Beyond tradition: shifting paradigms in the treatment of left-sided colonic emergencies

Dear Editor, Hartmann’s procedure, first introduced in the early 20th century, has been a mainstay in the management of left-sided colonic emergencies1–5. Traditionally favored for its perceived safety and simplicity, this procedure involves the resection of the diseased segment of the colon with an end colostomy and closure of the rectal stump. However, a century later, the medical community continues to debate its role, particularly when compared with resection and primary anastomosis (RPA). A recent multicenter observational study provides compelling insights that challenge the continued predominance of Hartmann’s procedure in contemporary surgical practice6. The study reported that Hartmann’s procedure remains the most frequently used surgical treatment for left-sided colonic emergencies. Approximately 57.3% of the patients underwent Hartmann’s operation, compared to 31.6% who received RPA. This preference persists despite growing evidence suggesting that primary anastomosis, especially in certain patient populations, can offer superior outcomes. The robust regression analysis highlights several key factors influencing the choice between Hartmann’s procedure and RPA. First, younger patients with fewer comorbidities (ASA score ≤3) were more likely to undergo RPA. Second, the patients with large bowel obstruction favored RPA, whereas those with colonic ischemia and perforation were more often treated with Hartmann’s procedure. Third, more experienced surgeons and high-volume centers tended to prefer RPA, highlighting a potential gap in practice between different hospital settings and the experience levels of the operating surgeons. Fourth, surgeries conducted during regular working hours were more likely to result in RPA, indicating that logistical factors might unduly influence surgical decision-making. The study’s outcomes further fuel the debate over the optimal surgical approach. Severe complications (Clavien–Dindo ≥3b) were significantly higher in the Hartmann’s procedure group. Furthermore, the study shows a stark difference in mortality rates: 13.7% for Hartmann’s procedure compared to just 2.5% for RPA6. Moreover, the ostomy reversal rates are telling: only 21.6% of Hartmann’s patients underwent reversal at one year, compared to 64.7% for RPA, underlining a significant impact on patient quality of life. These findings challenge the traditional reliance on Hartmann’s procedure, especially in a subset of patients who could benefit more from RPA. The high complication and low reversal rates associated with Hartmann’s procedure underscore the need for a paradigm shift towards more RPA, particularly in stable patients without significant comorbidities. While the study is robust in its multicenter, international approach, several limitations need consideration. First, the non-randomized design may introduce selection bias, with sicker patients potentially more likely to receive Hartmann’s procedure, skewing outcome comparisons. Second, the influence of surgeon preference and experience can significantly affect the choice of procedure, potentially limiting the generalizability of the findings. Third, the differences in postoperative care protocols across centers can influence outcomes, particularly complications and mortality rates. To integrate these findings into clinical practice, several steps are necessary. First, current guidelines should reflect the nuanced understanding that RPA can be the preferred option in selected patient groups, encouraging a move away from a one-size-fits-all approach. Second, surgeons, especially those in training, should be educated about the evolving evidence, ensuring that surgical decision-making is based on the latest research and patient-specific factors. Third, efforts should be made to standardize care across different settings, ensuring that all patients receive optimal treatment regardless of the time of day or the surgeon’s experience level. In conclusion, the evidence suggests a shift towards resection and primary anastomosis, particularly in well-selected patients, to improve outcomes and reduce the burden of stoma-related quality-of-life issues. While the traditional role of Hartmann’s procedure remains intact for unstable patients and those with significant comorbidities, the surgical community must embrace this evolving paradigm to enhance patient care. Continued research and a commitment to evidence-based practice are essential to refining these surgical decisions further, ensuring that every patient receives the most appropriate and effective treatment for their specific condition. Ethical approval Ethical approval is not applicable for this correspondence article. Consent Informed consent is not applicable for this correspondence article. Sources of funding None. Author contribution Y.W.A.: conceptualization, project administration, supervision, validation, writing—original draft and writing—review and editing. E.B.M.: conceptualization, project administration, supervision, validation, writing—original draft and writing—review and editing. S.G.: writing—original draft and writing—review and editing. H.S.: writing—original draft and writing—review and editing. P.S.: supervision, validation, writing—original draft and writing—review and editing. R.K.S.: writing—original draft and writing—review and editing. M.N.K.: writing—original draft and writing—review and editing. Q.S.Z.: writing—original draft and writing—review and editing. S.R.: writing—original draft and writing—review and editing. A.A.: supervision, validation, writing—review and editing. Conflicts of interest disclosure None. Research registration unique identifying number (UIN) None. Guarantor Yeabsira Worku Atena and Endalkachew Belayneh Melese. Data availability statement None. Provenance and peer review Not commissioned, externally peer-reviewed.

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