How is bowel movement managed from a Hartman pouch?

Management of Bowel Movement from Hartmann Pouch

The Hartmann pouch (rectal stump) requires active surveillance and management, as it remains at risk for complications including diversion colitis, perforation, and neoplasm formation despite being defunctionalized. 1, 2

Understanding the Hartmann Pouch

The Hartmann pouch is the blind rectal segment left after sigmoid resection with end colostomy creation. This defunctionalized segment is not simply inert tissue—it remains metabolically active and prone to pathology. 2, 3

Key Management Principles

Immediate Postoperative Period

Monitor aggressively for early complications:

• Assess for fever, tachycardia, hypotension, and altered mental status indicating infection or sepsis 4
• Evaluate the surgical site and check for abdominal tenderness, distention, or peritoneal signs suggesting rectal stump leak 4
• Obtain blood cultures if fever is present and monitor C-reactive protein (CRP) as an inflammatory marker 4
• Perform CT abdomen/pelvis if there is any concern for intra-abdominal abscess or rectal stump leak 4

Antibiotic Management

Provide appropriate antimicrobial coverage:

• Target Gram-negative bacilli and anaerobes for perforated colorectal pathology with peritonitis 4
• Duration: 4 days if adequate source control achieved in immunocompetent patients; extend up to 7 days in immunocompromised or critically ill patients 4
• For septic shock: Use meropenem 1g q6h by extended infusion, doripenem 500mg q8h by extended infusion, or imipenem/cilastatin 500mg q6h by extended infusion 4

Long-Term Surveillance of the Hartmann Pouch

The defunctionalized rectal pouch requires ongoing monitoring, as it develops pathology in a significant proportion of patients:

• Perform contrast-enhanced radiography of the Hartmann pouch routinely, as abnormalities are detected in 19% of patients, including clinically silent leaks, diversion colitis, adhesions, strictures, and recurrent tumor 5
• Use water-soluble contrast medium rather than barium to avoid complications from extravasation if a leak is present 5
• Conduct proctoscopy and contrast studies for close observation of the rectal pouch, particularly in long-term pouches where neoplasm formation has been documented 2
• Mild diversion colitis develops in virtually every pouch examined endoscopically, with severe colitis occurring in a subset of patients 3

Special Considerations for High-Risk Patients

Immunocompromised patients require particularly close monitoring:

• These patients may have atypical presentations with less pronounced inflammatory markers despite serious infections 4
• Steroid-dependent patients are at especially high risk for complications and recurrent disease in the Hartmann pouch 1
• In steroid-treated patients, ensure all diseased bowel is resected during the initial procedure to prevent recurrent diverticulitis in the residual rectal segment 1

Reversal Considerations

Most Hartmann procedures are never reversed:

• Only 23.3% of patients undergo reversal, with a median time interval of 285 days between creation and reversal 6
• Emergency Hartmann procedures performed for benign disease (72.5% of emergency cases) have lower reversal rates than those performed for malignancy 6
• In 42 cases of diverticulitis, colostomy closure was not performed due to patient age, medical/surgical contraindications, or patient preference 3
• Twelve pouches required removal due to severe complications 3

Complications Requiring Pouch Removal

Be prepared to remove the Hartmann pouch in cases of:

• Perforated diverticulitis in the residual rectal segment (documented even 10 months post-initial surgery) 1
• Severe diversion colitis unresponsive to conservative management 3
• Neoplasm formation in long-term pouches 2
• Recurrent carcinoma in the pouch 5

Common Pitfalls to Avoid

• Do not assume the Hartmann pouch is benign simply because it is defunctionalized—it remains at risk for multiple pathologies 2, 3
• Do not use barium for contrast studies of the pouch—water-soluble contrast is safer if a leak is present 5
• Do not leave diseased bowel in high-risk patients (especially those on steroids)—resect all diverticular disease at the initial operation 1
• Do not neglect routine surveillance—clinically silent leaks can occur months after pouch creation 5