Few rectal cancer patients, operated with Hartmann's procedure, developed pelvic complications despite a higher age, more co-morbidities, metastases in different localities and functional inferiority when compared with the patients operated with anterior resection or abdominoperineal excision. Hartmann's procedure is a valid alternative procedure in the old and frail rectal cancer patient.

A prophylactic stoma mesh did not reduce the rate of clinically or computed tomography-verified parastomal hernias. High BMI was associated with an increased risk of parastomal hernia formation regardless of prophylactic stoma mesh.

BackgroundThe use of Hartmann’s procedure in the old and frail and/or in patients with fecal incontinence is increasing, even though some data have reported high postoperative rates of pelvic abscesses. Abdominoperineal excision with intersphincteric dissection has been proposed as a better alternative and is performed increasingly both nationally and internationally. However, no studies have been performed to support this. The aim of this study is to randomize patients between Hartmann’s procedure and abdominoperineal excision with intersphincteric dissection and compare post-operative surgical morbidity and quality of life. The hypothesis is that intersphincteric abdominoperineal excision provides less pelvic and perineal morbidity.Methods/designIn this multicentre randomized controlled study, Hartmann’s procedure will be compared with intersphincteric abdominoperineal excision in patients with rectal cancer unsuitable for an anterior resection. The patients are operated in different ways around the ano-rectum, otherwise the same procedure is performed with total mesorectal excision and all will receive a colostomy. The one-month postoperative control will focus on post-operative surgical complications, especially the perineal-pelvic, reoperations and other interventions. After one year, late complications such as pain in the perineal or pelvic area or disorders such as secretion or bleeding from the anorectal stump will be recorded and a follow-up of quality of life performed. Histological and oncological data will also be recorded, the latter up to 5 years post-operatively.DiscussionThe HAPIrect trial is the first randomized controlled trial comparing standard low Hartmann’s procedure with intersphincteric abdominoperineal excision in patients with rectal cancer with the aim of categorizing the post-operative surgical morbidity.Trial registrationClinicalTrials.gov Identifier: NCT01995396. Date of registration November 25, 2013.

PurposeTo describe the postoperative surgical complications in patients with rectal cancer undergoing Hartmann’s procedure (HP).MethodsData were retrieved from the Swedish Colorectal Cancer Registry for all patients with rectal cancer undergoing HP in 2007–2014. A retrospective analysis was performed using prospectively recorded data. Characteristics of patients and risk factors for intra-abdominal infection and re-laparotomy were analysed.ResultsOf 10,940 patients resected for rectal cancer, 1452 (13%) underwent HP (median age, 77 years). The American Society of Anesthesiologists (ASA) score was 3–4 in 43% of patients; 15% had distant metastases and 62% underwent a low HP. The intra-abdominal infection rate was 8% and re-laparotomy rate was 10%. Multivariable logistic regression analysis identified preoperative radiotherapy (OR, 1.78; 95% CI, 1.14–2.77), intra-operative bowel perforation (OR, 1.99; 95% CI, 1.08–3.67), T4 tumours (OR, 1.68; 95% CI 1.04–2.69) and female gender (OR, 1.73; 95% CI, 1.15–2.61) as risk factors for intra-abdominal infection. ASA score 3–4 (OR, 1.62; 95% CI, 1.12–2.34), elevated BMI (OR, 1.05; 95% CI, 1.02–1.09) and female gender (OR, 2.06; CI, 1.41–3.00) were risk factors for re-laparotomy after HP. The rate of intra-abdominal infection was not increased after a low HP.ConclusionsDespite older age and co-morbidities including more advanced cancer, patients undergoing Hartmann’s procedure had low rates of serious postoperative complications and re-laparotomy. A low HP was not associated with a higher rate of intra-abdominal infection. HP seems to be appropriate for old and frail patients with rectal cancer.

Objective: To investigate the ability of Magnetic resonance cholangiopancreatography (MRCP) to exclude choledocholithiasis (CDL) in symptomatic patients. Material and methods: Patients suspected of choledocholithiasis who underwent MRCP from 2008 through 2013 in a population based study at the National University Hospital of Iceland were retrospectively analysed, using ERCP and/or intraoperative cholangiography as a gold standard diagnosis for CDL. Results: Overall 920 patients [66% women, mean age 55 years (SD 21)] underwent MRCP. A total of 392 patients had a normal MRCP of which 71 underwent an ERCP investigation demonstrating a CBD stone in 29 patients. A normal MRCP was found to have a 93% negative predictive value (NPV) and 89% probability of having no CBD stone demonstrated as well as no readmission due to gallstone disease within six months following MRCP. During a 6-month follow-up period of the 321 patients who did not undergo an ERCP nine (2.8%) patients were readmitted with right upper quadrant pain and elevated liver tests which later normalised with no CBD stone being demonstrated, three (0.9%) patients were readmitted with presumed gallstone pancreatitis, two (0.6%) patients were readmitted with cholecystitis and two (0.6%) patients were lost to follow-up. Seven patients of those 321 underwent an intraoperative cholangiography (IOC) and all were negative for CBD stones. For the sub-group requiring ERCP following a normal MRCP the NPV was 63%. Conclusion: Our results support the use of MRCP as a tool for exclusion of choledocholithiasis with the potential to reduce the amount of unnecessary ERCP procedures. ARTICLE HISTORY

Introduction: There are little data on the post-operative outcome of anterior resection (AR) for rectal cancer in men who had received radiotherapy for prostate cancer previously. The aim of this study was to assess the rate of anastomotic leakage (AL) after AR in these patients. Methods: All men who underwent bowel resection because of rectal cancer between 2000 and 2016 and had been diagnosed previously with prostate cancer were identified by linking the Swedish Colorectal Cancer Registry with the National Prostate Cancer Register. The medical records of men who underwent AR and had previously received radiotherapy for prostate cancer were reviewed. Results: In total, 13299 men had undergone a bowel resection for rectal cancer, 188 of whom had previously received radiotherapy for prostate cancer. Among those who had received radiation therapy, 59 men (31%) had an AR: 50 men (85%) received a diverting ileostomy, 42 men (71%) had an American Society of Anesthesiologists score of 1e2 and 36 men (61%) had tumour stage 1e2. AL was found in 12/59 men (20%), one of whom had a re-laparotomy. There was no 90-day mortality. Conclusions: In the combined national population-based registries, a minority of patients with rectal cancer had an AR after previous radiotherapy for prostate cancer. These patients were healthy with early cancer stages and, in this selected group of patients, the AL rate was much lower than that reported previously.

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