The role of Hartmann’s procedure in the elective management of rectal cancer: results of a Brazilian cohort study

ABSTRACT Background: although preservation of bowel continuity is a major goal in rectal cancer surgery, a colorectal anastomosis may be considered an unacceptably high-risk procedure, particularly for patients with multiple comorbidities. We aimed to assess rates of surgical complications in rectal cancer patients according to the type of procedure they had undergone. Materials and Methods: this cohort included all rectal cancer patients undergoing elective resection at a referral academic hospital over 16 years. There were three study groups according to the type of performed operation: (1) rectal resection with anastomosis without defunctioning stoma (DS); (2) rectal resection with anastomosis and DS; and (3) Hartmann’s procedure (HP). Postoperative complications and clinical outcomes were assessed. Results: four-hundred and two patients were studied. The 118 patients in group 3 were significantly older (>10 years), had higher Charlson Comorbidity Index scores, and more ASA class ≥3 than patients in the other two groups. Sixty-seven patients (16.7%) had Clavien-Dindo complications grade ≥ III, corresponding to an incidence of 11.8%, 20.9%, and 14.4% in groups 1, 2, and 3, respectively (p=0.10). Twenty-nine patients (7.2%) had major septic complications that required reoperation, with an incidence of 10.8%, 8.2% and 2.5% in groups 1, 2 and 3, respectively (p=0.048). Twenty-one percent of the group 2 patients did not undergo the stoma closure after a 24-month follow-up. Conclusion: HP was associated with a lower incidence of reoperation due to intra-abdominal septic complications. This procedure remains an option for patients in whom serious surgical complications are anticipated.摘要 背景：尽管保留肠道连续性是直肠癌手术的核心目标之一，但结直肠吻合术仍可能被视为风险过高的手术操作，尤其针对合并多种基础疾病的患者。本研究旨在根据手术方式类型，评估直肠癌患者的手术并发症发生率。 材料与方法：本队列研究纳入某转诊教学医院16年间所有接受择期切除术的直肠癌患者。根据所实施手术的类型分为三组：（1）直肠切除吻合术且未行临时性造口（defunctioning stoma, DS）；（2）直肠切除吻合术联合临时性造口；（3）哈特曼手术（Hartmann’s procedure, HP）。对术后并发症及临床结局进行评估。 结果：本研究共纳入402例患者。第3组的118例患者年龄显著高于其余两组（差距超10年），查尔森合并症指数（Charlson Comorbidity Index）评分更高，美国麻醉医师协会（ASA）分级≥3级的比例也更高。67例患者（16.7%）出现克莱文-迪多（Clavien-Dindo）分级≥Ⅲ级的并发症，三组发生率分别为11.8%、20.9%与14.4%（P=0.10）。29例患者（7.2%）发生需再次手术的严重脓毒症并发症，三组发生率分别为10.8%、8.2%与2.5%（P=0.048）。随访24个月后，第2组中有21%的患者未接受造口还纳术。 结论：哈特曼手术与腹腔内脓毒症并发症所致再次手术的更低发生率相关，该术式仍可作为预计会发生严重手术并发症患者的可选方案。