Oncological Outcomes in Intentional vs Unintentional Low Hartmann’s and Restorative LAR

Overview

This population-based study compared oncological outcomes between low Hartmann’s procedure (low-HP), both planned and unplanned, and restorative low anterior resection (rLAR) in rectal cancer patients. Findings indicate that unplanned low-HP is associated with worse oncological outcomes, including higher local recurrence rates and positive resection margins, compared to planned low-HP and rLAR.

Background

Total mesorectal excision (TME) type influences oncological outcomes in rectal cancer surgery. When tumor location permits, restorative low anterior resection (rLAR) with an anastomosis is preferred for sphincter preservation. Low Hartmann’s procedure (low-HP), involving an end-colostomy without an anastomosis, is performed either intentionally due to anticipated risks or unplanned due to intraoperative difficulties. Previous studies suggest low-HP may have poorer oncological outcomes, but factors contributing to this remain unclear. This study aimed to elucidate differences in outcomes between these surgical approaches using a nationwide Dutch cohort.

Data Highlights

Key Findings

• Unplanned low-HP is associated with significantly worse oncological outcomes compared to planned low-HP and rLAR.
• Patients undergoing unplanned low-HP often have more comorbidities, higher age, and more neoadjuvant irradiation.
• Technical difficulties such as narrow pelvis, obesity, and bulky distal tumors contribute to intraoperative decision for unplanned low-HP.
• Positive resection margins (R1) and higher local recurrence rates are more frequent in low-HP, especially unplanned cases.
• Despite a decreasing trend, low-HP was still performed in 14% of rectal cancer resections in the Netherlands in 2016, with wide interhospital variability.
• Preoperative counseling includes discussion of possible intraoperative change from restorative to non-restorative procedures due to technical challenges.

Clinical Implications

Surgeons should carefully assess preoperative risk factors that may necessitate conversion from rLAR to low-HP to optimize oncological outcomes. Enhanced preoperative planning and patient counseling regarding the possibility of unplanned low-HP are essential. Efforts to reduce unplanned low-HP through surgical expertise and multidisciplinary decision-making may improve local control and survival.

Conclusion

Unplanned low Hartmann’s procedures in rectal cancer are linked to inferior oncological outcomes compared to planned low-HP and restorative LAR. Understanding factors leading to unplanned low-HP can guide surgical planning and improve patient prognosis.

References

1. Dutch Snapshot Research Group 2020-2021 -- Population-Based Rectal Cancer Surgery Outcomes
2. Dutch ColoRectal Audit (DCRA) 2016 -- Rectal Cancer Surgical Data
3. Dutch National Rectal Cancer Guidelines 2016 -- Treatment Recommendations