The Challenges of the Hartmann's Rectal Stump Reversal: A Clinical Audit and Review of the Literature

Background: Hartmann's procedure is performed in patients who are not candidates for immediate reestablishment of colonic continuity. A shrunken rectal stump poses a great challenge at the time of its reversal. Objective: To determine the factors [level of inferior mesenteric artery (IMA) ligation and duration prior to Hartmann's reversal] contributing to a shrunken rectal stump. The value of imaging and success rate of the technique used in the Hartmann's reversal were also assessed. Methods: A retrospective analysis of 36 patients who underwent Hartmann's procedure and reversal between 2012 and 2014 was performed. Patient demographic profile, initial pathology, operation setting, level of IMA ligation, complications, duration prior to reversal, imaging modality, state of rectal stump, outcome, and reversal technique were documented. Results: Thirty-six patients were considered for reversal of Hartmann's procedure. In 95.5% of subjects who underwent a high IMA ligation, proximal rectum stricture and short, shrunken rectal stumps were noted. Patients who underwent reversal after 6 months had a significant incidence of a short shrunken rectal stump (n = 19; 82.6%). The percentage of successful outcomes in the reversal of the short rectal stump using the stapling technique was 93.8% (n = 27). Twenty-six patients who underwent barium enema correlated strongly with the operation findings. Conclusion: High ligation in Hartmann's procedure contributes to a short shrunken rectal stump. The duration prior to reversal of more than 6 months correlates with a shrunken rectal stump. Preoperative imaging evaluation serves as a good predictor for the length of the rectal stump. A staples anastomotic technique shows good outcome.