What is the optimal timing for Hartmann's procedure (Hartmann reversal) reversal?

From the Guidelines

Hartman's reversal should be postponed beyond 3 months, as it is considered a deferrable procedure for up to 3 months or beyond, according to the NHS guidelines [ 1 ].

Key Considerations

• The NHS guidelines categorize Hartman's reversal as a Level 4 procedure, which is deferrable beyond 3 months [ 1 ].
• The ACS guidelines also support postponing Hartman's reversal, categorizing it as a Tier 2a or Tier 2b procedure, which can be postponed if possible or considered for ambulatory surgery center (ASC) [ 1 ].
• The ESMO guidelines do not specifically address Hartman's reversal but prioritize life-threatening conditions and those with significant overall survival (OS) gain or improvement in quality of life (QoL) [ 1 ].

Clinical Decision-Making

When deciding on the timing for Hartman's reversal, it is essential to consider the patient's overall health status, nutritional status, and presence of any comorbidities that may increase surgical risk.

• A contrast enema should be performed prior to reversal to confirm distal bowel integrity and absence of strictures or leaks.
• The patient should be in good nutritional status with albumin levels above 3.5 g/dL and have no signs of active infection or significant comorbidities.
• The procedure involves mobilizing the colostomy, resecting the end portions, and performing an end-to-end anastomosis to restore bowel continuity.

Prioritization

In the context of the COVID-19 pandemic, prioritization of elective surgeries should be based on the magnitude of benefit and the potential impact on overall outcome [ 1 ].

• Hartman's reversal is considered a non-urgent procedure and can be postponed beyond 3 months without significant impact on overall outcome.
• The decision to postpone or proceed with Hartman's reversal should be made on a case-by-case basis, taking into account the patient's individual needs and circumstances.

From the Research

Timing for Hartman Reversal

• The optimal time for reversal of Hartmann's procedure is controversial, with studies suggesting different timelines for the procedure 2, 3, 4.
• A study published in 1994 found that operative difficulty appears to be less after a delay of 15 weeks 2.
• Another study published in 2016 reported a mean time interval between the initial procedure and the reversal of 181.6 days (range 95-330 days) 3.
• A 2023 study found that the median time for reversal was 14.0 (IQR 10-23) months 4.

Factors Affecting Timing

• The decision to reverse Hartmann's procedure should be made after a careful risk/benefit analysis for each individual patient, taking into account factors such as age, underlying condition, and overall health 5.
• A study published in 2008 found that laparoscopic reversal of Hartmann's procedure is a technically demanding but feasible operation with a low postoperative morbidity and mortality 6.
• The choice of operative method, whether laparoscopic or open, may also affect the timing of the reversal procedure 5.

Outcomes and Complications

• Reversal of Hartmann's procedure is associated with a significant morbidity rate, with surgical site infections being the most common type of complication encountered 4.
• A study published in 2014 found that the laparoscopic approach requires profound surgical expertise and is associated with a lower rate of major complications compared to the open procedure 5.
• The timing of the reversal procedure may also affect the rate of complications, with earlier reversals potentially leading to a higher rate of operative difficulty and morbidity 2.