Hartmann's procedure versus intersphincteric abdominoperineal excision (HiP Study): a multicentre prospective cohort study

Abstract

Aim In patients with low rectal cancer it is occasionally necessary to avoid a low coloanal anastomosis due to patient frailty or poor function. In such situations there are two alternative approaches: Hartmann's procedure (HP) or intersphincteric abdominoperineal excision (IAPE). There are few data to guide surgeons as to which of these two procedures is the safest. The aim of this study was to determine the surgical complication rates associated with each procedure. Method This was a multicentre, nonrandomized prospective cohort study of patients undergoing either HP or IAPE. The primary objective was to determine surgical complication rates. Secondary objectives included length of stay, time to adjuvant therapy and quality of life at 90 days. Results One hundred and seventy nine patients were recruited between April 2016 and June 2019; approximately two thirds of patients underwent HP and one third IAPE. The overall complication rate was high in both groups (54% for the HP group and 52% for the IAPE group). Surgery-specific complication rates were also high, but not significantly different: 43% for HP and 48% for IAPE. The pelvic abscess rate in HP was 11% and was significantly higher in patients with a palpable staple line (15% vs 2%). There was a higher incidence of serious medical complications following IAPE (16% vs 5%), along with a reduction in 90-day quality of life scores. Conclusion This is the largest prospective study to compare HP and IAPE in patients undergoing rectal cancer surgery where primary anastomosis is not deemed appropriate. With similar complication rates, these data support the ongoing use of either HP or IAPE in this patient group.

The complication profile of low Hartmann's in rectal cancer: a systematic review and meta‐analysis

“…The LH group had a higher proportion of ASA Class 3-4 patients at 38-67%, as compared to 17-48% in the ISAPR group. Five studies [7][8][9]12,13 reported on tumour staging, with similar percentages of Stage IIIa or Dukes C stages noted in the LH (50%) and ISAPR (47.6%) groups (Table 3).…”

“…After screening for full text reviews, a total of 12 studies were included in the study. The majority of papers 1,2,6,[8][9][10][11] have only elective patients in their inclusion criteria. Some papers have intentionally excluded emergency cases.…”

“…Seven studies compared LH with APR/ISAPR, 2,3,6,8,9,12,13 with three studies comparing LH with restorative anterior resection 10,11,14 . Two studies focused on outcomes of LH alone 15,16 (Table 2).…”

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

“…The increasing incidence of rectal cancer, especially among older people, compels surgeons to reconsider the treatment for rectal cancer [1,2]. The role of HP as a treatment option for rectal cancer has long been debated and its use varies widely between countries [3][4][5].…”

Hartmann’s procedure versus intersphincteric abdominoperineal excision for mid to low rectal cancers – are they comparable?

“…I read with great interest the excellent study by Hayley Fowler and colleagues and led by Dale Vimalachandran entitled ‘Hartmann's procedure versus intersphincteric abdominoperineal excision (HiP Study): a multicentre prospective cohort study’ [1]. This is a relevant topic of clinical interest to the colorectal community.…”