Review of ‘Hartmann’s procedure versus intersphincteric abdominoperineal excision (HiP Study): a multicentre prospective cohort study’.

H. Fowler et al. Colorectal disease Oct 2020 [Epub ahead of print]

What is known about this subject?

The two main options for a non-restorative low rectal resection are Hartmann’s procedure (HP) or abdominoperineal excision in the intersphincteric plane (IAPE). While HP is a quicker and less invasive option, it is associated with a risk of staple line disruption and pelvic sepsis. We don’t know which procedure is better.

What does this study add?

Design: This is a multicentre nonrandomized prospective cohort study including 35 centres in the UK between 1 April 2016 and 1 June 2019.

Primary endpoints: The overall surgical related complication.

Secondary endpoints: Overall complication rate, length of stay, time to adjuvant therapy and quality of life at 90 days.

Results: The study included 179 patients (HP: 112, IAPE: 67).

  • Any grade of surgical complication: Similar (HP:43% vs IAPE:48%).
  • Overall complication rate: Similar (HP:54% vs IAPE:52%).
  • SSI: Similar. 11% pelvic abscess in HP vs 12% perineal wound complications in IAPE. More radiological drainage in HP group (67%) vs IAPE (13%) P = 0.03
  • Pelvic abscess: More common in patients with palpable staple line 15% vs 2% in non palpable (higher) staple line (P = 0.03).
  • Fewer Grade 3 and above medical complication in HP (5%) vs IAPE (16%) P = 0.01.
  • Pelvic abscess: more common in patients with a palpable staple line (15%) vs 2% in non palpable (higher) staple line (P = 0.03).
  • A significant drop in the 90 days emotional well-being scores in the IAPE (-6.25) vs HP (0) group (P = 0.008).
  • Time to adjuvant chemotherapy was similar in both groups.

Implications for colorectal practice?

This is the largest prospective study to date on this topic. As expected, a higher rate of pelvic sepsis was noted after HP especially in patients with clinically palpable staple line and the authors suggested that transanal drains may benefit this group of patients. The rate of pelvic sepsis was still much lower than previously reported. On the other hand, IAPE patients developed more significant medical complications and were emotionally worse 3 months after surgery compared to the HP group.

The study main limitation is non-randomization and selection bias was evident, however, there is no doubt that the data from the HiP study will help in the preoperative discussion and will inform our future decisions in this group of patients.