What is the effect of Hartmann's (Hartmann's solution) reversal in patients with morbid obesity?

From the Guidelines

Hartmann's reversal in morbid obesity should be approached with caution, considering the high risk of complications, and is best performed after weight optimization and at least 3-6 months from the initial procedure, with a laparoscopic approach preferred when possible. The decision to perform Hartmann's reversal in morbidly obese patients requires careful consideration of the potential risks and benefits, as the procedure can be technically challenging due to the presence of thick adipose tissue and adhesions 1.

Key Considerations

• Weight optimization, ideally with BMI reduction below 40, is crucial to reduce the risk of complications during the procedure 1.
• A minimum of 3-6 months should be allowed to pass from the initial Hartmann's procedure to permit inflammation to resolve, making the reversal procedure safer and more feasible 1.
• Laparoscopic approach is preferred when surgeon expertise allows, as it offers better visualization despite technical difficulty, although the role of laparoscopic surgery in emergency colorectal operations is still unclear 1.
• The procedure involves mobilizing the rectal stump, which may be difficult to locate due to adhesions and adipose tissue, and liberal use of ureteral stents and intraoperative endoscopy can help identify the rectal stump.

Preoperative and Postoperative Management

• Preoperative bowel preparation with mechanical cleansing and oral antibiotics is recommended, along with standard perioperative antibiotics (typically cefazolin 2g and metronidazole 500mg IV) 1.
• Postoperatively, enhanced recovery protocols should be implemented, including early mobilization, early feeding, and multimodal pain management to minimize the risk of complications.
• The procedure carries higher risks of complications in obese patients, including anastomotic leak (5-15%), wound infection (10-20%), and cardiopulmonary complications, which stem from technical challenges of operating through thick adipose tissue, poor visualization, and comorbidities associated with obesity 1.

From the Research

Hartman's Reversal in Morbid Obesity

• Hartman's reversal is a surgical procedure that is associated with high postoperative adverse events, particularly in obese patients 2, 3, 4.
• Obesity is an independent predictor of morbidity after Hartman's reversal, with obese patients experiencing significantly greater overall morbidity, wound infections, and diverting ileostomy at reversal 2.
• The study by 2 found that patients with a BMI of 29 or higher had a higher risk of complications after Hartman's reversal, suggesting that weight loss may be beneficial before undergoing the procedure.
• Another study by 3 found that Hartman's reversal remains a highly morbid procedure, with a significant risk of morbidity associated with restoration of intestinal continuity, particularly in obese patients.
• The use of low-molecular-weight heparin (LMWH) for venous thromboembolism prophylaxis may be beneficial in patients undergoing bariatric surgery, including those with morbid obesity 5, 6.
• A study by 6 found that LMWH was more effective than unfractionated heparin for the prevention of postoperative venous thromboembolism among patients undergoing bariatric surgery, without increasing the risk of bleeding.

Complications and Morbidity

• The overall morbidity rate for Hartman's reversal is high, ranging from 43.8% to 54% in different studies 2, 3, 4.
• Common complications include ileus, wound infection, and anastomotic leak 3.
• Obese patients are at higher risk of developing these complications, particularly wound infections and diverting ileostomy at reversal 2.
• The study by 4 found that Hartman's reversal was associated with a higher prevalence of surgical or medical complications compared with primary resection and anastomosis.

Surgical Approach and Outcomes

• The choice of surgical approach, either open or laparoscopic, may affect outcomes in Hartman's reversal 3.
• A laparoscopic approach may decrease morbidity in selected patients, but has a high conversion rate to open surgery 3.
• The study by 2 found that an open approach was associated with a higher risk of complications after Hartman's reversal.