Long-term Quality of Life After Surgery for Mid- and High Rectal Cancer: Hartmann's Procedure Versus Anterior Resection and Abdominoperineal Resection.

BACKGROUND/AIM: Anterior resection is the gold standard surgery for high and middle rectal tumors. In cases where anterior resection is not feasible, the surgeon resorts to a non-restorative approach such as Hartmann's procedure or abdominoperineal resection. It is not well studied how Hartmann's procedure impacts quality of life. This cross-sectional cohort study compares the long-term quality of life after Hartmann's procedure with anterior resection and abdominoperineal resection. PATIENTS AND METHODS: Patients operated for high- or middle rectal cancer in the southern healthcare region of Sweden between 2007 and 2017 were identified and data were extracted from the Swedish Colorectal Cancer Registry. Further clinical variables were retrieved from medical charts. Quality of life was evaluated by SF-12-, EQ-5D-5L- and EORTC QLQ - CR29 questionnaires. RESULTS: Out of 521 patients included, 51 had undergone Hartmann's procedure, 381 anterior resection and 89 abdominoperineal resection. Hartmann patients were significantly older with more comorbidities. Median follow-up time was 104 months. There were no differences between groups in overall quality of life. Patients subjected to Hartmann's procedure reported inferior mobility, self-care, daily activities and reduced estimation of general health compared to those who had anterior resection. Abdominoperineal resection was associated with more impotence compared to Hartmann's procedure. CONCLUSION: Overall long-term QoL after Hartmann's procedure was comparable to anterior resection and abdominoperineal resection. In certain symptoms patients with Hartmann's procedure for rectal cancer scored worse compared to anterior resection, but patients were older and frailer making causal inference impossible.

Hartmann's procedure in rectal cancer surgery is often an intraoperative decision: a retrospective multicenter study.

PURPOSE: This study aimed to investigate patient-related factors predicting the selection of rectal cancer patients to Hartmann's procedure as well as to investigate how often, and on what grounds, anterior resection is intraoperatively changed to Hartmann's procedure. METHODS: Prospectively collected data from the Swedish Colorectal Cancer Registry regarding patients with rectal cancer operated upon from January 1 2007 to June 30 2017 in the county of Skåne were retrospectively reviewed. Data were expanded with further details from medical charts. A univariable analysis was performed to investigate variables associated with unplanned HP and significant variables included in a multivariable logistic regression analysis. RESULTS: Altogether, 1141 patients who underwent Hartmann's procedure (275 patients, 24%), anterior resection (491 patients, 43%), or abdominoperineal resection (375 patients, 33%) were included. Patients undergoing Hartmann's procedure were significantly older and had more frequently comorbidity. The decision to perform Hartmann's procedure was made preoperatively in 209 (76%) patients, most commonly because of a comorbidity (27%) or oncological reasons (25%). Patient preference was noted in 8% of cases. In 64 cases (23%), the decision was made intraoperatively, most often due to anastomotic difficulties (60%) and oncological reasons (22%). Anastomotic difficulties were most often reported due to technical difficulties, a low tumor or neoadjuvant radiotherapy. Male gender was a significant risk factor for undergoing unplanned Hartmann's procedure. CONCLUSIONS: The decision to perform Hartmann's procedure was frequently made intraoperatively. Hartmann's procedure should be considered and discussed preoperatively in old and frail patients, especially in the presence of mid-rectal cancer and/or male gender, since these factors increase the risk of intraoperative anastomotic difficulties.

Low incidence of pelvic sepsis following Hartmann's procedure for rectal cancer: a retrospective multicentre study.

BACKGROUND: Results of previous studies regarding pelvic sepsis after Hartmann's procedure (HP) for rectal cancer have been inconsistent and few studies report the risk factors. This study aimed to investigate the incidence of pelvic sepsis after HP, identify risk factors and describe when as well as how pelvic sepsis was diagnosed and treated. METHODS: Data were collected from the Swedish Colorectal Cancer Registry on all patients undergoing HP for rectal cancer in the county of Skåne from 2007-2017. Patients diagnosed with pelvic sepsis were compared with patients without pelvic sepsis and risk factors for developing pelvic sepsis were analysed in a multivariable model. RESULTS: A total of 252 patients were included in the study, with 149 (59%) males, and a median age of 75 years (range 20-92). Altogether, 27 patients (11%) were diagnosed with pelvic sepsis. Risk factors for developing pelvic sepsis were neoadjuvant radiotherapy (OR 7.96, 95% CI 2.54-35.36) and BMI over 25 kg/m2 (OR 5.26, 95% CI 1.80-19.50). Median time from operation to diagnosis was 21 days (range 5-355) with 11 (40%) patients diagnosed beyond 30 days postoperatively. The majority of cases 19 (70%) were treated conservatively and none needed major surgery. CONCLUSION: Pelvic sepsis occurred in 11% of patients. Neoadjuvant radiotherapy and higher BMI were significant risk factors for developing pelvic sepsis. Forty percent of patients were diagnosed later than 30 days postoperatively and most patients were successfully treated conservatively. Our findings suggest that HP is a valid treatment option for rectal cancer when anastomosis is inappropriate, even in patients receiving neoadjuvant radiotherapy.