Transcript Document

Laparoscopic vs open reversal of Hartmann’s in unselected patients – a teaching centre
experience over 8 years including long-term follow-up
Nottingham University Hospitals, Queens Medical Centre
R K Maitra, C Maxwell-Armstrong, T Pinkney, J Smith, C Gornall, J H Scholefield, J P Williams, M H Robinson, J F Abercrombie, N C Armitage, A G Acheson
Introduction:
Reversal of Hartmann’s has a high reported morbidity and mortality (5% and 50% respectively). Laparoscopic reversal of Hartmann’s was first described in 1996
with a number of studies showing reduced short-term morbidity and hospital stay compared to open procedures. Our series is one of the largest comparing open to
laparoscopic reversal of Hartmann’s.
Methods:
All laparoscopic cases were maintained on a prospective database from 2003. We identified all open reversals from the same period. Retrospective review of all
patients was performed including long-term outcomes and follow up. All patients presenting to 2 consultants had attempted laparoscopic reversals – this
constituted 85% (n=35) of the laparoscopic patients.
Patients divided into 3 groups – laparoscopically completed procedures (‘laparoscopic’ group), laparoscopic procedures converted to open (‘converted’ group), open
procedures (‘open’ group).
Conversion rate 31%
• No significant differences in age or sex between the three groups.
• More patients in the converted group had previous peritonitis but this
was not statistically significant.
• Significantly increased risk of conversion with previous peritonitis
(p=0.034)
Short-term outcomes
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No significant difference in operating times (p=0.658)
Significantly lower post-operative morbidity in laparoscopic group (0.036)
Higher rate of 30-day return to theatre, not significant (p>0.05)
Significantly shorter hospital stay in laparoscopic group (p<0.001)
Significantly lower anastomotic leak
No correlation between operating times and BMI in laparoscopic patients
(r=0.146, p=0.41)
• No correlation between surgeon experience and operating times in
laparoscopic patients (r=-0.26, p=0.147)
Long-term outcomes
• No significant difference in re-admission rates (p<0.05)
• Significantly lower re-operation rates in laparoscopic compared to
open groups (p=0.009)
• Significantly lower rate of stoma-site herniae between laparoscopic
and open groups (p=0.001)
Total 74
Laparoscopic 28
Converted 13
Open 33
4-month follow-up
12-month follow-up
>12-month follow-up 25
(33%)
Laparoscopic 7 (28%)
Converted 5 (38%)
Open 13 (39%)
Missing 8 (10%)
Laparoscopic 4
(14%)
Converted 1 (7%)
Open 3 (9%)
Discharged 14
(18%)
Laparoscopic 7
(25%)
Converted 2 (15%)
Open 5 (15%)
Discharged 27
(36%)
Laparoscopic 10
(35%)
Converted 5 (38%)
Open 12 (36%)
Conclusions:
• Laparoscopic reversal has a high conversion rate in unselected patients
• Risk of conversion is significantly higher in patients with previous peritonitis
• Laparoscopically completed reversals have better outcomes
• Reduced 30-day morbidity
• Shorter post-operative hospital stay
• Reduced rate of re-operations (small difference)
• Fewer stoma-site heraniae
Summary of literature
Papers comparing laparoscopic to open reversals highlighted
Significant differences in red
year
Hospital
Number ofoperation
stay
Total
ReRepatients duration
(days)
Mortality morbidity admissions operation
(Lap vs
(mins) (Lap Conversion(Lap vs (%) (Lap (%) (Lap (%) (Lap vs (%) (Lap vs
open)
vs Open) rate (%)
Open)
vs Open) vs Open) Open)
Open)
Macpherson et al
Delgado et al
Kohler et al
Vacher et al
Rosen et al
Khaikin et al
Faure et al
Slawik et al
Carus et al
1996
12
162
1998
11
144
1999
19
114
2002
38
2005
22
158
2006
27
228
200714 vs 20 143 vs 180
2008
28
80
2008
28
69
Haughn et al
200861 vs 61
154 vs 200
Chouillard et al
200944 vs 44
195 vs 160
Mazeh et al
200941 vs 41
193 vs 209
Achkasov et al
Svenningsen et al
Leroy et al
Hai et al
201036 vs 35 179vs 266
201021 vs 22 285 vs 158
2011
42
117
2011
28
166
8
7
11
7.5
15.8
15
10 2.631579
23.5
9
4.2
14
14.8
6
33
14.39.5 vs 11
14 vs 30
7
3
7
11
17.9
8.6
14.3
3.3 vs
16.4
16.4 vs 16.4 13.1 vs 3.3
11.4 vs
9.14.8 vs 6.8 2.2 vs 0 28.6
4.8 vs
19.56.4 vs 8
12.1
9.1
0vs12.9
5.9 vs 9.1
54 vs 6
10 vs 14
9.5
7
19.04762
0
10.7