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Pelvic Anastomosis Without Protective Ileostomy is Safe in Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

  • Peritoneal Surface Malignancy
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

During cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), surgeons are reluctant to perform unprotected pelvic anastomosis despite lack of supporting data. We analyzed pelvic anastomosis outcomes and factors that influence ostomy creation in CRS/HIPEC patients.

Methods

A single-center, descriptive study of patients with rectal resection during CRS/HIPEC was conducted using a prospective database. Surgical variables were reviewed. Multinomial logistic regression of outcomes (end or protective ostomy) was performed with pre- and intraoperative factors as predictors.

Results

Overall, 274 of 789 CRS/HIPEC patients underwent rectal resection, including 243 (89%) with pelvic anastomosis [232 (85%) without ostomy, 11 (4%) with protective ileostomy] and 31 (11%) with no anastomosis [16 (6%) with end colostomy, 15 (5%) with end ileostomy]. The median age was 57 and 29% (79) were male. Of 243 pelvic anastomosis patients, 3 (1.2%) had rectal anastomotic leaks, including 1 with a protective ileostomy. Other anastomotic leaks occurred in 3.6%. Overall, 13% had Clavien-Dindo complications ≥ IIIB and the readmission rate was 30%. Mortality at 30 days and 100 days was 0.4% and 2.2%, respectively. Male gender and primary rectal cancer were associated with protective ileostomy [odds ratio (OR) = 7.01, 95% CI: 1.6–31.5, p = 0.011, and OR = 16.4, 95% CI: 3–88.4, p = 0.001, respectively). Male gender and prior pelvic surgery were associated with end colostomy (OR = 13.9, 95% CI: 3.7–53, p < 0.0001, and OR = 17.2, 95% CI: 3.8–78.6, p < 0.0001).

Conclusions

Pelvic bowel reconstruction without protective or end ostomy during CRS/HIPEC is safe. Protective ileostomy is associated with male gender and primary rectal cancer. End colostomy is associated with male gender and prior pelvic surgery.

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References

  1. Brandl A, Raue W, Aigner F, Arroyave MC, Pratschke J, Rau B. Safety of extraperitoneal rectal resection and ileo- or colorectal anastomosis without loop ileostomy in patients with peritoneal metastases treated with CRS and HIPEC. Colorectal Dis. 2018;20:O61–7.

    Google Scholar 

  2. von Breitenbuch P, Piso P, Schlitt HJ. Safety of rectum anastomosis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Surg Oncol. 2018;118(3):551–6.

    Google Scholar 

  3. Pakraftar S, Ramalingam L, Shuai Y, et al. Institutional experience with ostomies created during cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion. Ann Surg Oncol. 2017;24(13):3811–7.

    PubMed  Google Scholar 

  4. Whealon MD, Gahagan JV, Sujatha-Bhaskar S, et al. Is fecal diversion needed in pelvic anastomoses during hyperthermic intraperitoneal chemotherapy (HIPEC)? Ann Surg Oncol. 2017;24(8):2122–8.

    PubMed  Google Scholar 

  5. Stiles ZE, Hinkle NM, Munene G, Dickson PV, Davidoff AM, Deneve JL. The impact of ostomy creation after cytoreduction and hyperthermic intraperitoneal chemotherapy in a newly established peritoneal malignancy program. Am Surg. 2018;84(6):776–82.

    PubMed  Google Scholar 

  6. Carlsson E, Berndtsson I, Hallen AM, Lindholm E, Persson E. Concerns and quality of life before surgery and during the recovery period in patients with rectal cancer and an ostomy. J Wound Ostomy Cont Nurs. 2010;37(6):654–61.

    Google Scholar 

  7. Mitchell KSJ, Delfont S, Bracey ML, Endacott R. Top ten concerns burdening people with cancer: perceptions of patients with cancer and the nurses caring for them. Eur J Oncol Nurs. 2018;33:102–6.

    PubMed  Google Scholar 

  8. Montedori A, Cirocchi R, Farinella E, Sciannameo F, Abraha I. Covering ileo- or colostomy in anterior resection for rectal carcinoma. Cochrane Database Syst Rev. 2010(5):CD006878.

    Google Scholar 

  9. Vonk-Klaassen SM, de Vocht HM, den Ouden ME, Eddes EH, Schuurmans MJ. Ostomy-related problems and their impact on quality of life of colorectal cancer ostomates: a systematic review. Qual Life Res. 2016;25(1):125–33.

    PubMed  Google Scholar 

  10. Herrle F, Sandra-Petrescu F, Weiss C, Post S, Runkel N, Kienle P. Quality of life and timing of stoma closure in patients with rectal cancer undergoing low anterior resection with diverting stoma: a multicenter longitudinal observational study. Dis Colon Rectum. 2016;59(4):81–290.

    PubMed  Google Scholar 

  11. Leong AP, Londono-Schimmer EE, Phillips RK. Life-table analysis of stomal complications following ileostomy. Br J Surg. 1994;81(5):727–9.

    CAS  PubMed  Google Scholar 

  12. Londono-Schimmer EE, Leong AP, Phillips RK. Life table analysis of stomal complications following colostomy. Dis Colon Rectum. 1994;37(9):916–20.

    CAS  PubMed  Google Scholar 

  13. Shabbir J, Britton DC. Stoma complications: a literature overview. Colorectal Dis. 2010;12(10):958–64.

    CAS  PubMed  Google Scholar 

  14. Mrak K, Uranitsch S, Pedross F, et al. Diverting ileostomy versus no diversion after low anterior resection for rectal cancer: a prospective, randomized, multicenter trial. Surgery. 2016;159(4):1129–39.

    PubMed  Google Scholar 

  15. Wong NY, Eu KW. A defunctioning ileostomy does not prevent clinical anastomotic leak after a low anterior resection: a prospective, comparative study. Dis Colon Rectum. 2005;48(11):2076–9.

    CAS  PubMed  Google Scholar 

  16. Paul BK, Ihemelandu C, Sugarbaker PH. Prior surgical score: an analysis of the prognostic significance of an initial nondefinitive surgical intervention in patients with peritoneal carcinomatosis of a colorectal origin undergoing cytoreductive surgery and perioperative intraperitoneal chemotherapy. Dis Colon Rectum. 2018;61(3):347–54.

    PubMed  Google Scholar 

  17. Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. Cancer Treat Res. 1996;82:359–74.

    CAS  PubMed  Google Scholar 

  18. Sugarbaker PH. New standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome? Lancet Oncol. 2006;7(1):69–76.

    PubMed  Google Scholar 

  19. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.

    PubMed  PubMed Central  Google Scholar 

  20. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017;161(3):584–91.

    PubMed  Google Scholar 

  21. Rahbari NN, Weitz J, Hohenberger W, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of rectal cancer. Surgery. 2010;147(3):339–51.

    PubMed  Google Scholar 

  22. Alyami M, Kim BJ, Villeneuve L, et al. Ninety-day post-operative morbidity and mortality using the National Cancer Institute’s common terminology criteria for adverse events better describe post-operative outcome after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Int J Hyperth. 2018;34(5):532–7.

    Google Scholar 

  23. Shankar S, Ledakis P, El Halabi H, Gushchin V, Sardi A. Neoplasms of the appendix: current treatment guidelines. Hematol Oncol Clin North Am. 2012;26(6):1261–90.

    PubMed  Google Scholar 

  24. Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007;246(2):207–14.

    PubMed  PubMed Central  Google Scholar 

  25. Huser N, Michalski CW, Erkan M, et al. Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg. 2008;248(1):52–60.

    PubMed  Google Scholar 

  26. Jung SH, Yu CS, Choi PW, et al. Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum. 2008;51(6):902–8.

    PubMed  Google Scholar 

  27. Vignali A, Fazio VW, Lavery IC, et al. Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients. J Am Coll Surg. 1997;185(2):105–13.

    CAS  PubMed  Google Scholar 

  28. Sugarbaker PH. Avoiding diverting ileostomy in patients requiring complete pelvic peritonectomy. Ann Surg Oncol. 2016;23(5):1481–5.

    PubMed  Google Scholar 

  29. Miller K, Moritz E. Circular stapling techniques for low anterior resection of rectal carcinoma. Hepatogastroenterology. 1996;43(10):823–31.

    CAS  PubMed  Google Scholar 

  30. Allen W, Wells CI, Greenslade M, Bissett IP, O’Grady G. Association between circular stapler diameter and stricture rates following gastrointestinal anastomosis: systematic review and meta-analysis. World J Surg. 2018;42(10):3097–105.

    CAS  PubMed  Google Scholar 

  31. Shimada S, Matsuda M, Uno K, Matsuzaki H, Murakami S, Ogawa M. A new device for the treatment of coloproctostomic stricture after double stapling anastomoses. Ann Surg. 1996;224(5):603–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  32. Shimada S, Yagi Y, Yamamoto K, Matsuda M, Baba H. Novel treatment of intractable rectal strictures associated with anastomotic leakage using a stenosis-cutting device. Int Surg. 2007;92(2):82–8.

    PubMed  Google Scholar 

  33. Offodile AC, 2nd, Feingold DL, Nasar A, Whelan RL, Arnell TD. High incidence of technical errors involving the EEA circular stapler: a single institution experience. J Am Coll Surg. 2010;210(3):331–5.

    PubMed  Google Scholar 

  34. Wiggins T, Markar SR, Arya S, Hanna GB. Anastomotic reinforcement with omentoplasty following gastrointestinal anastomosis: a systematic review and meta-analysis. Surg Oncol. 2015;24(3):181–6.

    CAS  PubMed  Google Scholar 

  35. Senagore A, Lane FR, Lee E, et al. Bioabsorbable staple line reinforcement in restorative proctectomy and anterior resection: a randomized study. Dis Colon Rectum. 2014;57(3):324–30.

    PubMed  Google Scholar 

  36. Placer C, Enriquez-Navascues JM, Elorza G, et al. Preventing complications in colorectal anastomosis: results of a randomized controlled trial using bioabsorbable staple line reinforcement for circular stapler. Dis Colon Rectum. 2014;57(10):1195–201.

    PubMed  Google Scholar 

  37. Araujo SE, Seid VE, Kim NJ, Bertoncini AB, Nahas SC, Cecconello I. Assessing the extent of colon lengthening due to splenic flexure mobilization techniques: a cadaver study. Arq Gastroenterol. 2012;49(3):219–22.

    PubMed  Google Scholar 

  38. Brennan DJ, Moynagh M, Brannigan AE, Gleeson F, Rowland M, O’Connell PR. Routine mobilization of the splenic flexure is not necessary during anterior resection for rectal cancer. Dis Colon Rectum. 2007;50(3):302–7. (discussion 307).

    CAS  PubMed  Google Scholar 

  39. Nowakowski M, Malczak P, Mizera M, et al. The safety of selective use of splenic flexure mobilization in sigmoid and rectal resections-systematic review and meta-analysis. J Clin Med. 2018;7(11):392.

    PubMed Central  Google Scholar 

  40. Parthasarathy M, Greensmith M, Bowers D, Groot-Wassink T. Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17 518 patients. Colorectal Dis. 2017;19(3):288–98.

    CAS  PubMed  Google Scholar 

  41. Gachabayov M, Bergamaschi R, Boni L, Uranues S, Fingerhut A. Splenic flexure mobilization in sigmoid and rectal resections: a systematic review and meta-analysis of observational studies. Surg Technol Int. 2019;34:169–82.

    PubMed  Google Scholar 

  42. Frasson M, Flor-Lorente B, Rodriguez JL, et al. Risk factors for anastomotic leak after colon resection for cancer: multivariate analysis and nomogram from a multicentric, prospective, national study with 3193 patients. Ann Surg. 2015;262(2):321–30.

    PubMed  Google Scholar 

  43. Nikolian VC, Kamdar NS, Regenbogen SE, et al. Anastomotic leak after colorectal resection: a population-based study of risk factors and hospital variation. Surgery. 2017;161(6):1619–27.

    PubMed  Google Scholar 

  44. Midura EF, Hanseman D, Davis BR, et al. Risk factors and consequences of anastomotic leak after colectomy: a national analysis. Dis Colon Rectum. 2015;58(3):333–8.

    PubMed  Google Scholar 

  45. Qin Q, Ma T, Deng Y, et al. Impact of preoperative radiotherapy on anastomotic leakage and stenosis after rectal cancer resection: post hoc analysis of a randomized controlled trial. Dis Colon Rectum. 2016;59(10):934–42.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care at Mercy, Baltimore, MD, USA

    Ekaterina Baron MD, Vadim Gushchin MD, FACS, Mary Caitlin King BS, Andrei Nikiforchin MD & Armando Sardi MD, FACS

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  1. Ekaterina Baron MD
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  2. Vadim Gushchin MD, FACS
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Correspondence to Armando Sardi MD, FACS.

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Baron, E., Gushchin, V., King, M.C. et al. Pelvic Anastomosis Without Protective Ileostomy is Safe in Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 27, 4931–4940 (2020). https://doi.org/10.1245/s10434-020-08479-6

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  • DOI: https://doi.org/10.1245/s10434-020-08479-6

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