Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study

E G M van Geffen; F S Verheij; S M J A Hazen; T C Sluckin; E C J Consten; J-W T Dekker; J Nederend; K C M J Peeters; J H W de Wilt; S van Dieren; R Hompes; J B Tuynman; C A M Marijnen; P J Tanis; M Kusters

doi:10.1007/s10151-025-03169-5

Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study

E G M van Geffen
, F S Verheij
, S M J A Hazen
, T C Sluckin
, E C J Consten
, J-W T Dekker
, J Nederend
, K C M J Peeters
, J H W de Wilt
, S van Dieren
, R Hompes
, J B Tuynman
, C A M Marijnen
, P J Tanis^*
, M Kusters
,

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

1 Downloads (Pure)

Abstract

BACKGROUND: In the Netherlands, approximately 15% of patients with rectal cancer undergo a low Hartmann's procedure (low-HP). This is often preoperatively planned to avoid poor functional outcome or complications, but might be unplanned as a result of intraoperative difficulties. Low-HPs seem to be associated with worse oncological outcomes.

METHODS: All patients who underwent either restorative low anterior resection (rLAR), planned low-HP, or unplanned low-HP for primary rectal cancer in 2016 were included from a nationwide cohort. Main outcomes were 4-year local recurrence (LR) rate and disease-free survival (DFS).

RESULTS: Of 2043 patients, 1704 underwent rLAR (83.4%), 253 planned low-HP (12.4%), and 86 unplanned low-HP (4.2%). Among intended rLAR patients (n = 1790), independent risk factors for unplanned low-HP were older age, higher body mass index (BMI), higher American Society of Anesthesiologists (ASA) score, and more distal tumor location. Oncological outcomes after low-HPs were worse than after rLARs (LR 13.7% vs 5.6%, DFS 54.7% vs 71.8%, both p < 0.001), but similar for unplanned and planned low-HP. In multivariable analysis, unplanned and planned low-HP were not associated with LR or DFS, but R1 resection was (HR 6.6 (4.1-10.6), HR 3.0 (2.2-4.0), respectively). In R1 resections, the distal margin was more often involved after low-HP (70.0% vs 28.6%, p = 0.013) compared to rLAR.

CONCLUSION: Poor outcomes in univariable analysis after low-HP appear to be associated with more challenging procedures and increased risk of involved resection margin rather than the low-HP itself. In case of expected difficulties, an extralevator abdominoperineal excision or referral to an expert center might be an alternative to improve resection margins.

TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT05539417, retrospectively registered on September 16, 2022.

Original language	English
Article number	4
Journal	Techniques in coloproctology
Volume	30
Issue number	1
DOIs	https://doi.org/10.1007/s10151-025-03169-5
Publication status	Published - 23 Nov 2025

Keywords

Conversion to open surgery
Minimally invasive surgical procedures
Rectal cancer
Resection margins

Access to Document

10.1007/s10151-025-03169-5Licence: CC BY

Oncological outcomes of planned and unplanned low Hartmann’s procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional studyFinal published version, 841 KBLicence: CC BY

Cite this

van Geffen, E. G. M., Verheij, F. S., Hazen, S. M. J. A., Sluckin, T. C., Consten, E. C. J., Dekker, J.-W. T., Nederend, J., Peeters, K. C. M. J., de Wilt, J. H. W., van Dieren, S., Hompes, R., Tuynman, J. B., Marijnen, C. A. M., Tanis, P. J., Kusters, M. (2025). Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study. Techniques in coloproctology, 30(1), Article 4. https://doi.org/10.1007/s10151-025-03169-5

@article{6a7cde6b82d94c368ab706209faa4b23,

title = "Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study",

abstract = "BACKGROUND: In the Netherlands, approximately 15\% of patients with rectal cancer undergo a low Hartmann's procedure (low-HP). This is often preoperatively planned to avoid poor functional outcome or complications, but might be unplanned as a result of intraoperative difficulties. Low-HPs seem to be associated with worse oncological outcomes.METHODS: All patients who underwent either restorative low anterior resection (rLAR), planned low-HP, or unplanned low-HP for primary rectal cancer in 2016 were included from a nationwide cohort. Main outcomes were 4-year local recurrence (LR) rate and disease-free survival (DFS).RESULTS: Of 2043 patients, 1704 underwent rLAR (83.4\%), 253 planned low-HP (12.4\%), and 86 unplanned low-HP (4.2\%). Among intended rLAR patients (n = 1790), independent risk factors for unplanned low-HP were older age, higher body mass index (BMI), higher American Society of Anesthesiologists (ASA) score, and more distal tumor location. Oncological outcomes after low-HPs were worse than after rLARs (LR 13.7\% vs 5.6\%, DFS 54.7\% vs 71.8\%, both p < 0.001), but similar for unplanned and planned low-HP. In multivariable analysis, unplanned and planned low-HP were not associated with LR or DFS, but R1 resection was (HR 6.6 (4.1-10.6), HR 3.0 (2.2-4.0), respectively). In R1 resections, the distal margin was more often involved after low-HP (70.0\% vs 28.6\%, p = 0.013) compared to rLAR.CONCLUSION: Poor outcomes in univariable analysis after low-HP appear to be associated with more challenging procedures and increased risk of involved resection margin rather than the low-HP itself. In case of expected difficulties, an extralevator abdominoperineal excision or referral to an expert center might be an alternative to improve resection margins.TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT05539417, retrospectively registered on September 16, 2022.",

keywords = "Conversion to open surgery, Minimally invasive surgical procedures, Rectal cancer, Resection margins",

author = "\{van Geffen\}, \{E G M\} and Verheij, \{F S\} and Hazen, \{S M J A\} and Sluckin, \{T C\} and Consten, \{E C J\} and Dekker, \{J-W T\} and J Nederend and Peeters, \{K C M J\} and \{de Wilt\}, \{J H W\} and \{van Dieren\}, S and R Hompes and Tuynman, \{J B\} and Marijnen, \{C A M\} and Tanis, \{P J\} and M Kusters and Martijn Intven",

note = "{\textcopyright} 2025. The Author(s).",

year = "2025",

month = nov,

day = "23",

doi = "10.1007/s10151-025-03169-5",

language = "English",

volume = "30",

journal = "Techniques in coloproctology",

issn = "1123-6337",

publisher = "Springer Science and Business Media Deutschland GmbH",

number = "1",

}

van Geffen, EGM, Verheij, FS, Hazen, SMJA, Sluckin, TC, Consten, ECJ, Dekker, J-WT, Nederend, J, Peeters, KCMJ, de Wilt, JHW, van Dieren, S, Hompes, R, Tuynman, JB, Marijnen, CAM, Tanis, PJ, Kusters, M 2025, 'Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study', Techniques in coloproctology, vol. 30, no. 1, 4. https://doi.org/10.1007/s10151-025-03169-5

Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study. / van Geffen, E G M; Verheij, F S; Hazen, S M J A et al.
In: Techniques in coloproctology, Vol. 30, No. 1, 4, 23.11.2025.

Research output: Contribution to journal › Article › Academic › peer-review

TY - JOUR

T1 - Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer

T2 - a population-based cross-sectional study

AU - van Geffen, E G M

AU - Verheij, F S

AU - Hazen, S M J A

AU - Sluckin, T C

AU - Consten, E C J

AU - Dekker, J-W T

AU - Nederend, J

AU - Peeters, K C M J

AU - de Wilt, J H W

AU - van Dieren, S

AU - Hompes, R

AU - Tuynman, J B

AU - Marijnen, C A M

AU - Tanis, P J

AU - Kusters, M

AU - Intven, Martijn

PY - 2025/11/23

Y1 - 2025/11/23

N2 - BACKGROUND: In the Netherlands, approximately 15% of patients with rectal cancer undergo a low Hartmann's procedure (low-HP). This is often preoperatively planned to avoid poor functional outcome or complications, but might be unplanned as a result of intraoperative difficulties. Low-HPs seem to be associated with worse oncological outcomes.METHODS: All patients who underwent either restorative low anterior resection (rLAR), planned low-HP, or unplanned low-HP for primary rectal cancer in 2016 were included from a nationwide cohort. Main outcomes were 4-year local recurrence (LR) rate and disease-free survival (DFS).RESULTS: Of 2043 patients, 1704 underwent rLAR (83.4%), 253 planned low-HP (12.4%), and 86 unplanned low-HP (4.2%). Among intended rLAR patients (n = 1790), independent risk factors for unplanned low-HP were older age, higher body mass index (BMI), higher American Society of Anesthesiologists (ASA) score, and more distal tumor location. Oncological outcomes after low-HPs were worse than after rLARs (LR 13.7% vs 5.6%, DFS 54.7% vs 71.8%, both p < 0.001), but similar for unplanned and planned low-HP. In multivariable analysis, unplanned and planned low-HP were not associated with LR or DFS, but R1 resection was (HR 6.6 (4.1-10.6), HR 3.0 (2.2-4.0), respectively). In R1 resections, the distal margin was more often involved after low-HP (70.0% vs 28.6%, p = 0.013) compared to rLAR.CONCLUSION: Poor outcomes in univariable analysis after low-HP appear to be associated with more challenging procedures and increased risk of involved resection margin rather than the low-HP itself. In case of expected difficulties, an extralevator abdominoperineal excision or referral to an expert center might be an alternative to improve resection margins.TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT05539417, retrospectively registered on September 16, 2022.

AB - BACKGROUND: In the Netherlands, approximately 15% of patients with rectal cancer undergo a low Hartmann's procedure (low-HP). This is often preoperatively planned to avoid poor functional outcome or complications, but might be unplanned as a result of intraoperative difficulties. Low-HPs seem to be associated with worse oncological outcomes.METHODS: All patients who underwent either restorative low anterior resection (rLAR), planned low-HP, or unplanned low-HP for primary rectal cancer in 2016 were included from a nationwide cohort. Main outcomes were 4-year local recurrence (LR) rate and disease-free survival (DFS).RESULTS: Of 2043 patients, 1704 underwent rLAR (83.4%), 253 planned low-HP (12.4%), and 86 unplanned low-HP (4.2%). Among intended rLAR patients (n = 1790), independent risk factors for unplanned low-HP were older age, higher body mass index (BMI), higher American Society of Anesthesiologists (ASA) score, and more distal tumor location. Oncological outcomes after low-HPs were worse than after rLARs (LR 13.7% vs 5.6%, DFS 54.7% vs 71.8%, both p < 0.001), but similar for unplanned and planned low-HP. In multivariable analysis, unplanned and planned low-HP were not associated with LR or DFS, but R1 resection was (HR 6.6 (4.1-10.6), HR 3.0 (2.2-4.0), respectively). In R1 resections, the distal margin was more often involved after low-HP (70.0% vs 28.6%, p = 0.013) compared to rLAR.CONCLUSION: Poor outcomes in univariable analysis after low-HP appear to be associated with more challenging procedures and increased risk of involved resection margin rather than the low-HP itself. In case of expected difficulties, an extralevator abdominoperineal excision or referral to an expert center might be an alternative to improve resection margins.TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT05539417, retrospectively registered on September 16, 2022.

KW - Conversion to open surgery

KW - Minimally invasive surgical procedures

KW - Rectal cancer

KW - Resection margins

UR - https://www.scopus.com/pages/publications/105023864293

U2 - 10.1007/s10151-025-03169-5

DO - 10.1007/s10151-025-03169-5

M3 - Article

C2 - 41276685

AN - SCOPUS:105023864293

SN - 1123-6337

VL - 30

JO - Techniques in coloproctology

JF - Techniques in coloproctology

IS - 1

M1 - 4

ER -

Oncological outcomes of planned and unplanned low Hartmann's procedure and restorative low anterior resection for rectal cancer: a population-based cross-sectional study

Abstract

Keywords

Access to Document

Other files and links

Fingerprint

Cite this