LAUSR

We read with great interest the article from Pateet et al. [1] highlighting an interesting and debatable topic of rectal stump length predicting the postoperative outcomes in Hartman’s reversal (HR) surgery. We agree with the conclusion of this study and our practice and thought process is mainly in line with the content of this article. Initially, in 1921, Henri Hartmann had described Hartmann’s procedure (HP) for resection of sigmoid and rectal cancers [2]. However, at present, it is done for patients with complicated diverticular disease, traumatic colonic injuries, and clinically unstable patients [3]. HR involves mobilization of the rectal stump and restoring the continuity of the bowel. It is reported that around 13–69% of patients after HP end up having permanent stoma due to unsuccessful reversal or being deemed unfit [4]. Some studies have favored HR with acceptable morbidity and mortality even in challenging cases [5]. HR is usually not performed in patients with anticipated dense adhesions around the rectal stump or very short length of the stump [6]. Many studies in the past have discussed predictive factors for HR including age, benign vs malignant, ASA classification, stump adhesions, and the rectal stump length [7]. The timing of the reversal has also been discussed in the past and there is no consensus over it. Many studies have advocated for a delayed reversal of Hartmann’s giving more healing time and helping the final outcome. However, there are some studies that have contradicted this concept of time affecting the final outcome of HR [8]. As per the available literature, reported morbidity and mortality post-HR vary from 0 to 75% and 0–28% respectively [9]. Without any doubt, the final outcome of HR is dependent on multiple factors. Mazeh et al. [10] postulated that determining the rectal stump adhesions and length during open Hartmann’s surgery was helpful. However, in today’s time when a majority of the surgeons doing laparoscopic HP, this recommendation stands low in practical value. Radiotherapy is associated with dense rectal stump adhesions and eventually can affect the final outcome of HR. [11] We support that the rectal stump length per se would not affect the final outcome of HR. There are multiple factors that should be in consideration before HR. Proper evaluation, good communication with the patient, and a multimodal approach can help in managing such cases efficiently. Safety of the patient and weighing the benefits and risk factors should be based on the merit of individual cases and the surgeon’s acumen. More studies with a bigger sample size would be required to study the rectal stump length as an individual factor; however, we congratulate the author for their valuable study on an interesting topic in the colorectal field.