Strategies to Reduce the Risk of Rectal Stump Leakage After Hartmann's Procedure: A Structured Narrative Review

Rectal stump leakage (RSL) is a clinically significant complication following Hartmann's procedure, associated with substantial morbidity, prolonged hospital stay, and challenges during subsequent reversal surgery. This study presents a structured narrative review that provides a qualitative synthesis of the available evidence on mechanisms, risk factors, and strategies to reduce the risk of RSL. Given the heterogeneity of the literature, predominantly retrospective study designs, and inconsistent definitions of stump leakage, formal quantitative synthesis was not feasible. Available evidence suggests that RSL is a multifactorial process driven by impaired tissue healing, mechanical stress, technical factors related to stump construction, and an adverse pelvic environment. Reported associations include male sex, low body mass index, short rectal stump length, and prior pelvic radiotherapy, although the strength and consistency of these relationships vary across studies. Preventive strategies, including attention to stump length and placement, optimization of tissue perfusion, and reduction of intraluminal pressure through decompression techniques, may mitigate risk, but robust comparative data remain limited. Many proposed interventions are supported primarily by observational evidence or extrapolation from anastomotic leak literature. This review emphasizes a mechanism-based, risk-informed approach to prevention while clearly distinguishing between factors supported by quantitative signals and those that remain biologically plausible but unproven. Key gaps include the absence of validated risk prediction models, the lack of prospective Hartmann-specific data, and inconsistent outcome definitions. Future research should focus on prospective cohort studies, standardized reporting frameworks, and the development of clinically applicable risk stratification tools to guide intraoperative decision-making and improve outcomes following Hartmann's procedure.