Short-term outcomes following emergency Hartmann procedure: a comparison between colorectal and noncolorectal surgeons

Jae Won Jo; Sung Chul Lee; Jung Wook Suh; Hwan Namgung; Dong-Guk Park

doi:10.3393/ac.2025.01389.0198

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Original Article Others Short-term outcomes following emergency Hartmann procedure: a comparison between colorectal and noncolorectal surgeons: Jae Won Jo , Sung Chul Lee , Jung Wook Suh , Hwan Namgung , Dong-Guk Park; Annals of Coloproctology 2026;42(3):315-323.
DOI: https://doi.org/10.3393/ac.2025.01389.0198
Published online: June 26, 2026

Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea

Correspondence to: Sung Chul Lee, MD, PhD Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, 119 Dandae-ro, Dongnam-gu, Cheonan 31116, Korea Email: leesc292513@gmail.com

• Received: November 16, 2025 • Revised: January 26, 2026 • Accepted: March 20, 2026

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ARTICLE INFORMATION
REFERENCES

Abstract

Purpose
Given the increasing staffing shortages that often necessitate noncolorectal surgeons performing emergency colorectal procedures, this study aims to evaluate the effect of surgeon subspecialty on short-term postoperative outcomes in patients undergoing emergency Hartmann procedure and whether strengthening residency training in Hartmann procedure could improve surgical outcomes.
Methods
This retrospective study included 141 patients who underwent emergency Hartmann procedure at a single tertiary center between January 2010 and December 2021. Patients were categorized into colorectal and noncolorectal groups. The clinical characteristics, operative details, and outcomes were compared. Complications were classified using the Clavien-Dindo classification. Logistic regression analysis was used to identify complications and mortality.
Results
The noncolorectal group showed higher age (75 years vs. 69 years, P=0.038), hypertension prevalence (58.4% vs. 40.4%, P=0.039), and physiological instability (C-reactive protein >6.0 mg/dL: 55.1% vs. 36.5%, P=0.034; lactate: 1.90 mmol/L vs. 0.80 mmol/L, P<0.001). Complications were lower in the colorectal group (68.5% vs. 36.5%, P<0.001), with fewer major complications (Clavien-Dindo grade ≥III, 51.7% vs. 15.4%). The colorectal group had a lower mortality rate (25.8% vs. 3.8%, P=0.001). In the multivariate analysis, surgery performed by noncolorectal surgeons remained a significant independent risk factor for complications (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.27–6.89; P=0.012) and mortality (OR, 15.53; 95% CI, 2.11–114.18; P=0.006) even after adjusting for age, diagnosis, American Society of Anesthesiologists physical status, C-reactive protein levels, and time to surgery.
Conclusion
Emergency Hartmann procedure for acute conditions yielded better short-term outcomes when performed by colorectal surgeons. These findings suggest that surgeon subspecialty is a critical determinant of survival, independent of patient severity or surgical timing. Improving surgical residency training in Hartmann procedure may enhance outcomes when noncolorectal surgeons must perform it due to staffing constraints.
Keywords: Hartmann procedure; Emergency surgery; Surgeon subspeciality; Postoperative complications; Mortality

INTRODUCTION

Hartmann procedure is a surgical procedure typically performed in cases of perforation or obstruction of the left colon or rectum. It involves the resection of the diseased bowel segment, closure of the distal rectal stump, and formation of an end colostomy. Although initially proposed for the management of rectal cancer in high-risk patients, it is now widely applied in emergency settings for various conditions, such as diverticulitis, ischemic colitis, and traumatic colonic perforation [1]. As it avoids bowel anastomosis, Hartmann procedure enables rapid control of the source of contamination and facilitates prompt stoma formation. As a result, it is associated with a shorter operative time and reduced risk of major complications, such as anastomotic leakage [2, 3], making it particularly valuable for patients in poor general condition.

Hartmann procedure accounts for 20% to 30% of all emergency colorectal surgeries [4]. In many cases of colonic perforation with generalized peritonitis, patients present with physiological instability, including hypotension and acute kidney injury due to septic shock progression [5]. Consequently, high rates of postoperative complications (30%–50%) and mortality (10%–30%) have been reported [4, 6]. Given this high risk and complexity, surgeons’ technical proficiency and subspecialty training may significantly affect their surgical outcomes [7]. Previous studies on short-term outcomes after Hartmann procedure have focused on patient-related factors, such as age and comorbidities [8]. However, relatively few studies have explored the influence of surgeon specialization on clinical outcomes. A recent large-scale, multicenter study from the United Kingdom suggested that surgeon subspecialty may affect the postoperative prognosis in patients undergoing emergency abdominal surgery. In particular, colorectal procedures performed by noncolorectal surgeons have been associated with poorer outcomes, including higher 30-day mortality, increased reoperation rates, and longer hospital stays. These findings suggest that surgeon specialization may play a critical role in determining the success of emergency surgery [9]. However, because this study included various surgical procedures (e.g., right hemicolectomy, left hemicolectomy, and Hartmann procedure), there may be bias due to differences in surgical complexity and indications. Furthermore, it remains unclear whether these differences in outcomes are primarily due to the surgeons' technical expertise or are confounded by patient-specific factors such as physiological instability and the degree of surgical urgency.

Therefore, the present study aimed to evaluate the effect of surgeon subspecialty on short-term postoperative outcomes, including postoperative complications, intensive care unit (ICU) admission, and mortality, among patients who underwent emergency Hartmann procedure at a single institution. To address potential selection bias, we performed a comprehensive multivariate analysis adjusting for clinical markers of severity and the time interval from presentation to surgery. Specifically, outcomes were compared between procedures performed by colorectal surgeons and those performed by noncolorectal surgeons.

METHODS

Ethics statement

This study was approved by the Institutional Review Board of Dankook University Hospital (No. 2025-07-023) and was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Informed consent was waived due to the use of deidentified data and the retrospective nature of the study. All patient data were anonymized to ensure confidentiality, and no identifiable personal information was included.

Study design

This retrospective study was conducted at a single tertiary institution and included patients who underwent emergency Hartmann procedure at the Dankook University Hospital between January 2010 and December 2021. All data were collected from electronic medical records, and clinical information, operative details, and postoperative outcomes were reviewed retrospectively.

Patient selection

Among the initially identified 158 patients, those with incomplete records (n=1) and those who underwent elective surgery (n=16) were excluded from the final analysis. Of the 16 patients who underwent elective Hartman procedure, 5 underwent the procedure due to anastomotic stricture following prior low anterior resection, and 11 underwent cytoreductive surgery for peritoneal metastasis from colorectal, gastric, or ovarian cancer (Fig. 1).

Patient and operative data

Patients were categorized into 2 groups based on the surgeon’s subspecialty: those operated on by a colorectal surgeon (colorectal group, n=3) and those operated on by a noncolorectal surgeon (noncolorectal group, n=8). All surgeons in both groups were board-certified faculty members at our tertiary institution. As of 2023, the average post-residency experience was 22.7 years (range, 9–35 years) for the colorectal group and 16 years (range, 9–24 years) for the noncolorectal group. Colorectal surgeons were board-certified colorectal specialists who obtained subspecialty certification from the Korean Society of Coloproctology and were primarily responsible for the diagnosis and surgical management of colorectal diseases at our institution. Noncolorectal surgeons were defined as general surgeons without colorectal subspecialty certification, primarily practicing in other subspecialty areas, such as upper gastrointestinal surgery, hepatobiliary and pancreatic surgery, breast surgery, or vascular surgery.

Information regarding the operating surgeon was obtained from the operative reports and clinical documentation. Surgeon subspecialties were verified using institutional personnel records and membership data from professional surgical societies. The clinical characteristics and short-term surgical outcomes were compared between the 2 groups. Patient-related variables included age, sex, hypertension, diabetes mellitus, cardiovascular disease, pulmonary disease, and history of malignancy and surgery. Preoperative laboratory findings, such as white blood cell count, C-reactive protein (CRP), and lactate levels, were also collected. To evaluate the impact of surgical urgency, the time interval from hospital admission to the commencement of surgery (time to surgery) was also recorded. Surgery-related variables included the etiology of colonic perforation (benign vs. malignant), operative time, estimated blood loss, intraoperative transfusion, American Society of Anesthesiologists (ASA) physical status score, need for ICU admission, duration of ICU stay, total length of hospital stay, and reversal status and time to reversal. The primary outcome measures were postoperative complications within 30 days, mortality, Clavien-Dindo classification of surgical complications, ICU requirement and duration, and total length of hospital stay. Complication severity was graded using the Clavien-Dindo classification, with grades I and II classified as minor complications and grade III or higher as major complications.

Hartmann procedure

All Hartmann procedures were performed via open laparotomy under general anesthesia. Resection was performed after identification of the diseased segment within the abdominal cavity. A thoracoabdominal or contour stapler was used for the transection of the distal bowel. Following resection, the remnant colon or rectal stump was closed in a blind-ended manner and was left intraperitoneally. An end colostomy was created using the proximal colon through the left lower quadrant of the abdominal wall. Depending on the degree of intra-abdominal contamination, copious irrigation was performed using a 0.9% sodium chloride (NaCl) solution. A closed suction drain was routinely placed in the pelvic cavity, and an additional drain was inserted if severe localized inflammation was present. All procedures were performed by board-certified general surgeons affiliated with our institution.

Statistical analysis

Descriptive statistics were generated for the clinical and pathological variables in patients with and without postoperative complications. Continuous variables were compared using either the Student t-test or the Wilcoxon rank sum test, depending on the data distribution. In contrast, categorical variables were analyzed using the Pearson chi-square test or Fisher exact test, as appropriate. Potential predictors of complications were first examined using univariate logistic regression. Variables with a P-value of <0.1 (or 0.05) in the univariate analysis, along with clinically relevant variables such as age and sex, regardless of their statistical significance, were entered into the multivariable logistic regression model to adjust for potential confounders. Statistical significance was defined as a 2-sided P-value of <0.05. All analyses were performed using R ver. 4.3.1 (R Foundation for Statistical Computing).

RESULTS

Clinical and pathological characteristics

A total of 141 patients were included in this study. Among them, 89 (63.1%) were operated on by noncolorectal surgeons, and 52 (36.9%) by colorectal surgeons. Compared to the colorectal group, the noncolorectal group had a higher mean age (75 years vs. 69 years, P=0.038) and an increased prevalence of hypertension (58.4% vs. 40.4%, P=0.039). The benign causes of colonic perforation include diverticulitis, stercoral colitis, trauma, and ischemia. Benign disease was more common in the noncolorectal group (69.7% vs. 30.8%), whereas malignant disease was more frequently observed in the colorectal group (30.3% vs. 69.2%); this difference was statistically significant (P<0.001). Regarding perioperative laboratory findings, the noncolorectal group had a higher proportion of patients with CRP levels exceeding 6.0 mg/dL (55.1% vs. 36.5%, P=0.034) and a higher mean lactate level (1.90 mmol/L vs. 0.80 mmol/L, P<0.001) than the colorectal group.

Regarding operative parameters, the colorectal group had a significantly longer operative time (177.1 minutes vs. 243.9 minutes, P<0.001). The proportion of patients classified as high risk (ASA physical status III–V) was higher in the noncolorectal group (76.4% vs. 57.7%, P=0.020). ICU admission (92.1% vs. 65.4%, P<0.001) and duration of ICU stay (7.45 days vs. 4.37 days, P<0.001) were significantly more frequent in the noncolorectal group. Although the total length of hospital stay was slightly longer in the noncolorectal group, the difference was not statistically significant (28.61 days vs. 27.25 days, P=0.059). Hartmann reversal was performed in 41 patients (46.1%) in the noncolorectal group and 21 (40.4%) in the colorectal group, but this difference was not statistically significant (P=0.512) (Table 1).

Postoperative morbidity and mortality

Postoperative complications occurred in 80 patients (56.7%). The incidence was significantly lower in the colorectal group than in the noncolorectal group (68.5% vs. 36.5%, P<0.001). Major complications (grades III–V) were more frequent in the noncolorectal group than in the colorectal group (51.7% vs. 15.4%). Among the minor complications (grades I–II), ileus (n=11) was the most common. Among the major complications (grades III–IV), wound complications due to surgical site infections (n=11) were the most prevalent. Among grade V events, septic shock was the leading cause of death, accounting for 16 cases (Table 2). The 30-day postoperative mortality rate was significantly higher in the noncolorectal group (25.8% vs. 3.8%, P=0.001).

Univariate analysis of risk factors for postoperative complications showed that surgery performed by a noncolorectal surgeon was associated with a 3.78-fold higher risk of complications. Increasing age was also a significant factor, with each additional year associated with a 1.04-fold increase in the risk of complications. Patients with benign etiologies of colonic perforation had a 2.21-fold higher risk than those with malignant etiologies. High ASA physical status (odds ratio [OR], 2.75; P=0.007) and elevated lactate levels (OR, 1.84; P=0.003) were also associated with an increased risk of complications. Multivariate analysis showed that surgery performed by a noncolorectal surgeon remained an independent risk factor, with a 2.96-fold higher risk of complications (95% confidence interval [CI], 1.27–6.89; P=0.012). Along with surgery by a noncolorectal surgeon, advanced age (OR, 1.04; 95% CI, 1.00–1.07; P=0.042) was also an independent risk factor for complications. Other variables including diagnosis, ASA physical status, CRP levels, and time to surgery were not statistically significant (Table 3).

Univariate analysis of factors associated with mortality revealed that patients operated on by noncolorectal surgeons had an 8.71-fold higher risk. Older age was also a risk factor with a 1.04-fold increase per year. Benign causes of perforation were associated with a 2.40-fold higher mortality risk than malignant causes. Elevated lactate level was also a significant risk factor (OR, 1.32; P=0.007). Multivariate analysis revealed that surgery performed by a noncolorectal surgeon remained a significant predictor of mortality, with a 15.53-fold increased risk (95% CI, 2.11–114.18; P=0.006). Notably, time to surgery was also independently associated with mortality (OR, 1.10; 95% CI, 1.01–1.20; P=0.029). In contrast, variables such as diagnosis, age, ASA physical status, and CRP levels were not statistically significant in the multivariate model (Table 4).

DISCUSSION

This study is notable for its focused analysis of the influence of surgeon subspecialty on short-term postoperative outcomes in patients undergoing Hartmann procedure under emergency conditions. To date, the principal prognostic factors reported for this procedure have predominantly been patient-related, including advanced age, comorbidities, and physiological parameters, whereas evaluations centered on surgeon subspecialty or technical expertise are comparatively uncommon. Empirical research that directly compares the impact of surgeon specialty on outcomes in emergency surgery settings in Korea remains scarce. Moreover, most previous studies have addressed a heterogeneous range of emergency colorectal operations involving various techniques, with few analyses focusing on Hartmann procedures. In this context, this study makes clinically and academically meaningful contributions. Recognizing the differing frequencies and operative circumstances under which colorectal and noncolorectal surgeons perform Hartmann procedures in clinical practice, we assessed the influence of surgeon specialty on postoperative outcomes using contemporary clinical data, thereby providing actionable evidence to support improvements in emergency surgical systems and inform surgical training programs.

Our data revealed significant differences in short-term outcomes after Hartmann procedure according to the surgeon’s subspecialty, with statistically meaningful associations confirmed in both univariate and multivariate analyses. Patients operated on by colorectal surgeons had significantly shorter ICU and overall hospital stays, as well as lower rates of major complications and 30-day mortality, than those treated by nonspecialists. Notably, these favorable outcomes were achieved despite longer operative times, suggesting that factors beyond technical proficiency, such as careful preoperative patient assessment, well-considered surgical planning, and stable intraoperative performance, may have contributed positively [10]. In univariate analysis, in addition to surgeon subspecialty, factors such as age, benign versus malignant disease, blood transfusion, ASA physical status, and lactate were significantly associated with complications and mortality. However, in the multivariate analysis, surgeon subspecialty emerged as the most consistent independent risk factor for both outcomes. For mortality specifically, the time interval from presentation to surgery was also identified as an independent predictor (OR, 1.10; P=0.029), whereas advanced age and other physiological markers (ASA physical status and CRP levels) did not reach statistical significance in the final multivariable models. The persistence of surgeon subspecialty as a primary determinant of outcomes, even after adjusting for clinical severity and surgical timing, suggests that the superior results in the colorectal group are not merely due to the selection of more stable patients but rather reflect the impact of specialized surgical expertise. ICU admission and extended hospital stay are frequently observed in patients with higher complication and mortality rates, and these variables often show strong correlations with both surgeon subspecialty and baseline patient conditions. Owing to potential collinearity, these variables were excluded from the final multivariate model.

The outcomes observed in this study are consistent with those reported in previous international investigations, thereby strengthening the validity of our findings. A large-scale analysis using the UK National Emergency Laparotomy Audit (NELA) database showed that less favorable outcomes were observed when colorectal procedures were performed by noncolorectal specialists during emergency laparotomy [11]. A multicenter study in the United States also revealed that emergency colorectal surgery performed by colorectal surgeons was associated with significantly better results in key measures, such as mortality, complication rates, and length of hospital stay, consistent with the present findings [12]. In our cohort, patients operated on by noncolorectal surgeons had significantly higher rates of preoperative high-risk patients (ASA physical status III–V: 48.2% vs. 21.3%, P=0.020), hypertension prevalence (36.9% vs. 14.9%, P=0.039), CRP >6.0 mg/dL (34.8% vs. 13.5%, P=0.034), and elevated lactate levels (1.90 mmol/L vs. 0.80 mmol/L, P<0.001), indicating that this group had a higher proportion of physiologically unstable patients. These differences in patient distribution might initially suggest a selection bias where more critically ill patients were managed by noncolorectal surgeons. However, our multivariable model specifically controlled the physiological markers and the time interval from hospital presentation to surgery (Tables 3, 4). Even after this rigorous adjustment, the surgeon’s subspecialty remained a significant independent predictor of mortality (OR, 15.53; P=0.006). This robust finding indicates that the superior outcomes in the colorectal group are not merely a result of selection bias but are fundamentally linked to specialized surgical expertise and decision-making during the perioperative period.

This study presents meaningful findings; however, several limitations should be noted. First, the study population included not only patients who were admitted directly through the emergency department and underwent surgery but also those who were initially hospitalized in other departments and subsequently required emergency surgery due to complications such as perforation or peritonitis. In cases where colorectal cancer was diagnosed during medical ward admission and an emergent event, such as perforation, occurred before planned intervention, colorectal surgeons were often in charge of the surgery. This may have resulted in a higher proportion of malignant disease cases included in the colorectal group, thereby introducing a possible selection bias. Second, because this was a single-center retrospective cohort study, the sample size was insufficient to achieve statistical significance for certain variables, limiting the generalizability of the results. Further multicenter studies with larger cohorts are warranted. Third, the noncolorectal group comprised 8 surgeons with diverse training backgrounds, subspecialties, and operative styles, which may have led to variability in surgical strategies. However, both groups were experienced faculty, with the noncolorectal group averaging 16 years of post-residency experience. This suggests that the observed differences in outcomes resulted from the absence of colorectal-specific expertise rather than a lack of general surgical seniority. Fourth, due to the retrospective nature of this study focusing on Hartmann procedure, we could not include the entire population of patients with left colonic emergencies who might have received primary anastomosis, which remains a limitation in evaluating the overall treatment strategy selection. However, given that the majority of our patients presented with severe physiological instability or fecal peritonitis, Hartmann procedure was prioritized as a life-saving measure. Therefore, our findings should be interpreted within the context of high-risk patients for whom restorative surgery was deemed clinically unsuitable.

Nevertheless, this study provides empirical evidence that the subspecialty and experience of the operating surgeon can contribute, at least in part, to improved outcomes in high-risk emergency procedures, such as Hartmann procedure, offering important implications for future emergency surgery systems and surgical training programs. In clinical practice, assigning a colorectal surgeon to every emergency Hartmann procedure is often impractical. Surgical procedures performed during off-hours, such as nights or weekends, are frequently undertaken by on-duty general surgeons. In small or rural hospitals, the availability of colorectal specialists is limited. Notably, in the United Kingdom’s emergency surgery system, a so-called “weekend effect” has been observed, in which surgery performed during weekends or nighttime hours is associated with increased mortality, a phenomenon closely linked to limitations in specialist availability and institutional resources [13, 14]. To address such challenges, the acute surgical unit model has recently been introduced, with benefits such as shorter time to surgical assessment, reduced hospital stay, and decreased mortality [15]. However, whether this model can compensate for differences in surgeon subspecialities remains uncertain and may even introduce structural bias [16]. For example, if a recurring pattern emerges in which colorectal surgeons tend to perform procedures during daytime hours through interdepartmental referral, while nonspecialists operate at night, the consistency of outcomes and their interpretation may be compromised. Hartmann procedure should therefore be regarded not merely as a technical act but as an operation that requires specialized clinical judgment and strategic planning tailored to emergency conditions. Therefore, structured education and simulation-based training for Hartmann procedure should be strengthened in future surgical residency programs. Providing residents with sufficient operative experience and opportunities for independent performance of Hartmann procedure during training may help ensure technical proficiency and safety when noncolorectal surgeons are required to operate in emergency settings, ultimately contributing to quality improvements in emergency surgical care. Consistent with this, some studies have shown no significant differences in key outcomes such as complications and mortality rates between colorectal surgery performed by residents and that performed by attending surgeons [17, 18]. In the future, the appropriate allocation of specialist surgeons and optimization of training systems may play an essential role in improving the results of emergency surgery.

Hartmann procedure, performed as an emergency laparotomy for acute abdominal conditions, appears to be safer when performed by a colorectal surgeon. However, it is often impractical for all emergency Hartmann procedures to be performed by colorectal surgeons, and improvements in surgical residency training programs may help enhance outcomes achieved by noncolorectal surgeons.

ARTICLE INFORMATION

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: JWJ; Data curation: JWJ, JWS; Formal analysis: JWJ, HN; Investigation: JWS; Methodology: DGP; Supervision: SCL; Validation: SCL; Visualization: HN; Writing–original draft: JWJ; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Fig. 1.

Patient selection for emergency Hartmann procedure.

Table 1.

Comparison of patient characteristics and surgical variables according to surgeon subspeciality (n=141)

Characteristic	Noncolorectal group (n=89)	Colorectal group (n=52)	P-value
Age (yr)	75.0 (62.0–80.0)	69.0 (56.8–76.2)	0.038
Sex			0.064
Male	37 (41.6)	30 (57.7)
Female	52 (58.4)	22 (42.3)
Body mass index (kg/m²)	22.37±3.34	21.92±3.54	0.462
Hypertension	52 (58.4)	21 (40.4)	0.039
Diabetes mellitus	22 (24.7)	12 (23.1)	0.826
Cardiovascular disease	14 (15.7)	3 (5.8)	0.080
Pulmonary disease	3 (3.4)	6 (11.5)	0.076
Previous cancer history	9 (10.1)	5 (9.6)	0.924
Previous operation history	25 (28.1)	9 (17.3)	0.149
White blood cell (/μL)	9,900 (4,670–15,690)	10,895 (6,448–16,338)	0.352
Lactate (mmol/L)	1.90 (1.30–3.30)	0.80 (0.70–1.20)	<0.001
CRP >6.0 mg/dL	49 (55.1)	19 (36.5)	0.034
Time to surgery (day)	0 (0–0)	3 (1–6)	<0.001
Estimated blood loss (mL)	465.79±799.73	422.69±560.66	0.733
Operative time (min)	177.08±56.60	243.92±107.01	<0.001
ASA physical status			0.020
I–II (low risk)	21 (23.6)	22 (42.3)
III–V (high risk)	68 (76.4)	30 (57.7)
Transfusion	62 (69.7)	32 (61.5)	0.323
Diagnosis			<0.001
Cancer	27 (30.3)	36 (69.2)
Benign	62 (69.7)	16 (30.8)
Postoperative complication (Clavien-Dindo grade)	61 (68.5)	19 (36.5)	<0.001
I–II	15 (16.9)	11 (21.2)
III–V	46 (51.7)	8 (15.4)
Length of stay (day)	28.61±34.67	27.25±17.95	0.059
ICU admission	82 (92.1)	34 (65.4)	<0.001
ICU stay (day)	7.45±10.50	4.37±8.79	<0.001
30-Day mortality	23 (25.8)	2 (3.8)	0.001
Hartmann reversal	41 (46.1)	21 (40.4)	0.512
Time to reversal (day)	63.06±87.14	65.65±93.67	0.868

Values are presented as mean±standard deviation, number (%), or median (interquartile range).

CRP, C-reactive protein; ASA, American Society of Anesthesiologists; ICU, intensive care unit.

Table 2.

Types and severity of postoperative complications after the Hartmann procedure

Complication	No. of patients (Clavien-Dindo classification)
	Grades I–II^a		Grades III–IV^b		Grade V^b
	Noncolorectal group (n=15)	Colorectal group (n=11)	Noncolorectal group (n=23)	Colorectal group (n=6)	Noncolorectal group (n=23)	Colorectal group (n=2)
Surgical site infection	6		9	2
Ileus	6	5
Abdominal fluid collection			1
Psychiatric disease		2
Cardiovascular disease		2	2	1	3
Pleural effusion			6	3
Pneumonia	2	2	2		4	1
Acute kidney injury	1		3
Cerebral infarct					1
Septic shock					15	1

^aMinor complication.

^bMajor complication.

Table 3.

Univariate and multivariate logistic regression analysis of risk factors for postoperative complications

Factor	Univariate analysis		Multivariate analysis
Factor	OR (95% CI)	P-value	OR (95% CI)	P-value
Sex
Female	1 (Reference)		1 (Reference)
Male	0.63 (0.32–1.23)	0.173	1.30 (0.43–3.91)	0.857
Age (yr)	1.04 (1.01–1.07)	0.003	1.04 (1.00–1.07)	0.042
Diagnosis
Cancer	1 (Reference)		1 (Reference)
Benign	2.21 (1.12–4.37)	0.022	1.57 (0.65–3.57)	0.329
Surgeon subspecialty
Colorectal	1 (Reference)		1 (Reference)
Noncolorectal	3.78 (1.84–7.78)	<0.001	2.96 (1.27–6.89)	0.012
ASA physical status
I–II (low risk)	1 (Reference)		1 (Reference)
III–V (high risk)	2.75 (1.32–5.76)	0.007	1.56 (0.65–3.73)	0.320
CRP >6.0 mg/dL	1.49 (0.76–2.91)	0.246	1.06 (0.49–2.29)	0.874
Lactate (mmol/L)	1.84 (1.23–2.75)	0.003	1.61 (0.98–2.64)	0.059
Time to surgery (day)	1.00 (0.99–1.01)	0.611	1.01 (0.95–1.07)	0.822

OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists; CRP, C-reactive protein.

Table 4.

Univariate and multivariate logistic regression analysis of factors associated with mortality

Factor	Univariate analysis		Multivariate analysis
Factor	OR (95% CI)	P-value	OR (95% CI)	P-value
Sex
Female	1 (Reference)		1 (Reference)
Male	0.84 (0.35–2.01)	0.698	2.04 (0.62–6.71)	0.239
Age (yr)	1.04 (1.00–1.08)	0.044	1.04 (1.00–1.09)	0.060
Diagnosis
Cancer	1 (Reference)		1 (Reference)
Benign	2.40 (0.93–6.25)	0.070	1.72 (0.52–5.56)	0.381
Surgeon subspecialty
Colorectal	1 (Reference)		1 (Reference)
Noncolorectal	8.71 (1.96–38.69)	0.004	15.53 (2.11–114.18)	0.006
ASA physical status^a
I–II (low risk)	1 (Reference)
III–V (high risk)	Perfect prediction
CRP >6.0 mg/dL	1.78 (0.74–4.30)	0.198	1.25 (0.45–3.43)	0.669
Lactate (mmol/L)	1.32 (1.08–1.62)	0.007	1.26 (1.00–1.59)	0.051
Time to surgery (day)	1.03 (0.97–1.09)	0.355	1.10 (1.01–1.20)	0.029

OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists; CRP, C-reactive protein.

^aFor the ASA physical status, a perfect prediction was observed because all mortality cases occurred exclusively within the high-risk group (ASA physical status III–V), with no mortality in the low-risk group (ASA physical status I–II). Consequently, a definitive OR could not be mathematically calculated.

REFERENCES

1. Desai DC, Brennan EJ, Reilly JF, Smink RD. The utility of the Hartmann procedure. Am J Surg 1998;175:152–4. Article PubMed
2. Li D, Baxter NN, McLeod RS, Moineddin R, Wilton AS, Nathens AB. Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis. Dis Colon Rectum 2014;57:1397–405. PubMed
3. Trenti L, Biondo S, Golda T, Monica M, Kreisler E, Fraccalvieri D, et al. Generalized peritonitis due to perforated diverticulitis: Hartmann's procedure or primary anastomosis? Int J Colorectal Dis 2011;26:377–84. Article PubMed PDF
4. Alves A, Panis Y, Mathieu P, Mantion G, Kwiatkowski F, Slim K. Postoperative mortality and morbidity in French patients undergoing colorectal surgery: results of a prospective multicenter study. Arch Surg 2005;140:278–83. Article PubMed
5. Menegozzo CA, Teixeira-Júnior F, Couto-Netto SD, Martins-Júnior O, Bernini CO, Utiyama EM. Outcomes of elderly patients undergoing emergency surgery for complicated colorectal cancer: a retrospective cohort study. Clinics (Sao Paulo) 2019;74:e1074. Article PubMed PMC
6. Zorcolo L, Covotta L, Carlomagno N, Bartolo DC. Toward lowering morbidity, mortality, and stoma formation in emergency colorectal surgery: the role of specialization. Dis Colon Rectum 2003;46:1461–7. Article PubMed
7. Boyce SA, Bartolo DC, Paterson HM. Subspecialist emergency management of diverticulitis is associated with reduced mortality and fewer stomas. Colorectal Dis 2013;15:442–7. Article
8. Hallam S, Mothe BS, Tirumulaju R. Hartmann's procedure, reversal and rate of stoma-free survival. Ann R Coll Surg Engl 2018;100:301–7. Article PubMed PMC
9. Boyd-Carson H, Doleman B, Herrod PJ, Anderson ID, Williams JP, Lund JN, et al. Association between surgeon special interest and mortality after emergency laparotomy. Br J Surg 2019;106:940–8. Article PubMed PDF
10. Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg 2007;94:145–61. PubMed
11. NELA Project team. The second patient report of the National Emergency Laparotomy Audit (NELA): December 2014 to November 2015. Royal College of Anaesthetists; 2016.PDF
12. Biondo S, Kreisler E, Millan M, Fraccalvieri D, Golda T, Frago R, et al. Impact of surgical specialization on emergency colorectal surgery outcomes. Arch Surg 2010;145:79–86. Article PubMed
13. Aylin P, Yunus A, Bottle A, Majeed A, Bell D. Weekend mortality for emergency admissions. A large, multicentre study. Qual Saf Health Care 2010;19:213–7. Article PubMed
14. Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ 2013;346:f2424.Article PubMed PMC
15. To KB, Kamdar NS, Patil P, Collins SD, Seese E, Krapohl GL, et al. Acute care surgery model and outcomes in emergency general surgery. J Am Coll Surg 2019;228:21–8. Article PubMed
16. Kinnear N, Jolly S, Herath M, Han J, Tran M, O'Callaghan M, et al. The acute surgical unit: an updated systematic review and meta-analysis. Int J Surg 2021;94:106109.Article PubMed
17. Tonelli CM, Lorenzo I, Bunn C, Kulshrestha S, Agnew SP, Abdelsattar ZM, et al. Does resident autonomy in colectomy procedures result in inferior clinical outcomes? Surgery 2022;171:598–606. Article PubMed
18. Montroni I, Ghignone F, Rosati G, Zattoni D, Manaresi A, Taffurelli M, et al. The challenge of education in colorectal cancer surgery: a comparison of early oncological results, morbidity, and mortality between residents and attending surgeons performing an open right colectomy. J Surg Educ 2014;71:254–61. Article PubMed

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Short-term outcomes following emergency Hartmann procedure: a comparison between colorectal and noncolorectal surgeons

Ann Coloproctol. 2026;42(3):315-323. Published online June 16, 2026

DOI: https://doi.org/10.3393/ac.2025.01389.0198

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Figure

Short-term outcomes following emergency Hartmann procedure: a comparison between colorectal and noncolorectal surgeons

Fig. 1. Patient selection for emergency Hartmann procedure.

Fig. 1.

Short-term outcomes following emergency Hartmann procedure: a comparison between colorectal and noncolorectal surgeons

Characteristic	Noncolorectal group (n=89)	Colorectal group (n=52)	P-value
Age (yr)	75.0 (62.0–80.0)	69.0 (56.8–76.2)	0.038
Sex			0.064
Male	37 (41.6)	30 (57.7)
Female	52 (58.4)	22 (42.3)
Body mass index (kg/m²)	22.37±3.34	21.92±3.54	0.462
Hypertension	52 (58.4)	21 (40.4)	0.039
Diabetes mellitus	22 (24.7)	12 (23.1)	0.826
Cardiovascular disease	14 (15.7)	3 (5.8)	0.080
Pulmonary disease	3 (3.4)	6 (11.5)	0.076
Previous cancer history	9 (10.1)	5 (9.6)	0.924
Previous operation history	25 (28.1)	9 (17.3)	0.149
White blood cell (/μL)	9,900 (4,670–15,690)	10,895 (6,448–16,338)	0.352
Lactate (mmol/L)	1.90 (1.30–3.30)	0.80 (0.70–1.20)	<0.001
CRP >6.0 mg/dL	49 (55.1)	19 (36.5)	0.034
Time to surgery (day)	0 (0–0)	3 (1–6)	<0.001
Estimated blood loss (mL)	465.79±799.73	422.69±560.66	0.733
Operative time (min)	177.08±56.60	243.92±107.01	<0.001
ASA physical status			0.020
I–II (low risk)	21 (23.6)	22 (42.3)
III–V (high risk)	68 (76.4)	30 (57.7)
Transfusion	62 (69.7)	32 (61.5)	0.323
Diagnosis			<0.001
Cancer	27 (30.3)	36 (69.2)
Benign	62 (69.7)	16 (30.8)
Postoperative complication (Clavien-Dindo grade)	61 (68.5)	19 (36.5)	<0.001
I–II	15 (16.9)	11 (21.2)
III–V	46 (51.7)	8 (15.4)
Length of stay (day)	28.61±34.67	27.25±17.95	0.059
ICU admission	82 (92.1)	34 (65.4)	<0.001
ICU stay (day)	7.45±10.50	4.37±8.79	<0.001
30-Day mortality	23 (25.8)	2 (3.8)	0.001
Hartmann reversal	41 (46.1)	21 (40.4)	0.512
Time to reversal (day)	63.06±87.14	65.65±93.67	0.868

Complication	No. of patients (Clavien-Dindo classification)
	Grades I–II^a		Grades III–IV^b		Grade V^b
	Noncolorectal group (n=15)	Colorectal group (n=11)	Noncolorectal group (n=23)	Colorectal group (n=6)	Noncolorectal group (n=23)	Colorectal group (n=2)
Surgical site infection	6		9	2
Ileus	6	5
Abdominal fluid collection			1
Psychiatric disease		2
Cardiovascular disease		2	2	1	3
Pleural effusion			6	3
Pneumonia	2	2	2		4	1
Acute kidney injury	1		3
Cerebral infarct					1
Septic shock					15	1

Factor	Univariate analysis		Multivariate analysis
Factor	OR (95% CI)	P-value	OR (95% CI)	P-value
Sex
Female	1 (Reference)		1 (Reference)
Male	0.63 (0.32–1.23)	0.173	1.30 (0.43–3.91)	0.857
Age (yr)	1.04 (1.01–1.07)	0.003	1.04 (1.00–1.07)	0.042
Diagnosis
Cancer	1 (Reference)		1 (Reference)
Benign	2.21 (1.12–4.37)	0.022	1.57 (0.65–3.57)	0.329
Surgeon subspecialty
Colorectal	1 (Reference)		1 (Reference)
Noncolorectal	3.78 (1.84–7.78)	<0.001	2.96 (1.27–6.89)	0.012
ASA physical status
I–II (low risk)	1 (Reference)		1 (Reference)
III–V (high risk)	2.75 (1.32–5.76)	0.007	1.56 (0.65–3.73)	0.320
CRP >6.0 mg/dL	1.49 (0.76–2.91)	0.246	1.06 (0.49–2.29)	0.874
Lactate (mmol/L)	1.84 (1.23–2.75)	0.003	1.61 (0.98–2.64)	0.059
Time to surgery (day)	1.00 (0.99–1.01)	0.611	1.01 (0.95–1.07)	0.822

Factor	Univariate analysis		Multivariate analysis
Factor	OR (95% CI)	P-value	OR (95% CI)	P-value
Sex
Female	1 (Reference)		1 (Reference)
Male	0.84 (0.35–2.01)	0.698	2.04 (0.62–6.71)	0.239
Age (yr)	1.04 (1.00–1.08)	0.044	1.04 (1.00–1.09)	0.060
Diagnosis
Cancer	1 (Reference)		1 (Reference)
Benign	2.40 (0.93–6.25)	0.070	1.72 (0.52–5.56)	0.381
Surgeon subspecialty
Colorectal	1 (Reference)		1 (Reference)
Noncolorectal	8.71 (1.96–38.69)	0.004	15.53 (2.11–114.18)	0.006
ASA physical status^a
I–II (low risk)	1 (Reference)
III–V (high risk)	Perfect prediction
CRP >6.0 mg/dL	1.78 (0.74–4.30)	0.198	1.25 (0.45–3.43)	0.669
Lactate (mmol/L)	1.32 (1.08–1.62)	0.007	1.26 (1.00–1.59)	0.051
Time to surgery (day)	1.03 (0.97–1.09)	0.355	1.10 (1.01–1.20)	0.029

Table 1. Comparison of patient characteristics and surgical variables according to surgeon subspeciality (n=141)

Values are presented as mean±standard deviation, number (%), or median (interquartile range).

CRP, C-reactive protein; ASA, American Society of Anesthesiologists; ICU, intensive care unit.

Table 2. Types and severity of postoperative complications after the Hartmann procedure

Minor complication.

Major complication.

Table 3. Univariate and multivariate logistic regression analysis of risk factors for postoperative complications

OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists; CRP, C-reactive protein.

Table 4. Univariate and multivariate logistic regression analysis of factors associated with mortality

OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists; CRP, C-reactive protein.

For the ASA physical status, a perfect prediction was observed because all mortality cases occurred exclusively within the high-risk group (ASA physical status III–V), with no mortality in the low-risk group (ASA physical status I–II). Consequently, a definitive OR could not be mathematically calculated.