as; 0%-30% (minimal), 30%-60% (moderate), 60%-90% (substantial), and 90%-100% (considerable). All statistical analyses were performed on IBM SPSS version 22 and R Studio version 0.99.486, with a P value <0.05 considered significant.
| Results|| |
Study design and quality
A review was undertaken in accordance with PRISMA guidelines. The initial search identified 1633 studies for the title and abstract review, of which 59 were included for full-text assessment. Four studies were excluded because of small sample size, eight due to the stratification of patients to an individual surgical pathway, and 29 due to the lack of an appropriate comparison. The remaining 18 studies were retrospective in nature and of good quality as demonstrated, and were therefore included in the study [Figure 1] and [Table 1].
|Table 1: The Newcastle-Ottawa Scale assessing the quality of each publication. Score ≥6 is deemed good quality |
Click here to view
A total of 7824 patients were included in the study: 1586 in the LHR and 6238 in the OHR groups. There was no statistical difference based on gender. The range for mean age and BMI in the LHR group was 46–62.5 years old and 20.8–29.7, respectively, compared with 49–64.3 years old and 24.8–30.8 in the OHR group [Table 2].
Laparoscopic versus open Hartmann's reversal primary outcome
The pooled morbidity rate for the LHR group was significantly lower at 16.8% (266 patients) compared with 23.7% (1480 patients) in the OHR group [Table 3]. Specific morbidities including cardiac complications, pulmonary complications, sepsis, wound infection, and urinary complications were lower in the LHR group [Table 4].
Assessing safety of laparoscopic Hartmann's reversal
Gauging the safety of LHR compared to OHR, there was no significant difference with regard to anastomotic leak (1.6% vs 3.8%; P.098) and mortality (0.2% vs 0.5%; P.158). The advantage of LHR was the lower rate of ileus (5.5% vs 13.4%; P.001), estimated blood loss (mean 149.7 mL vs 288.1 mL; P.01), and LOS (6.3 vs 10.3 days; P < 0.001), without a difference in the mean operative time (196.3 vs 200.7 min; P .719) [Table 3] and [Table 4].
|Table 3: Comparative analysis of operative factors and overall morbidity and mortality between patients who underwent laparoscopic or open Hartmann's reversal |
Click here to view
|Table 4: Comparative analysis of postoperative complications between patients who underwent laparoscopic or open Hartmann's reversal |
Click here to view
Pooled odds ratio random-effects model
Results for overall morbidity, wound infection, and ileus were pooled as identified in 10 or more studies. The risk of adverse outcomes was lower in the laparoscopic cohort, as compared to the open cohort; with overall morbidity odds ratio (OR) 0.52 (95% CI 0.45–0.61, P.001, [Figure 2]), wound infection OR 0.55 (95% CI 0.44–0.68, P .001, [Figure 3]), and ileus OR 0.37 (95% CI 0.21–0.67, P .001, [Figure 4]). There was moderate inter-study heterogeneity in the pooled analysis of morbidity and wound infection but not ileus, with an estimated I2 statistic of 56.2%, 31.3%, and 0% (necessitating the random-effects model).
|Figure 2: Forest plot of overall morbidity, measured as odds ratios for laparoscopic Hartmann's reversal in each study and a pooled odds ratio (Original)|
Click here to view
|Figure 3: Forest plot of calculated odds ratios for wound infection in each study (laparoscopic Hartmann's reversal [LHR] group) and a pooled odds ratio (Original)|
Click here to view
|Figure 4: Forest plot of calculated odds ratios for ileus in each study (LHR group) and a pooled odds ratio (Original)|
Click here to view
| Discussion|| |
This study reports the largest number of pooled patients comparing open with laparoscopic approach for reversal of Hartmann's to date. The meta-analysis affirms that laparoscopic reversal is safe in a select group of patients with an overall morbidity rate of 16.8% and a mortality rate of 0.2%.
A significant benefit of LHR is the shorter LOS, with a mean reduction of 4 days as compared to the open approach. The reason for the reduction is multifactorial, including lower complication rates, reduced return to theater, and reduced ileostomy formation obviating the need for stomal education. However, it is still uncertain whether the benefits of a shorter LOS offset consumable equipment cost used for laparoscopic procedures.
The National Institute for Health and Care Excellence (NICE) guidance assessment group performed a systematic review of the economic impact of laparoscopic and open approaches in colorectal surgery. They noted that the mean cost for laparoscopic surgery was higher in all studies except one and that the cost was not offset by the savings of a shorter LOS. Despite this short-coming, a recent meta-analysis by Chao et al. studied the impact of a laparoscopic procedure in low and middle-income countries and found laparoscopic surgery to be safe, effective, and cost-efficient. However, this was in the setting of adaptive strategies implemented to save on the cost of the procedure, which can be adopted in hospitals of developed countries.
Laudicella et al. conducted a large retrospective population-based study of 55,358 patients from the National Health Service in the United Kingdom and found that patients who had undergone a laparoscopic colorectal cancer resection were £2107 (95% CI 2000–2215; P .01) less expensive at 30 days and £2202 (95% CI 2092–2316; P .01) less expensive at 90 days as compared to patients who had undergone an open colorectal cancer resection. The difference was explained by a shorter stay and lower readmission rate in patients undergoing minimally invasive procedures, consistent with the results of this systematic review. Attention must be drawn to the patient's quality of life after surgery irrespective of the cost implications. In a systematic review from 2010, five studies comparing laparoscopic versus open surgery reported better quality of life in favor of laparoscopic surgery at time points as early as 1–2 weeks. Within the LHR cohort, there was a significant lower risk of overall morbidity (OR 0.33) and ileus (OR 0.87); thereby facilitating early discharge and early return to work.
One of the risks associated with LHR is conversion to open surgery, at a rate of 14.3% in this study. Common indications are extensive adhesions, difficulty in identifying the rectal stump, obesity, and intra-operative failure., It is difficult to predict the likelihood of conversion, although Mazeh et al. reported that marking the rectal stump at the time of the patient's Hartmann's procedure and an adhesion grading system applied at the commencement of laparoscopy predicted the likelihood of completion. An early decision to convert is critical to avoid the risk of inadvertent intra-abdominal injury. Hence, important considerations must be made when selecting patients for a laparoscopic approach, including the likelihood of encountering significant intra-abdominal adhesions (likelihood increases from previous disease processes or gross contamination in perforated diverticulitis or Crohn's disease), a high American Society of Anesthesiologists score (III-V), poor functional status, a high BMI, multiple previous major abdominal surgeries, or evidence of intestinal obstruction.,,
Moreover, it is also prudent to have adequate training and laparoscopic experience. In a meta-analysis by Sammour et al., 10 randomized trials comparing laparoscopic versus open abdominal surgery concluded that laparoscopic surgery was associated with a higher total intraoperative complication rate, with an estimated OR of 1.37 (P.01). The most defining result was the higher rate of bowel injury, with an estimated OR of 1.88 (P.02). Patients who sustain a bowel injury frequently suffer a poorer outcome, with a protracted hospital stay, especially in those with delayed recognition of the intra-abdominal injury.
The limitations include the absence of prospective or randomized trials comparing the two approaches for Hartmann's reversal, lending the studies to selection bias as a confounding factor. Furthermore, it was difficult to combine data on patient characteristics due to the heterogeneity in the reported parameters, making it difficult to ascertain the differences between the two cohorts. Finally, the learning curve effect with LHR is difficult to define and measure, and may underestimate the outcomes reported.
| Conclusion|| |
Laparoscopic Hartmann's reversal is safe with substantial benefits identified in infection-related morbidity, early return of gut function, and shorter LOS. While there is a moderate rate of conversion, early recognition of this is needed to reduce the potential intraoperative complications. Although it conversion, a degree of case selection is crucial.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
van de Wall BJ, Draaisma WA, Schouten ES, Broeders IA, Consten EC. Conventional and laparoscopic reversal of the Hartmann procedure: A review of literature. J Gastrointest Surg 2010;14:743-52.
Mazeh H, Greenstein AJ, Swedish K, Nguyen SQ, Lipskar A, Weber KJ, et al
. Laparoscopic and open reversal of Hartmann's procedure--A comparative retrospective analysis. Surg Endosc 2009;23:496-502.
Studer P, Schnuriger B, Umer M, Kroll D, Inderbitzin D, Candinas D. Laparoscopic versus open end colostomy closure: A single-center experience. Am Surg 2014;80:361-5.
Yang PF, Morgan MJ. Laparoscopic versus open reversal of Hartmann's procedure: A retrospective review. ANZ J Surg 2014;84:965-9.
Clermonts SH, de Ruijter WM, van Loon YT, Wasowicz DK, Heisterkamp J, Maring JK, et al
. Reversal of Hartmann's procedure utilizing single-port laparoscopy: An attractive alternative to laparotomy. Surg Endosc 2016;30:1894-901.
Gorey TF, O'Connell PR, Waldron D, Cronin K, Kerin M, Fitzpatrick JM. Laparoscopically assisted reversal of Hartmann's procedure. Br J Surg 1993;80:109.
Brathwaite S, Kuhrt M, Yu L, Arnold M, Husain S, Harzman AE. Retrospective evaluation of laparoscopic versus open Hartmann's reversal: A single-institution experience. Surg Laparosc Endosc Percutan Tech 2015;25:e156-8.
Rosen MJ, Cobb WS, Kercher KW, Heniford BT. Laparoscopic versus open colostomy reversal: A comparative analysis. J Gastrointest Surg 2006;10:895-900.
Leroy J, Costantino F, Cahill RA, D'Agostino J, Wu WH, Mutter D, et al
. Technical aspects and outcome of a standardized full laparoscopic approach to the reversal of Hartmann's procedure in a teaching centre. Colorectal Dis 2011;13:1058-65.
Lo CK, Mertz D, Loeb M. Newcastle-Ottawa Scale: Comparing reviewers' to authors' assessments. BMC Med Res Methodol 2014;14:45.
Law M, Jackson D, Turner R, Rhodes K, Viechtbauer W. Two new methods to fit models for network meta-analysis with random inconsistency effects. BMC Med Res Methodol 2016;16:87.
National Institute for Health and Care Excellence. Laparoscopic surgery for colorectal cancer [Internet]. [London]: NICE; 2006. (Technology appraisal guidance [TA105]). Available from: https://nice.org.uk/ guidance/ta105. [Updated 2014 March; Cited 2020 May].
Chao TE, Mandigo M, Opoku-Anane J, Maine R. Systematic review of laparoscopic surgery in low- and middle-income countries: Benefits, challenges, and strategies. Surg Endosc 2016;30:1-10.
Laudicella M, Walsh B, Munasinghe A, Faiz O. Impact of laparoscopic versus open surgery on hospital costs for colon cancer: A population-based retrospective cohort study. BMJ Open 2016;6:e012977.
Bartels SAL, Vlug MS, Ubbink DT, Bemelman WA. Quality of life after laparoscopic and open colorectal surgery: A systematic review. World J Gastroenterol 2010;16:5035-41.
Melkonian E, Heine C, Contreras D, Rodriguez M, Opazo P, Silva A, et al
. Reversal of the Hartmann's procedure: A comparative study of laparoscopic versus open surgery. J Minim Access Surg 2017;13:47-50.
Shukla PJ, Barreto G, Gupta P, Shrikhande SV. Laparoscopic surgery for colorectal cancers: Current status. J Minim Access Surg 2006;2:205-10.
Cohen ME, Bilimoria KY, Ko CY, Hall BL. Development of an American College of Surgeons National Surgery Quality Improvement Program: Morbidity and mortality risk calculator for colorectal surgery. J Am Coll Surg 2009;208:1009-16.
Sammour T, Kahokehr A, Srinivasa S, Bissett IP, Hill AG. Laparoscopic colorectal surgery is associated with a higher intraoperative complication rate than open surgery. Ann Surg 2011;253:35-43.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]