The Hartmann procedure revisited.

The results of 37 consecutive cases of Hartmann's procedure over a 5-year period (1985-1990) were reviewed. The series consisted of 27 emergency procedures (11 diverticular disease, 13 carcinoma, two trauma and one sigmoid volvulus) and ten elective procedures (nine carcinoma and one peridiverticular abscess). The indications for emergency procedures were obstruction and perforation. All patients presented with faecal peritonitis owing to colonic perforation. The mean (range) age was 79.4 (34-90) years. The postoperative mortality rate was 30 per cent overall (11 of 37), 33 per cent (four of 12) in the diverticulitis group, 23 per cent (five of 22) in the carcinoma group, and 100 per cent in the iatrogenic trauma group. Death was mainly due to sepsis (82 per cent). Postoperative complications were mainly wound infections, which occurred in 43 per cent (16 of 37) cases. In 25 per cent of the surviving patients, re-establishment of continuity was performed in three of 17 (18 per cent) of the carcinoma group and three of seven (43 per cent) of the diverticulitis group. No attempt at restoration of intestinal continuity was made in six cases due to medical risk in two, extensive carcinoma in two and local recurrence with metastatic disease in two. Three patients refused all further intervention. There were no postoperative deaths after the restoration of continuity. This series reflects the severity of the pathology in this high risk group of patients. However, the operation can be life-saving for a selected group of patients and offers good palliation for advanced colorectal tumours.