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. 2023 Jun 2;18(6):e0286562. doi: 10.1371/journal.pone.0286562

Postoperative effects of laparoscopic Hartmann reversal: A multicenter propensity score matched study

Kil-yong Lee 1, Jaeim Lee 1,*, Seong Taek Oh 1, Chul Seung Lee 2, Nam Suk Kim 3, Ju Myung Song 4, Ri-Na Yoo 5, Byung Jo Choi 6
Editor: Yasunori Sato7
PMCID: PMC10237654  PMID: 37267375

Abstract

Background

Although the advantages of laparoscopic Hartmann reversal (LHR) compared to open Hartmann reversal (OHR) have been reported in the literature, the number of multicenter studies with good matching investigating this topic is rare. In the present study, we aimed to confirm the advantages of LHR in terms of short-term outcomes through propensity score matching of LHR and OHR groups, using data collected from multiple institutions.

Methods

Patients who underwent Hartmann reversal at six institutions under the Catholic Medical Center of the Catholic University of Korea between January 1, 2005, and December 31, 2021, were included. The patients were divided into the LHR and OHR groups based on the technique used. The two groups were matched using propensity score matching (1:1 ratio, logistic regression with the nearest-neighbor method). The primary outcome was postoperative ileus (POI) frequency, and secondary outcomes were time to solid diet (days) and length of stay (days).

Results

Among 337 patients, propensity score matching was performed on 322, after excluding 15 who had undergone open conversion. Of these, 63 patients were assigned to each group through propensity score matching. There was no difference in the frequency of adhesiolysis (77.8% vs. 82.5%, p = 0.503) or the operation time. (210 (IQR 159–290) vs. 233 (IQR 160–280), p = 0.718) between the two groups. As the primary outcome, the LHR group showed significantly lower POI frequency than the OHR group. (4.8% vs. 22.2%, p = 0.0041) Regarding the secondary outcomes, the LHR group showed a shorter period to solid diet than the OHR group. The length of hospital stay was also significantly shorter in the LHR group (4 vs. 6, p < 0.0001; 9 vs. 12, p<0.0001).

Conclusion

LHR is an effective method to ensure faster recovery of patients after surgery compared to OHR.

Introduction

Laparoscopic colorectal surgery for colorectal disease has several advantages, including a reduction in both postoperative pain and hospital stay [1–3]. Furthermore, even highly difficult laparoscopic surgeries such as those of adhesive small bowel obstruction can be safely performed [4]. Hartmann’s operation is performed when primary anastomosis of the colon is difficult due to severe peritonitis caused by left colonic perforation or unstable vital signs [5], and Hartmann reversal is often performed in some patients who have undergone Hartmann’s procedure. However, there are cases in which surgeons hesitate to use laparoscopic surgery because of the difficulty of detachment due to peritoneal adhesions caused by a history of previous surgery [6–10]. However, it has been reported that laparoscopic surgery can be performed safely even with single incision during Hartmann reversal [5, 11, 12]. Nevertheless, there is debate regarding the merits of laparoscopic Hartmann’s reversal over open procedures due to the lack of randomized controlled studies.

To address this knowledge gap, in the present study, we aimed to confirm the advantages of laparoscopic Hartmann reversal (LHR) by confirming the difference in postoperative complications using propensity score matching in two groups of patients (laparoscopic vs open approaches) among patients undergoing Hartmann reversal at several centers.

Methods

This study is a multicenter retrospective cohort study. This study was approved by the institutional review board (IRB) of the Catholic University of Korea and was performed in accordance with the IRB’s guidelines and regulations. The requirement for informed consent was waived by the IRB.

Patients

Patients who underwent Hartman’s reversal at six institutions under the Catholic Medical Center of the Catholic University of Korea between January 1, 2005 and December 31, 2021, were included. The exclusion criteria were conversion and missing data for the covariates used in propensity score matching. All the data were retrospectively reviewed.

According to the research results of Ng et al [13] and Yang et al [14], when the sample size was calculated with 80% power and alpha 0.05, the minimum sample size required for each group was 60 patients.

Definition

Postoperative ileus (POI) was defined as any situation that requires a return to “nil per os” or the insertion of a nasogastric tube (NG) [15]. Stump length was measured using sigmoidoscopy prior to surgery. Anastomotic stricture was defined as the inability to pass a 13.2-mm colonoscope through the colon, or the feeling of resistance during its passage [16].

Outcomes

The primary outcome was POI frequency, and the secondary outcomes were time to solid diet (days), length of hospital stay (days), and postoperative complications.

Statistical analysis

Patients were divided into two groups: the LHR and the open Hartmann reversal (OHR) groups for comparison of the clinical characteristics. Continuous variables were assessed using the independent t-test or Wilcoxon rank sum test, and discontinuous variables were analyzed using the Chi-square test and Fisher exact test.

Propensity score matching (1:1 ratio using logistic regression with the nearest-neighbor method) was applied to correct for factors that differed between the two groups. The covariates were age, sex, body mass index, smoking, diabetes, hypertension, heart disease, pulmonary disease, liver disease, cerebrovascular disease, stump length, cause of perforation (cancer or benign), combined resection, anastomosis method, and stapler size.

Statistical analyses were performed using SAS ver 9.4 (SAS Institute Inc., Cary, NC, USA). Statistical significance was set at p<0.05.

Results

Of the 337 patients who underwent Hartmann’s reversal, 322 were included in this study, after excluding 15 who underwent conversion. Among the 322 included patients, 89 underwent LHR and 233 underwent OHR (Fig 1). The baseline characteristics are shown in Table 1. After propensity score matching, 63 participants were assigned to each group; their baseline characteristics are shown in Table 2. The post-matching patient number of this study was shown to be 82% in power analysis, which was an appropriate sample size.

Fig 1. Flow diagram of patient selection.

Fig 1

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Table 1. Baseline characteristics before propensity score matching.

Baseline characteristics before Propensity Score Matching
Variables LHR (n = 89) OHR (n = 233) p-value
Age (years) 69 (IQR 59–75) 66.5 (IQR 57–74) 0.2300(W)
Sex Male 45 (50.56%) 112 (48.07%) 0.6890(C)
Female 44 (49.44%) 121 (51.93%)
Height (cm) 160 (IQR 151.2–165.2) 157.6 (IQR 151.7–165.0) 0.7861(W)
Weight (kg) 58 (IQR 50.6–65.3) 58.7 (IQR 52.0–65.6) 0.8561(W)
Body mass index (kg/m 2 ) 23.2 (IQR 20.9–25.8) 23.4 (IQR 21.2–25.5) 0.8027(W)
Smoking No 76 (85.39%) 192 (82.40%) 0.6819(C)
Past 5 (5.62%) 12 (5.15%)
Present 8 (8.99%) 29 (12.45%)
ASA classification 1 9 (10.23%) 33 (14.16%) 0.6119(C)
2 68 (77.27%) 169 (72.53%)
3 11 (12.50%) 31 (13.30%)
Diabetes Yes 16 (17.98%) 45 (19.31%) 0.7844(C)
No 73 (82.02%) 188 (80.69%)
Hypertension Yes 54 (60.67%) 127 (54.51%) 0.3185(C)
No 35 (39.33%) 106 (45.49%)
Heart disease Yes 16 (17.98%) 31 (13.30%) 0.2882(C)
No 73 (82.02%) 202 (86.70%)
Pulmonary disease Yes 12 (13.48%) 20 (8.58%) 0.1888(C)
No 77 (86.52%) 213 (91.42%)
Liver disease Yes 3 (3.37%) 6 (2.58%) 0.7113(F)
No 86 (96.63%) 227 (97.42%)
Cerebrovascular disease Yes 10 (11.24%) 11 (4.72%) 0.0342*(C)
No 79 (88.76%) 222 (95.28%)
Cancer or benign Cancer 31 (34.83%) 80 (34.33%) 0.9332(C)
benign 58 (65.17%) 153 (65.67%)
Hartmann method Open 19 (21.35%) 202 (87.07%) <0.0001*(C)
Laparoscopy 66 (74.16%) 9 (3.88%)
Conversion 4 (4.49%) 21 (9.05%)
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LHR, Laparoscopic Hartmann Reversal; OHR, Open Hartmann Reversal; ASA, American Society of Anesthesiologists; IQR, interquartile range

p-value: Independent t-test (T) or Wilcoxon rank sum test (W)

p-value: Chi-square test (C) or Fishers exact test (F)

Table 2. Baseline characteristics after propensity score matching.

Baseline characteristics after Propensity Score Matching
Variables LHR (n = 63) OHR (n = 63) p-value
Age (years) 70 (IQR 62–75) 67 (IQR 57–75) 0.5695(W)
Sex Male 30 (47.62%) 28 (44.44%) 0.7207(C)
Female 33 (52.38%) 35 (55.56%)
Height (cm) 158 (IQR 150.1–165.0) 156 (IQR 149.7–165.0) 0.8224(W)
Weight (kg) 58.73 ± 12.54 58.88 ± 10.83 0.9442(T)
Body mass index (kg/m 2 ) 23.3 (IQR 20.9–25.8) 23.4 (IQR 21.6–24.7) 0.9455(W)
Smoking No 57 (90.48%) 58 (92.06%) 0.5784(F)
Past 2 (3.17%) 0 (0.00%)
Present 4 (6.35%) 5 (7.94%)
ASA classification 1 7 (11.11%) 7 (11.11%) 0.9688(C)
2 47 (74.60%) 46 (73.02%)
3 9 (14.29%) 10 (15.87%)
Diabetes Yes 10 (15.87%) 10 (15.87%) 1.0000(C)
No 53 (84.13%) 53 (84.13%)
Hypertension Yes 39 (61.90%) 41 (65.08%) 0.7113(C)
No 24 (38.10%) 22 (34.92%)
Heart disease Yes 12 (19.05%) 9 (14.29%) 0.4733(C)
No 51 (80.95%) 54 (85.71%)
Pulmonary disease Yes 6 (9.52%) 4 (6.35%) 0.5098(C)
No 57 (90.48%) 59 (93.65%)
Liver disease Yes 1 (1.59%) 1 (1.59%) 1.0000(F)
No 62 (98.41%) 62 (98.41%)
Cerebrovascular disease Yes 7 (11.11%) 2 (3.17%) 0.1638(F)
No 56 (88.89%) 61 (96.83%)
Cancer or benign Cancer 22 (34.92%) 18 (28.57%) 0.4440(C)
benign 41 (65.08%) 45 (71.43%)
Hartmann method Open 7 (11.11%) 60 (95.24%) <0.0001*(F)
Laparoscopy 53 (84.13%) 1 (1.59%)
Conversion 3 (4.76%) 2 (3.17%)
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LHR, Laparoscopic Hartmann Reversal; OHR, Open Hartmann Reversal; ASA, American Society of Anesthesiologists; IQR, interquartile range

p-value: Independent t-test (T) or Wilcoxon rank sum test (W)

p-value: Chi-square test (C) or Fishers exact test (F)

Operation related factors

There were no differences in terms of stump length (p = 0.925), adhesiolysis (p = 0.503), anastomotic method (p = 0.803), diversion (p = 0.492), or surgery time (p = 0.718) between the two groups (Table 3).

Table 3. Operation related factors.

Operation related factors
Variables LHR (n = 63) OHR (n = 63) p-value
Stump length (cm) 15 (IQR 10–20) 15 (IQR 10–20) 0.9254(W)
Stump resection Yes 11 (17.46%) 12 (19.35%) 0.7846(C)
No 52 (82.54%) 50 (80.65%)
Adhesiolysis Yes 49 (77.78%) 52 (82.54%) 0.5028(C)
No 14 (22.22%) 11 (17.46%)
Combined resection Yes 9 (14.29%) 10 (15.87%) 0.8034(C)
No 54 (85.71%) 53 (84.13%)
Distance from anal verge to anastomosis (cm) 11 (IQR 8–15) 15 (IQR 9–17) 0.4869(W)
Anastomotic method end-to-end 54 (85.71%) 53 (84.13%) 0.8034(C)
Other 9 (14.29%) 10 (15.87%)
Circular stapler size (mm) 28 (IQR 25–28) 28 (IQR 25–28) 0.1771(W)
Diversion Yes 3 (4.76%) 6 (9.52%) 0.4915(F)
No 60 (95.24%) 57 (90.48%)
Surgery time (min) 210 (IQR 159–290) 233 (IQR 160–280) 0.7180(W)
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LHR, Laparoscopic Hartmann Reversal; OHR, Open Hartmann Reversal; IQR, interquartile range

p-value: Independent t-test (T) or Wilcoxon rank sum test (W)

p-value: Chi-square test (C) or Fishers exact test (F)

Primary outcome

The POI frequencies with prevalence in the LHR and OHR groups were 3 (4.76%) and 14 (22.2%), respectively, showing significant differences (p = 0.004) (Table 4).

Table 4. Postoperative outcomes.

Postoperative outcomes
Variables LHR (n = 63) OHR (n = 63) p-value
Length of stay (days) 9 (IQR 8–11) 12 (IQR 10–16) <0.0001*(W)
Time to solid diet (days) 4 (IQR 3–5) 6 (IQR 5–8) <0.0001*(W)
Clavien-Dindo classification <IIIa 60 (95.24%) 58 (92.06%) 0.7175(F)
≧IIIa 3 (4.76%) 5 (7.94%)
Postoperative ileus Yes 3 (4.76%) 14 (22.22%) 0.0041*(C)
No 60 (95.24%) 49 (77.78%)
Wound infection Yes 5 (7.94%) 9 (14.29%) 0.2568(C)
No 58 (92.06%) 54 (85.71%)
Anastomotic stricture Yes 0 (0.00%) 2 (7.69%) 0.2189(F)
No 29 (100.00%) 24 (92.31%)
Anastomotic leakage Yes 0 (0.00%) 0 (0.00%) NA
No 63 (100.00%) 63 (100.00%)
Intraabdominal abscess Yes 0 (0.00%) 0 (0.00%) NA
No 63 (100.00%) 63 (100.00%)
Open in a new tab

LHR, Laparoscopic Hartmann Reversal; OHR, Open Hartmann Reversal

p-value: Independent t-test (T) or Wilcoxon rank sum test (W)

p-value: Chi-square test (C) or Fishers exact test (F)

In the LHR group, two POI patients improved symptoms 2 and 3 days after L-tube insertion with parenteral nutritional support, respectively. However one patient underwent laparoscopic adhesiolysis with transverse colectomy to resolve adhesions.

Of the 13 POI patients in the OHR group, 3 patients spontaneously improved their symptoms without L-tube insertion. However, 1 patient underwent open adhesiolysis with T-colostomy to resolve the adhesion.

Secondary outcomes

The median lengths of stay in the LHR and OHR groups were 9 and 12 days, respectively, showing a significantly shorter length of stay in the LHR group (p<0.001). In terms of median time to solid diet, the LHR group showed a significantly shorter period than the OHR group (4 vs 6 days, p<0.001). There was no difference in postoperative complications between the two groups (Table 4).

Subgroup analysis

Of the 246 patients who underwent open or conversion Hartmann’s operation in included 322 patients (Fig 1), 223 had undergone OHR and 23 had undergone LHR; the frequency with prevalence of POI between the two groups was 1 (4.4%) for LHR and 48 (21.5%) for OHR (p = 0.055). In terms of median time to solid diet, the LHR group (5 days) showed a significantly faster diet than the OHR group (6 days) (p<0.001). The median lengths of stay in the LHR and OHR groups were 9 and 12 days, respectively, showing a significantly shorter length of stay in the LHR group (p<0.001). Complications did not differ between the two groups (S4 Table).

Discussion

Overall, the results of this study showed that LHR reduced POI frequency and decreased the time to solid diet and hospital stay compared to OHR. Similar results were observed in a group of patients who had previously undergone open Hartmann’s operation in the subgroup analysis.

In colorectal surgery, the advantages of minimally invasive surgery, such as laparoscopic surgery, compared to open surgery include a more rapid recovery and fewer postoperative complications, such as wound infection. As such, minimally invasive surgery is strongly recommended by the 2018 ERAS Society [17]. However, LHR is more difficult than general laparoscopic surgery because of the presence of intra-abdominal adhesions caused by a past surgical history [6–10]. Nevertheless, the current literature on laparoscopic Hartmann’s reversal highlights the advantages of the laparoscopic approach, such as reducing major complications after surgery and lowering the anastomotic leakage rate [18].

POI is a complication that not only causes patient dissatisfaction, but also prolongs hospital stay [19]. Furthermore, randomized controlled trials using scintigraphy and radiological transit studies to investigate the effect of laparoscopic colorectal surgery on gastrointestinal function confirmed that gastrointestinal function was improved following this surgery [20–22]. LHR has also been reported to significantly reduce POI [13, 14]. Although these studies have the disadvantage of using single-center data, we once again confirmed that LHR plays an important role in reducing POI through propensity score matching using multi-center data.

In our study, LHR shortened both the time to soft diet initiation and the length of hospital stay. This finding agrees with that of a recent meta-analysis [18]. In addition, the recently revised guidelines from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons strongly recommend adopting a minimally invasive surgical approach because of its advantages in terms of bowel function and length of hospital stay during colorectal surgery [23]. Although LHR is more difficult to perform than general colorectal surgery, if surgeons with the requisite expertise are available, LHR should be performed as it is thought to be helpful in the early recovery of patients, such as speeding up time to solid diet, reducing postoperative pain, and shortening the length of hospital stay.

LHR is a challenging operation because of adhesions due to previous surgical history [6–10]. Accordingly, there are inevitable cases in which it is difficult to complete surgery with the laparoscopic approach. According to a meta-analysis, the average conversion rate is generally around 16.1%, but has been reported to reach up to 50% [24]. In our study, of a total of 104 patients who underwent the laparoscopic approach, 15 (14.4%) required conversion, showing results similar to those in the previous literature. Furthermore, when we analyzed the difference between LHR, OHR and conversion (S4 Table), the Conversion group had a longer hospitalization period (p = 0.016), but was not affected by POI (p = 0.1530) or time to solid diet (p>0.999). There was no difference in other complications. However, the length of stay in the conversion group did not differ from that of the OHR group (p>0.999), and there was no difference in operation time (p = 0.640) or other complications compared to the OHR group. This suggests that open conversion while using the laparoscopic approach does not affect the postoperative prognosis.

The primary strength of our study is that it was a multicenter propensity score-matched study. Although this was a retrospective study, post hoc power analysis using the observed differences in the primary outcome variable showed that the result was significant; moreover, the estimated power was confirmed to be approximately 82.6%. However, the present study had some limitations, including the inevitable inclusion of bias owing to the retrospective design. Second, there was a lack of description in the records regarding why the patients underwent Hartmann’s operation and the degree of adhesion. It is thought that the specific reason such as severe comorbidity, elderly patients, proficiency of the surgeon for Hartmann’s operation may be related to the degree of adhesion, which may affect the decision of the method of Hartmann reversal. Additionally, although the record was not shown, it is possible that selective bias occurred as laparoscopic Hartmann’s operation was performed more often in the case of LHR. However, even in the subgroup analysis of the patient group who underwent Open Hartmann’s operation, the advantages of LHR were similar to the study results of the entire patient group; therefore, our results support the current recommendations to proceed with the laparoscopic approach if possible.

Conclusion

In conclusion, this study showed that LHR can be performed safely, and has the advantages of reducing POI and length of hospital stay compared with OHR. Because of the limitations of this retrospective study, a multicenter randomized study with long-term follow-up is needed to verify our results.

Supporting information

S1 Table. Baseline characteristics.

(XLSX)

Click here for additional data file. (10.6KB, xlsx)
S2 Table. Operation related factors.

(XLSX)

Click here for additional data file. (9.9KB, xlsx)
S3 Table. Postoperative outcomes.

(XLSX)

Click here for additional data file. (10KB, xlsx)
S4 Table. Baseline characteristics between LHR, conversion and OHR.

(XLSX)

Click here for additional data file. (17.9KB, xlsx)

Acknowledgments

It was supported by Uijeongbu St. Mary’s Hospital Clinical Research Coordinating Center as part of the clinical trial activation project.

Data Availability

Data cannot be shared publicly because of our institutional review board(IRB)'s policy. Data are available from the IRB of the Catholic University of Korea (contact via irbujb@catholic.ac.kr) for researchers who meet the criteria for access to confidential data.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Yasunori Sato

4 Apr 2023

PONE-D-23-05434

Postoperative effects of laparoscopic Hartmann reversal: A multicenter propensity score matched study.

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PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Title: Postoperative effects of laparoscopic Hartmann reversal: A multicenter propensity

score matched study.

The title is in line with study objectives and the results

Abstract: Structured and well written

Background: Detailed information on statement of problem as well as rational for the study clearly presented.

Methods: Fairly well described.

• Study design should be mentioned even though it is apparent from the methodology.

• Minimum sample size for the study was not calculated. This is desirable, as this will show whether the sample size in this study meets the minimum calculated sample size. If the sample size used is less than the calculated minimum sample size, then this can be a limitation in the study.

Result: Well written in details with relevant tables and figures

• The first column for most of the tables are without a label

• The state number of days for POI, hospital stay, etc are not really clear. Are these mean values or median? If it is mean value, please indicate it in the sentence and provide the standard deviation (SD) as well.

• Line 126 - Frequency cannot be in percentage. Please correct it. Is it the prevalence?

Discussion: The study findings are well discussed, with study limitations provided.

Conclusion: Clearly written with appropriate recommendation.

Reviewer #2: The author focused to the short-term outcomes of reversal Hartmann operation and compared the advantages of laparoscopic and opern surgery in this operation. They enrolled the patients from multi-institutions retrospectively and used the propensity score matched analysis for deep statistical analysis. From the analysis, the author have concluded that laparoscopic Hartmann reversal (LHR) is better method for fast recovery from the surgery and to prevent the postoprative bowel obstrution than open Hartmann reversal (OHR). Overall, the analysis seems to be fair and the results of this manuscript are similar to the previous studies and I agree with it. As the author pointed out, the study which reported the outcome of Hartmann reversal operation is not that many and these previous publications are mainly from single institution. This presented study is multi-instituional study with propensity score matced analysis and these background seems to strengthen the result compared to the previous studies. However, there are several concerns in this study which I want to point out.

1. As the author pointed out, the peritoneal adhesion will be the challenge to perform LHR. I feel that the conversion rate of LHR is another important outcome and I do not understand why the author excluded the 15 conversion cases from the analysis. It is more important to know how the LHR is difficult and conversion to open surgery may happen. Looking into the result, it seems that about 15% of patients were converted to open surgery and I recommend the author to analyze and discuss more deeply about it.

2. In Table 1, I see the data of the previous surrgery (Hartmann method) but this data is not presented in Table 2. This is very important imformation to consider the result of matching and I highly recommend to include it.

3. Hartmann operation will be considered when the anatomosis is considered to be difficult. However, reason of this decision will be various kinds of things; for example, perforation, severe comorbidity, elderly patients, profiency of the surgeon, etc. It would be better to include more specifc data why the patients underwent Hartmann operation at the beginning.

4. As the author mentioned in the limitation, there will be a selection bias since the patients with advanced cancer cannot undergo Hartmann reversal when they are under chemotherapy. It might be better to show how many patients underwent Hartmann surgery and how many had Hartmann reveersal.

5. The frequency of POI seems to be quite different. Is there any difference in the required treatment for these patient comparing LHR and OHR group? Were there any case which needed another surgery to treat POI? The primary outcome was set as POI and I recommend the author to analyze more deeply in it.

6. Although there was no significant difference, I am quite surprised that the incisional hernia was more frequent in LHR group. Why do you think this happened?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Prof. Tanimola Makanjuola Akande

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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Attachment

Submitted filename: PONE-D-23-05434_reviewer.pdf

Click here for additional data file. (869.2KB, pdf)
Attachment

Submitted filename: Comment PLOS One - PONE-D--23-05434.docx

Click here for additional data file. (14KB, docx)
PLoS One. 2023 Jun 2;18(6):e0286562. doi: 10.1371/journal.pone.0286562.r002

Author response to Decision Letter 0

19 Apr 2023

Review Comments to the Author

Reviewer #1: Title: Postoperative effects of laparoscopic Hartmann reversal: A multicenter propensity

score matched study.

The title is in line with study objectives and the results

Abstract: Structured and well written

Background: Detailed information on statement of problem as well as rational for the study clearly presented.

Methods: Fairly well described.

• Comment: Study design should be mentioned even though it is apparent from the methodology.

� We thank the reviewer for the considerate comments. Accordingly, we have indicated the study design at the beginning of the methods.

• Comment: Minimum sample size for the study was not calculated. This is desirable, as this will show whether the sample size in this study meets the minimum calculated sample size. If the sample size used is less than the calculated minimum sample size, then this can be a limitation in the study.

� According to the reviewer’s comments, we have calculated sample size. As reported by Ng et al. [1] and Yang et al. [2], with 80% power and alpha 0.05, the sample size required for each group was 60 patients. Therefore, in this study, the number of samples included is appropriate, with a total of 126 patients and 63 patients in each group; the power was confirmed to be about 82% in the power analysis. This information has been added it in the “Patients” and “Results” section.

References

1. Ng DC, Guarino S, Yau SL, Fok BK, Cheung HY, Li MK et al. Laparoscopic reversal of Hartmann's procedure: safety and feasibility. Gastroenterol Rep (Oxf). 2013;1(2):149-52. doi:10.1093/gastro/got018.

2. Yang PF, Morgan MJ. Laparoscopic versus open reversal of Hartmann's procedure: a retrospective review. ANZ J Surg. 2014;84(12):965-9. doi:10.1111/ans.12667.

Result: Well written in details with relevant tables and figures

• Comment: The first column for most of the tables are without a label

� Accordingly, we have added the label to the first column.

• Comment: The state number of days for POI, hospital stay, etc are not really clear. Are these mean values or median? If it is mean value, please indicate it in the sentence and provide the standard deviation (SD) as well.

� The number of days for hospital stay and the time to solid diet are described as the median. These have been added to the results section.

• Comment: Line 126 - Frequency cannot be in percentage. Please correct it. Is it the prevalence?

� This indicates the prevalence of POIs in each group. According to the reviewer’s comment, we have changed it to the number of occurrences as well as the percentage.

Discussion: The study findings are well discussed, with study limitations provided.

Conclusion: Clearly written with appropriate recommendation.

 

Reviewer #2: The author focused to the short-term outcomes of reversal Hartmann operation and compared the advantages of laparoscopic and open surgery in this operation. They enrolled the patients from multi-institutions retrospectively and used the propensity score matched analysis for deep statistical analysis. From the analysis, the author have concluded that laparoscopic Hartmann reversal (LHR) is better method for fast recovery from the surgery and to prevent the postoprative bowel obstrution than open Hartmann reversal (OHR). Overall, the analysis seems to be fair and the results of this manuscript are similar to the previous studies and I agree with it. As the author pointed out, the study which reported the outcome of Hartmann reversal operation is not that many and these previous publications are mainly from single institution. This presented study is multi-instituional study with propensity score matced analysis and these background seems to strengthen the result compared to the previous studies. However, there are several concerns in this study which I want to point out.

1. Comment: As the author pointed out, the peritoneal adhesion will be the challenge to perform LHR. I feel that the conversion rate of LHR is another important outcome and I do not understand why the author excluded the 15 conversion cases from the analysis. It is more important to know how the LHR is difficult and conversion to open surgery may happen. Looking into the result, it seems that about 15% of patients were converted to open surgery and I recommend the author to analyze and discuss more deeply about it.

� We appreciate the reviewer’s considerate comments. The initial intention of the group that underwent conversion was LHR; thus, if it were analyzed by intention-to-treat (ITT) method, this group should be analyzed by putting it in the LHR group. However, because the surgical method itself was open, it was excluded from our study.

Nonetheless, according to the reviewer's opinion, we performed further analysis to investigate whether a conversion group differs from other groups. Although the surgical time was longer in this group compared to that in the LHR group, there was no difference in other postoperative complications and POI. We have added a supplement table summarizing the analysis of the three groups and have summarized the results in the discussion section.

2. Comment: In Table 1, I see the data of the previous surgery (Hartmann method) but this data is not presented in Table 2. This is very important information to consider the result of matching and I highly recommend to include it.

� In the group that underwent open Hartmann's reversal, remarkably few cases were present where the previous operation was laparoscopic Hartmann's operation (3.9%); thus, we excluded Hartmann's method from matching in PSM and included this as a limitation in the discussion section. However, according to the reviewer's opinion, we have added the Hartmann method to Table 2 as well.

3. Comment: Hartmann operation will be considered when the anastomosis is considered to be difficult. However, reason of this decision will be various kinds of things; for example, perforation, severe comorbidity, elderly patients, proficiency of the surgeon, etc. It would be better to include more specifc data why the patients underwent Hartmann operation at the beginning.

� Our study focused on Hartmann's reversal and investigated data from multi-institutional electric medical records. Furthermore, there were cases where Hartmann's operation was performed at institutions other than our six institutions, and there were no records from the other hospital; even though there was a surgical record for Hartmann's operation, there was no mention of the reason why Hartmann's operation was performed, and we had to exclude that item. Therefore, we have added this as a limitation of our study in the discussion section.

4. Comment: As the author mentioned in the limitation, there will be a selection bias since the patients with advanced cancer cannot undergo Hartmann reversal when they are under chemotherapy. It might be better to show how many patients underwent Hartmann surgery and how many had Hartmann reveersal.

� According to the reviewer's opinion, the number of patients who underwent Hartmann's surgery in our institutes was investigated. In total, 1076 patients underwent Hartmann's operation in our hospital, and among them, 306 patients underwent Hartmann reversal. The remaining 31 patients who underwent Hartmann reversal in our institutes were patients who had undergone Hartmann's operation at other hospitals. This has been added to Figure 1.

5. Comment: The frequency of POI seems to be quite different. Is there any difference in the required treatment for these patient comparing LHR and OHR group? Were there any case which needed another surgery to treat POI? The primary outcome was set as POI and I recommend the author to analyze more deeply in it.

� In the LHR group, two POI patients showed an improvement in symptoms at 2 and 3 days, respectively, after L-tube insertion with parenteral nutritional support. However, one patient underwent laparoscopic adhesiolysis with transverse colectomy to resolve adhesions.

Of 13 POI patients in the OHR group, three patients showed spontaneous improvement in their symptoms without L-tube insertion. However, one patient underwent open adhesiolysis with T-colostomy to resolve the adhesion.

We have added these in the results section.

6. Comment: Although there was no significant difference, I am quite surprised that the incisional hernia was more frequent in LHR group. Why do you think this happened?

� The exact cause is not known, but the occurrence of incisional hernia was confirmed by CT; since CT was performed in only about 38 out of 63 patients in each group, this may have resulted in a difference in incidence rates.

Attachment

Submitted filename: Response to Reviewers_final.docx

Click here for additional data file. (27.1KB, docx)

Decision Letter 1

Yasunori Sato

9 May 2023

PONE-D-23-05434R1Postoperative effects of laparoscopic Hartmann reversal: A multicenter propensity score matched study.PLOS ONE

Dear Dr. Lee,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 23 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Yasunori Sato

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Authors have addressed all the issues and suggestions raised in the earlier review quite satisfactorily.

Reviewer #2: Thank you for the correction. Most of my comments are fully addressed. One last comment from me is below.

1. I recommend the author to exclude the details for incisional hernia. Author have pointed out that almost half of patients did not have CT evaluation. Considering this fact, this result seems to be missleading.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Prof. Tanimola Akande

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachment

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PLoS One. 2023 Jun 2;18(6):e0286562. doi: 10.1371/journal.pone.0286562.r004

Author response to Decision Letter 1

10 May 2023

Reviewer #1: Authors have addressed all the issues and suggestions raised in the earlier review quite satisfactorily.

� We thank the reviewer for reviewing the revised manuscript.

Reviewer #2: Thank you for the correction. Most of my comments are fully addressed. One last comment from me is below.

1. I recommend the author to exclude the details for incisional hernia. Author have pointed out that almost half of patients did not have CT evaluation. Considering this fact, this result seems to be missleading.

� We thank the reviewer for the considerate comments. Accordingly, we have excluded the details of incisional hernia from the revised manuscript.

Attachment

Submitted filename: Response_to_Reviewers.docx

Click here for additional data file. (21.1KB, docx)

Decision Letter 2

Yasunori Sato

19 May 2023

Postoperative effects of laparoscopic Hartmann reversal: A multicenter propensity score matched study.

PONE-D-23-05434R2

Dear Dr. Lee,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Yasunori Sato

Academic Editor

PLOS ONE

Acceptance letter

Yasunori Sato

25 May 2023

PONE-D-23-05434R2

Postoperative effects of laparoscopic Hartmann reversal: A multicenter propensity score matched study.

Dear Dr. Lee:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Yasunori Sato

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. Baseline characteristics.

    (XLSX)

    Click here for additional data file. (10.6KB, xlsx)
    S2 Table. Operation related factors.

    (XLSX)

    Click here for additional data file. (9.9KB, xlsx)
    S3 Table. Postoperative outcomes.

    (XLSX)

    Click here for additional data file. (10KB, xlsx)
    S4 Table. Baseline characteristics between LHR, conversion and OHR.

    (XLSX)

    Click here for additional data file. (17.9KB, xlsx)
    Attachment

    Submitted filename: PONE-D-23-05434_reviewer.pdf

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    Attachment

    Submitted filename: Comment PLOS One - PONE-D--23-05434.docx

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    Attachment

    Submitted filename: Response to Reviewers_final.docx

    Click here for additional data file. (27.1KB, docx)
    Attachment

    Submitted filename: PONE-D-23-05434_R1.pdf

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    Attachment

    Submitted filename: Response_to_Reviewers.docx

    Click here for additional data file. (21.1KB, docx)

    Data Availability Statement

    Data cannot be shared publicly because of our institutional review board(IRB)'s policy. Data are available from the IRB of the Catholic University of Korea (contact via irbujb@catholic.ac.kr) for researchers who meet the criteria for access to confidential data.

    Articles from PLOS ONE are provided here courtesy of PLOS

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