Short-term severe complications in laparoscopic and open Hartmann's reversals within an ERAS protocol

Abstract

Laparoscopic Hartmann's reversal is increasingly performed. Enhanced Recovery After Surgery (ERAS) protocols may improve postoperative recovery. However, evidence regarding whether male sex, delayed reversal and compliance to ERAS protocols influence the risk for anastomotic leakage (AL) remains limited. This cohort study included consecutive patients undergoing Hartmann's reversal at a tertiary colorectal centre between July 2015 and June 2025. Prospectively registered ERAS data were complemented by retrospective chart review. The primary outcome was severe complications within 30 days, defined as AL according to ISREC criteria or complications graded Clavien–Dindo >IIIa. Associations between male sex, time to reversal, intention-to-treat minimally invasive surgery (MIS), ERAS compliance, and severe complications were assessed using logistic regression adjusted for age, Body Mass Index, and American Society of Anesthesiologisists classification. One hundred seventy patients were included, of whom 94 (55 per cent) were male. The mean age was 60 years, and the mean interval to reversal was 18.5 months. One hundred forty-four patients were operated by MIS, 15 were converted and 11 by planned open surgery. Severe complications occurred in 17 and AL in 9 patients respectively. Male sex was associated with increased odds of severe complications (OR 3.21, 95% c.i. 1.03 to 10.02) while time to reversal and intention-to-treat MIS were not. Preoperative ERAS compliance was associated with reduced odds of severe complications (OR 0.93/point increase, P<0.05). Hartmann's reversal showed low rates of severe complications and AL irrespective of reversal timing. Male sex may increase the risk of severe complications, whereas improved ERAS compliance appears protective.