The Hartmann procedure: First choice or last resort in diverticular disease?

Objective: To critique changing trends in the surgical management of diverticular disease. Design: Case series. Two hundred twenty-seven consecutive patients required surgery for diverticular disease from 1988 to 1993. Patient records were reviewed retrospectively Operative procedures included primary resection in all patients with either anastomosis, anastomosis with proximal ileostomy, or the Hartmann procedure. Morbidity, mortality, and length of stay were then compared with each operative procedure and stage of disease. Patients were categorized according to the following pathologic stages: stage 0, no inflammation; stage 1, chronic inflammation; stage II, acute inflammation with or without microabscesses; stage III, pericolonic or mesenteric abscess; stage IV, pelvic abscess; and stage V, purulent or feculent peritonitis. Setting: A university hospital and private affiliated hospitals in a large metropolitan area. Main Outcome Measures: Study outcome parameters included mortality, morbidity, length of hospital stay, and leak rates. These outcomes were then compared with different disease stages and treatments. Results: Mean patient age was 66 years (range, 25-98 years). Male-female ratio was 84:143. Mean follow-up was 23 months (range, 1-132 months). There were 50 fistulas: 2.4 colovesical, 21 colovaginal, 3 colocolonic, 1 coloenteric and 1 colouterine. Surgery was categorized as elective for 196 patients (86%), urgent for 12 (5%), and emergent for 19 (8%). Primary resection was performed in all cases. Primary anastomosis was performed in 200 patients (88%), 183 without and 17 with proximal diversion. Twenty-seven patients (12%) underwent a Hartmann procedure with colostomy; 19 patients (70%) have since undergone colostomy closure. Morbidity occurred in 52 patients (23%), including 4 anastomotic leaks (2%). There were 3 perioperative deaths (1%). Mean length of initial hospital stay was 11 days (range, 4-59 days). Length of stay was 5 days (range, 4-7 days) for ileostomy closure (7% morbidity) and 13 days (range, 7- 35 days) for the colostomy closure after the Hartmann procedure (33% morbidity). Conclusions: Primary resection is virtually always possible in complicated diverticular disease. Primary anastomosis, with or without proximal diversion, is safe for patients with no abscesses or localized abscesses and should be considered on an individual basis for patients with pelvic abscesses and peritonitis. Colostomy closure after the Hartmann procedure is associated with significant length of hospitalization and morbidity and leaves one third of patients with permanent stomas.