Transverse blowhole colostomy versus Hartmann’s for urgent management of large bowel obstruction secondary to diverticular stricture

Abstract

Purpose

Sigmoid resection with end colostomy (Hartmann’s procedure) is the procedure of choice when a large bowel obstruction secondary to diverticular disease requires surgery. Less morbid alternatives are less common. This study compares a transverse blowhole colostomy as a first-stage intervention in diverticular-associated obstruction. Our primary aim was to compare colostomy reversal rates and postoperative outcomes between blowhole colostomy and Hartmann’s procedure.

Methods

This is a single-center, retrospective cohort study. An institutional database was utilized to retrospectively identify adult patients who underwent Hartmann’s procedure or blowhole colostomy for diverticular strictures with obstruction between 2012 and 2023.

Results

Thirty-nine patients underwent Hartmann’s procedure for diverticular strictures with obstruction and 15 patients underwent blowhole colostomy. The blowhole colostomy group had a significantly shorter postoperative length of stay (median 5 vs. 8 days, p = 0.01). Colostomy reversal was more frequent in the blowhole group (81.3% vs. 56.4%, p = 0.08), with a shorter median time to reversal (3 months vs. 4.7 months, p = 0.01). A significant increase in reversals performed using a minimally invasive approach (84.6% vs. 50%, p < 0.01) occurred in the blowhole colostomy group. No significant differences were observed in other postoperative outcomes, including proximal diversion after colostomy reversal.

Conclusions

Blowhole colostomy may be a viable alternative to a Hartmann’s procedure for diverticular-associated large bowel obstruction, offering potential benefits such as shorter hospital stays, higher rates of colostomy reversal, and a greater likelihood of minimally invasive reversal. Further prospective studies are needed to confirm these findings.

Introduction

Large bowel obstruction (LBO) due to diverticular disease is a challenging clinical scenario that frequently necessitates urgent surgical intervention. Traditionally, these cases have been managed with Hartmann’s procedure (HP), which involves resection of the affected sigmoid stricture and creation of an end colostomy. While effective for acute decompression, HP carries a substantial postoperative burden, including wound complications, hernia formation, and a high rate of delayed or failed colostomy reversal [1]. In many cases, the procedure cannot be in done via minimally invasive route and in the long-term the colostomy is never reversed, contributing to stoma-related morbidity and decreased patient quality of life [2]. Given the increasing incidence of diverticular disease and the limitations associated with conventional surgical approaches, there is growing interest in alternative strategies that may reduce perioperative risk while preserving long-term outcomes.

One such approach is the transverse blowhole colostomy (TBC). First described by Turnbull [3, 4], TBC is a simplified technique that diverts the colon without an initial formal resection. TBC may provide key advantages for acutely ill patients by offering a quicker, less invasive operation with shorter hospital stays and fewer complications [5]. In addition, it preserves the diseased sigmoid colon for elective resection at a later stage, ideally via a minimally invasive approach. TBC may facilitate improved patient recovery, decreased operative time, and decreased length of stay [6]. Although self-expanding metallic stents have demonstrated efficacy in malignant obstruction, they are not recommended for benign conditions such as diverticulitis due to a higher incidence of perforation and complications [7–10].

Despite growing anecdotal support and isolated case series suggesting the utility of TBC, high-quality comparative data are limited [11]. In the last 5 years, our department has increasingly employed this strategy in patients presenting with diverticular-associated LBO, and early clinical experience has shown promising outcomes. However, to date, no formal studies have evaluated the comparative effectiveness of TBC versus HP.

This study aims to evaluate the safety and efficacy of TBC compared to HP in patients undergoing urgent surgery for diverticular LBO. We hypothesize that TBC is associated with shorter hospitalization, higher rates of colostomy reversal, and increased likelihood of minimally invasive surgery during reversal. The results of this review may offer meaningful insights to guide surgical decision-making and optimize outcomes in patients presenting with diverticular LBO.

Methods

This study is a retrospective cohort analysis comparing two surgical approaches for the management of diverticular-related large bowel obstruction: the transverse (blowhole) colostomy and Hartmann’s procedure. All patient data were anonymized in accordance with HIPAA regulations. This study was approved by the IRB at Corewell Health West (IRB No. 2023–145). The retrospective nature of the study waived the need for individual patient consent.

The study aimed to evaluate perioperative outcomes related to the initial surgical procedure and the subsequent ostomy reversal procedure, if performed. Given the retrospective design, the primary outcome was a composite of 30-day postoperative complications, and secondary outcomes included rates of ostomy reversal and post-reversal complications.

All patients who underwent either a Hartmann’s procedure or a transverse colostomy for diverticular-related LBO between January 1, 2011, and March 1, 2023, were identified using administrative coding. Patients who underwent urgent or emergent surgical intervention for diverticular-associated LBO were included in the study. Patients undergoing elective surgery or those with obstruction due to malignancy, ischemia, or other non-diverticular etiologies were excluded.

Demographic, clinical, operative, and postoperative data were abstracted from the electronic medical record and organized into a secure research database.

Data were analyzed using descriptive and inferential statistical methods. Normally distributed continuous data were analyzed using t-tests, while non-normally distributed data were analyzed using the Mann–Whitney U test. Categorical variables were analyzed using chi-square tests or Fisher’s exact tests, as appropriate. A p-value of < 0.05 was considered statistically significant.

Results

A total of 55 patients met the inclusion criteria for this study, with 39 patients who underwent Hartmann’s procedure (HP) and 16 patients who underwent a transverse blowhole colostomy (TBC) for large bowel obstruction due to diverticular disease. There were no significant differences between the two groups in terms of age, sex, body mass index (BMI), or comorbidities (Table 1). There was a significant difference in preoperative albumin levels between the TBC and HP groups (3.33 versus 2.88; p = 0.04).

Table 1.

Demographic and preoperative characteristics of HP and TBC patients

	HP(n= 39)	TBC (n = 16)	p-value
Age	68.6	67.0	0.67
BMI	28.6	28.9	0.76
Sex (male)	30.8% (12)	56.3% (9)	0.07
CAD/CHF	17.9% (7)	26.7% (4)	0.48
DM	7.7% (3)	40.0% (6)	0.44
OSA	10.3% (4)	13.3% (2)	1.00
COPD	23.1% (9)	13.3% (2)	0.70
Tobacco use	28.2% (11)	37.5% (6)	0.49
Preoperative albumin	2.88	3.33	0.04

BMI body mass index, CAD/CHF coronary artery disease/congestive heart failure, DM diabetes mellitus, OSA obstructive sleep apnea, COPD chronic obstructive pulmonary disease

There was a significant difference in operative time in minutes between the TBC and HP group at the index surgery (44.6 versus 157.3, p < 0.01). However, operative time did not differ for the reversal procedure in either group (183.6 versus 203.7, p = 0.50). The TBC group demonstrated a significantly shorter median hospital length of stay compared to the HP group (5 versus 8 days, p = 0.01). Thirty-day readmission and reoperation rates were low and did not significantly differ between groups. No patients required a blood transfusion in the TBC group compared to the HP group with four patients needing transfusion. Both groups observed a single mortality within 30 days of operation. Incisional hernia was diagnosed in 7.7% of HP patients versus 6.7% of TBC patients within 1 year of the index operation. Surgical site infections (deep or superficial), ileus, and cardiac complications postoperatively were uncommon across both cohorts, with no significant differences observed (Table 2). These findings collectively suggest that TBC may be associated with a more favorable postoperative profile in selected patients.

Table 2.

Index surgery postoperative characteristics of HP and TBC patients

	HP (n = 39)	TBC (n = 16)	p-value
OR time (mins)	157.3	44.6	< 0.01
Blood transfusion	10.3% (4)	0% (0)	0.56
LOS (days)	8	5	0.01
Superficial SSI	7.7% (3)	0% (0)	0.55
Deep SSI	15.4% (6)	6.7% (1)	0.66
Ileus	5.1% (2)	0% (0)	1.00
Cardiac complications	7.7% (3)	6.7% (1)	1.00
30-day reoperation	7.7% (3)	6.7% (1)	1.00
30-day readmission	7.7% (3)	6.7% (1)	1.00
30-day mortality	2.6% (1)	6.7% (1)	1.00
Incisional hernia (1 year)	7.7% (3)	6.7% (1)	1.00

LOS length of stay, SSI surgical site infection

Following reversal, no significant differences were noted in the aforementioned postoperative characteristics, demonstrated in Table 3.

Table 3.

Reversal surgery postoperative characteristics of HP and TBC patients

	HP (n = 22)	TBC (n = 13)	p-value
OR time (mins)	203.7	183.6	0.50
Blood transfusion	4.5% (1)	0% (0)	1.00
LOS (days)	4	4	0.76
Superficial SSI	4.5% (1)	0% (0)	1.00
Deep SSI	9.1% (2)	0% (0)	0.52
Ileus	13.6% (3)	16.7% (2)	1.00
Cardiac complications	4.5% (1)	8.3% (1)	1.00
Anastomotic leak	0% (0)	0% (0)	1.00
30-day reoperation	9.1% (2)	0% (0)	0.53
30-day readmission	9.1% (2)	8.3% (1)	1.00
30-day mortality	0% (0)	8.3% (1)	1.00

LOS length of stay, SSI surgical site infection

Of the 16 patients in the TBC group, 13 underwent successful colostomy reversal, compared to 22 of 39 in the HP group. Although this difference in reversal rates did not reach statistical significance (81.3% versus 56.4%, p = 0.08), the TBC group demonstrated a significantly shorter median time to reversal (3.0 versus 4.7 months, p = 0.01) (Fig. 1).

Fig. 1.

The Kaplan–Meier curve comparing time to event (reversal) in months between the HP (blue line) and TBC (red line) groups. TBC, transverse blowhole colostomy; HP, Hartmann’s procedure

A higher percentage of TBC reversals were completed using a minimally invasive approach compared to HP (84.6% versus 50.0%, p < 0.01). Three of the TBC patients required proximal diversion at the time of reversal, whereas four HP patients did (Table 4).

Table 4.

Reversal outcomes of HP and TBC patients

Reversal outcome	HP (n = 39)	TBC (n = 16)	p-value
Reversal performed	56.4% (22)	81.3% (13)	0.08
Minimally invasive reversal	50.0% (11)	84.6% (11)	< 0.01
Median time to reversal (months)	4.7	3.0	0.01
Proximal diversion required	18.2% (4)	20.0% (3)	0.66

Discussion and conclusion

This study is among the first to systematically evaluate and compare outcomes between transverse blowhole colostomy (TBC) and Hartmann’s procedure (HP) for diverticular large bowel obstruction (LBO). Our findings suggest that TBC may offer favorable outcomes in select patients, including shorter index operation, shorter length of stay, higher rates of ostomy reversal, and greater use of minimally invasive techniques during reversal.

We found a difference in operative time at the index operation, with the TBC group taking significantly less time for completion compared to the HP group. As patients with LBO are often critically ill [12], a shorter operation with minimal anesthesia would be optimal. There was no difference in operative time for each group’s reversal surgery, showing that TBC ultimately does not affect the complexity of the definitive, second-stage operation.

A key finding in our cohort was the significantly shorter postoperative hospital stay among patients undergoing TBC compared to those undergoing HP. Prior literature has demonstrated that HP, while effective for colonic decompression, is associated with substantial perioperative morbidity and prolonged recovery [13]. In contrast, the TBC approach—focused on urgent decompression without resection—may provide patients time to stabilize and optimize prior to definitive elective resection. The avoidance of pelvic dissection during the initial procedure potentially contributes to this difference in length of stay [14].

Ostomy reversal is a key clinical endpoint in patients undergoing surgery for LBO. In our study, the TBC group demonstrated a higher reversal rate, shorter median time to reversal, and greater use of minimally invasive approaches compared to the HP group. These findings reflect one of the key theoretical benefits of the staged decompression strategy: preservation of normal tissue planes for a second-stage operation, often performed under optimized conditions [15, 16]. While the difference in overall reversal rate did not reach statistical significance, the time to reversal and approach type trends are notable.

Incisional hernia rates and superficial or deep SSI rates were low and did not significantly differ between groups. These findings suggest that, when performed carefully, TBC does not appear to increase short-term morbidity.

These results are consistent with prior studies examining staged surgical approaches for colonic obstruction. Amelung et al. and others have reported that initial decompression—via diverting ostomy or stenting—may reduce emergent surgical risk and improve outcomes [17]. Additionally, recent literature has shown that minimally invasive surgery following staged decompression is associated with lower complication rates and better patient-reported outcomes [18].

This study is limited by its retrospective design and single-center nature. The relatively small sample size, particularly in the TBC group, may limit the statistical power to detect small differences. Additionally, the decision to pursue TBC versus HP was at the discretion of the operating surgeon, introducing selection bias.

Nonetheless, this study highlights the potential utility of TBC as an alternative to HP for the management of diverticular LBO. Future prospective studies are needed to validate these findings and establish standardized selection criteria for staged decompression strategies. Until then, TBC should be considered in carefully selected patients where staged, minimally invasive resection is anticipated.

These findings underscore the importance of individualized surgical planning and suggest that TBC, in select cases, may contribute to improved short-term outcomes, enhanced recovery, and more timely return to bowel continuity. As minimally invasive techniques continue to evolve, incorporating TBC into the surgical armamentarium for diverticular LBO may improve both clinical outcomes and patient quality of life.

Author contribution

H.L. participated in data analysis and interpretation, and was primarily responsible for drafting the manuscript. K.C. was responsible for study conception and design, as well as data analysis and interpretation. K.L. assisted in data interpretation and drafting the manuscript. As the Principal Investigator, J.O. participated in study conception and design, data acquisition, and data interpretation. All authors provided critical revision of the manuscript content and gave final approval for submission.

Funding

No funds, grants, or other support was received.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.