What is the management of leukocytosis (elevated white blood cell count) after a Hartman procedure?

Management of Leukocytosis After Hartmann Procedure

Leukocytosis following a Hartmann procedure is common and usually represents a normal physiologic response to surgery that typically resolves without specific intervention, but monitoring for signs of infection is essential to rule out complications.

Understanding Post-Hartmann Leukocytosis

• Leukocytosis (elevated white blood cell count) is a common finding after major surgical procedures, representing a normal physiologic response to surgical trauma, similar to what is observed after other major surgeries like total hip and knee arthroplasty 1
• After a Hartmann procedure, which is commonly performed for complicated diverticulitis, colorectal cancer, or other emergent conditions, some degree of leukocytosis is expected 2
• The typical pattern involves WBC elevation peaking within the first 2 postoperative days and gradually declining to near-baseline levels by postoperative day 4 1

Assessment of Post-Hartmann Leukocytosis

Initial Evaluation:

• Assess for clinical signs of infection or sepsis (fever, tachycardia, hypotension, altered mental status) 2
• Evaluate the surgical site for signs of wound infection (erythema, purulent drainage, dehiscence) 3
• Check for abdominal tenderness, distention, or peritoneal signs that might indicate intra-abdominal infection 2
• Assess colostomy for proper function, viability, and absence of complications (necrosis, retraction) 3

Laboratory and Imaging Studies:

• Serial WBC counts to track the trend (rising vs. falling) 1
• Blood cultures if fever or other signs of systemic infection are present 2
• C-reactive protein (CRP) as an additional inflammatory marker 2
• CT scan of abdomen/pelvis if there is concern for intra-abdominal abscess or anastomotic leak from the rectal stump 2

Management Algorithm

Scenario 1: Isolated Leukocytosis Without Clinical Signs of Infection

• Monitor vital signs and clinical status 2
• Continue routine postoperative care without specific antibiotic therapy 2
• Ensure adequate hydration and pain control 2
• Follow WBC trend, expecting gradual normalization 1

Scenario 2: Leukocytosis With Clinical Signs of Infection

• Obtain appropriate cultures (blood, wound, urine) 2
• Initiate broad-spectrum antibiotic therapy according to WSES guidelines for intra-abdominal infections 2
• Consider CT imaging to identify potential sources of infection (intra-abdominal abscess, rectal stump leak) 2
• If abscess is identified:
  • Small abscess (<3-6 cm): may be treated with antibiotics alone 2
  • Larger abscess (>3-6 cm): percutaneous drainage plus antibiotics is recommended 2

Scenario 3: Leukocytosis With Signs of Sepsis/Septic Shock

• Immediate resuscitation following sepsis protocols 2
• Urgent source control if surgical complication identified 2
• Broad-spectrum antibiotics according to local antibiogram and patient risk factors 2
• Consider reoperation if there is evidence of:
  • Rectal stump leak
  • Intra-abdominal abscess not amenable to percutaneous drainage
  • Peritonitis
  • Colostomy necrosis or retraction 3

Special Considerations

• Immunocompromised patients may have atypical presentations with less pronounced leukocytosis despite serious infections 2
• Kidney transplant patients with leukocytosis after Hartmann procedure warrant particular attention as they may have more severe complications of diverticulitis 2
• The sensitivity of leukocytosis for diagnosing early postoperative infection is approximately 79%, but specificity is only 46%, highlighting the need to correlate with clinical findings 1
• Hartmann procedure has significant morbidity (up to 44%) and mortality (3-14%) rates, so postoperative complications including infection should be carefully monitored 4, 5, 3, 6

Common Pitfalls to Avoid

• Assuming all postoperative leukocytosis indicates infection; this can lead to unnecessary antibiotic use 2, 1
• Delaying imaging in patients with persistent leukocytosis and concerning clinical signs 2
• Failing to assess the colostomy site, which can be a source of complications in up to 20% of cases 3
• Overlooking rectal stump complications, which occur in approximately 5% of Hartmann procedures 3
• Neglecting to consider non-surgical causes of leukocytosis (e.g., medication reactions, pulmonary embolism, urinary tract infection) 1