How long after a Hartmann's procedure with double-barrel ostomy, including ileostomy and end colostomy, is a colonoscopy required?

From the Guidelines

Patients who have undergone a Hartmann's procedure with double barrel ileostomy and end colostomy should typically undergo colonoscopy surveillance approximately 1 year after the initial surgery, as recommended by the American Society of Clinical Oncology 1. This timing allows for assessment of the remaining colon and rectum while ensuring surgical sites have properly healed. The exact timing should be individualized based on the original indication for surgery, with earlier surveillance recommended for patients with high-risk conditions.

Key Considerations

• The frequency of subsequent surveillance colonoscopies should be dictated by the findings of the previous one, but they generally should be performed every 5 years if the findings of the previous one are normal 1.
• If a complete colonoscopy was not performed before diagnosis, a colonoscopy should be done as soon as reasonable after completion of adjuvant therapy and not necessarily at the 1-year time point 1.
• Prior to scheduling the colonoscopy, the surgeon should confirm adequate healing of anastomoses and surgical sites.
• The colonoscopy will need to be performed through the stoma or rectal stump, depending on the specific anatomy created during the Hartmann's procedure.
• Bowel preparation requirements may differ from standard colonoscopy protocols due to the altered anatomy, so coordination between the gastroenterologist and colorectal surgeon is essential to ensure proper preparation and safe examination of the remaining bowel.

Surveillance Protocol

• Surveillance should be guided by presumed risk of recurrence and functional status of the patient, with a focus on the first 2 to 4 years after surgery 1.
• Medical history, physical examination, and carcinoembryonic antigen testing should be performed every 3 to 6 months for 5 years, with more frequent testing for high-risk patients 1.
• A computed tomography scan (abdominal and chest) is recommended annually for 3 years, in most cases 1.

From the Research

Timing of Colonoscopy after Hartmann's Procedure

• The provided studies do not directly address the timing of colonoscopy after Hartmann's procedure with double barrel, ileostomy, and end colostomy 2, 3, 4, 5, 6.
• However, the studies discuss the outcomes and complications of Hartmann's procedure and its reversal, which may be relevant to the overall management of patients after such a procedure.
• For example, a study published in 2005 found that the mean time to closure of the colostomy was 168 days (range 69-385 days) after Hartmann's procedure 2.
• Another study published in 2021 reported a mean time interval of 14.4 months between the index procedure and reversal 5.
• It is essential to note that the timing of colonoscopy after Hartmann's procedure may depend on various factors, including the patient's overall health, the reason for the procedure, and the presence of any complications.

Factors Affecting Complications and Outcomes

• Several studies investigated the factors affecting complications and outcomes after Hartmann's procedure and its reversal 4, 5.
• A study published in 2020 found that patients with ASA 4, liver disease, and BMI < 30 were at higher risk of major complications after Hartmann's reversal 4.
• Another study published in 2021 reported that obese patients were at higher risk of morbidity after Hartmann's reversal 5.
• These findings may be relevant to the management of patients after Hartmann's procedure, including the timing of colonoscopy.

Morbidity and Mortality

• The studies reported significant morbidity and mortality rates after Hartmann's procedure and its reversal 3, 4, 5, 6.
• A study published in 2021 reported an overall morbidity rate of 54% and a major morbidity rate of 23% after Hartmann's reversal 5.
• These findings highlight the importance of careful patient selection and management after Hartmann's procedure.