Total colectomy as part of primary cytoreductive surgery in advanced Müllerian cancer. Gynecol Oncol. 2009;114:183-187. [PMID: 19427682 DOI: 10.1016/j.ygyno.2009.04.009]

Protective ostomies in ovarian cancer surgery: a systematic review and meta-analysis

OBJECTIVE

To assess the benefit of protective ostomies on anastomotic leak rate, urgent re-operations, and mortality due to anastomotic leak complications in ovarian cancer surgery.

METHODS

A systematic literature search was performed in MEDLINE, Web of Science, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials for all studies on anastomotic leak and ostomy formation related to ovarian cancer surgery. Non-controlled studies, case series, abstracts, case reports, study protocols, and letters to the editor were excluded. Meta-analysis was performed on the primary endpoint of anastomotic leak rate. Subgroup analysis was carried out based on type of bowel resection and bevacizumab use. Secondary endpoints were urgent re-operations and mortality associated with anastomotic leak, length of hospital stay, postoperative complications, 30-day readmission rate, adjuvant chemotherapy, survival, and reversal surgery in ostomy and non-ostomy patients.

RESULTS

A total of 17 studies (2,719 patients) were included: 16 retrospective cohort studies, and 1 case-control study. Meta-analysis of 17 studies did not show a decrease in anastomotic leak rate in ostomy patients (odds ratio [OR]=1.01; 95% confidence interval [CI]=0.60-1.70; p=0.980). Meta-analysis of ten studies (1,452 women) did not find a decrease in urgent re-operations in the ostomy group (OR=0.72; 95% CI=0.35-1.46; p=0.360). Other outcomes were not considered for meta-analysis due to the lack of data in included studies.

CONCLUSION

Protective ostomies did not decrease anastomotic leak rates, and urgent re-operations in ovarian cancer surgery. This evidence supports the use of ostomies in very select cases.

Total Colectomy as a Part of Ultra-Radical Surgery for Ovarian Cancer-Short- and Long-Term Outcomes

(1) Background: The aim of this study was to assess the outcomes for patients who underwent total colectomy (TC) as a part of surgery for ovarian cancer (OC). (2) Methods: We performed a retrospective analysis of 1636 OC patients. Residual disease (RD) was reported using Sugarbaker’s completeness of cytoreduction score. (3) Results: Forty-two patients underwent TC during primary debulking surgery (PDS), and four and ten patients underwent TC during the interval debulking surgery (IDS) and secondary cytoreduction, respectively. The median overall survival (mOS) in OC patients following the PDS was 45.1 months in those with CC-0 (21%) resection, 11.1 months in those with CC-1 (45%) resection and 20.0 months in those with CC-2 (33%) resection (p = 0.28). Severe adverse events were reported in 18 patients (43%). In the IDS group, two patients survived more than 2 years after IDS and one patient died after 28.6 months. In the recurrent OC group, the mOS was 6.9 months. Patient age above 65 years was associated with a shortened overall survival (OS) and the presence of adverse events. (4) Conclusions: TC as a part of ultra-radical surgery for advanced OC results in high rates of optimal debulking. However, survival benefits were observed only in patients with no macroscopic disease.

Retroileal colorectal anastomosis after left-sided or transverse colectomy for advanced serous carcinoma of the ovary or uterus

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In advanced or recurrent ovarian and uterine cancer, the ability to achieve optimal cytoreduction is a prognostic factor.

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Colonic resections are commonly required to achieve minimal or no residual disease.

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The retroileal technique can be used to achieve complete gross resection in cytoreductive surgery for gynecologic malignancy.

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Lack of postoperative complications and acceptable time interval to return of bowel function suggest this technique is safe.

The ability to achieve complete or optimal cytoreduction in advanced or recurrent ovarian and uterine cancer is a well-established prognostic factor. Colonic resections are commonly required to achieve minimal or no residual disease. When multiple colonic resections are required there is a corresponding difficulty in obtaining sufficient colonic mobility to create tension-free anastomoses for restoration of gastrointestinal continuity; specifically, when a left hemicolectomy or a transverse colectomy is required in addition to a rectosigmoid resection, it may be difficult to achieve a tension-free colorectal anastomosis. We describe the use of retroileal routing of the colon to address this scenario in the context of gynecologic cancer debulking surgery. We report four cases in which the surgeon encountered limited colonic mobility after performing either a left hemicolectomy or a transverse colonic resection in addition to a rectosigmoid resection. In using a retroileal path to perform the colorectal anastomosis, we were able to achieve well-perfused and tension-free anastomoses. Complete gross resection was achieved in all four cases, with acceptable rates of perioperative complications.

Subtotal Colectomy as Part of Debulking Surgery for Advanced-stage Ovarian Cancer

BACKGROUND/AIM

The presence of extensive lesions of peritoneal carcinomatosis is found in a significant number of cases of extended digestive resection surgery, such as subtotal colectomy. The aim of this study was to report a series of 17 cases that necessitated performing subtotal colectomy as part of cytoreductive surgery for advanced-stage ovarian cancer.

PATIENTS AND METHODS

Between 2012 and 2020 subtotal colectomy was associated as part of the debulking effort in 17 cases.

RESULTS

The median age at the time of surgery was 59 years, while the initial stage at the time of diagnosis was IIIC in 14 cases, and respectively IV in three cases. Optimal debulking surgery was achieved in all cases. The continuity of the digestive tract was reestablished in 11 cases, while in the remaining 6 cases a terminal ileostomy was performed.

CONCLUSION

Extended digestive tract resections may be needed in certain cases in order to maximize the debulking effort in patients with advanced-stage ovarian cancer.

Perioperative outcomes of extensive bowel resection during cytoreductive surgery in patients with advanced ovarian cancer

BACKGROUND AND OBJECTIVES

To achieve optimal cytoreduction, extensive bowel resections are sometimes required in patients with advanced ovarian cancer. Few studies have focused on the extent or number of resections of bowel surgeries and their feasibility.

METHODS

We retrospectively reviewed the medical records of patients with advanced ovarian cancer who underwent bowel surgery as part of debulking procedures at Ajou University Hospital from 2006 to 2018. Patients who received extensive bowel resections (two-segment resections or subtotal colectomy) were identified, and their perioperative outcomes were evaluated.

RESULTS

A total of 172 patients underwent bowel surgery. Of them, 128 (74.4%) underwent one-segment bowel resection, 25 (14.5%) underwent two-segment bowel resections, and 19 (11.1%) underwent subtotal colectomy. Although the operative time, transfusion rate, and postoperative bleeding events were higher in patients who underwent extensive bowel resection, the rates of perioperative complications were not significantly higher in this group. Anastomotic leakage occurred in two (1.5%) patients in the one-segment resection group, one (4.2%) patient in the multiple resection group, and two (10.5%) patients in the subtotal colectomy group.

CONCLUSIONS

Multiple bowel resections (up to two segments) are feasible and can be safely performed with an acceptable complication rate in patients with advanced ovarian cancer.

Radical surgery in ovarian cancer

While there is an ongoing debate regarding the timing of the maximal surgical effort in epithelial ovarian cancer, it is well established that patients with suboptimal tumor debulking derive no benefit from the surgical procedure. The amount of residual disease after cytoreductive surgery has been repeatedly identified as a strong predictor of survival, and accordingly, the surgical effort to achieve the goal of complete gross tumor resection has been constantly evolving. Centers that have adopted the concept of radical surgery in patients with advanced ovarian cancer have reported improvements in their patients' survival. In addition to the expected improvements in the pharmacologic treatment of this disease, some of the next challenges in the surgical management of ovarian cancer include the preoperative prediction of suboptimal debulking, improving the drug delivery to the tumor, and increasing access to centers of excellence in ovarian cancer regardless of geographical, financial, or other social barriers. This review will discuss an update on the role of surgery in the treatment of primary epithelial ovarian cancer as it has evolved since the emergence of the concept of surgical cytoreduction.

Benefit of negative pressure drain within surgical wound after cytoreductive surgery for ovarian cancer

OBJECTIVE

The objective of this study was to investigate the efficacy of subcutaneous negative-pressure wound drains on wound healing after cytoreductive surgery for ovarian cancer.

METHODS

A retrospective study was performed on patients who underwent cytoreductive surgery for epithelial ovarian cancer, between 2012 and 2013. The patients were divided into 2 groups, according to using (n = 163) and not using (n = 37) of subcutaneous wound drains, and wound outcomes were analyzed.

RESULTS

Patients' characteristics were not statistically different, except for the prolonged operative time in patients with wound drains (median, 395 vs 240 minutes; P = 0.001). A lower rate of wound infection (12.9% vs 27.0%; P = 0.032) was observed in the drain group. In the multivariate analysis, placement of subcutaneous wound drain was an independent prognostic factor for reducing wound complications: disruption (odds ratio [OR], 0.367; 95% confidence interval [CI], 0.145-0.929; P = 0.034) and wound infection (OR, 0.198; 95% CI, 0.068-0.582; P = 0.003). Bowel surgery at the time of cytoreductive surgery and prolonged operative time (≥360 minutes) were also associated with higher rates of disruption (OR, 2.845; 95% CI, 1.111-7.289; P = 0.029) and wound infection (OR, 4.212; 95% CI, 1.273-13.935; P = 0.019), respectively.

CONCLUSIONS

Installation of subcutaneous negative-pressure wound drain is an effective method to achieve clearer wound healing and less wound complications after cytoreductive surgery for ovarian cancer.

Quality of life and sexuality comparison between sexually active ovarian cancer survivors and healthy women

Objective

compare quality of life (QoL) and sexual functioning between sexually active ovarian cancer survivors and healthy women.

Methods

A cross-sectional study was performed in 103 successfully treated ovarian cancer survivors and 220 healthy women. All women had engaged in sexual activity within the previous 3 months, and ovarian cancer survivors were under surveillance after primary treatment without evidence of disease. QoL and sexual functioning were assessed using three questionnaires; the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), Ovarian Cancer Module (EORTC QLQ-OV28), and the Female Sexual Function Index (FSFI). Propensity score matching was used to adjust covariates between the ovarian cancer survivor and healthy women groups. In total, 73 ovarian cancer survivors and 73 healthy women were compared.

Results

Poorer social functioning (mean, 82.4 vs. 90.9; p=0.010) and more financial difficulties (mean, 16.4 vs. 7.8; p=0.019) were observed among ovarian cancer survivors than among healthy women. Sexuality, both in terms of desire, arousal, lubrication, orgasm, satisfaction, and pain and in terms of interest in sex, sexual activity, and enjoyment of sex (EORTC QLQ-OV28) were similar between the groups. However, vaginal dryness was more problematic in ovarian cancer survivors, with borderline statistical significance (p=0.081).

Conclusion

Sexuality was not impaired in ovarian cancer survivors who were without evidence of disease after primary treatment and having sexual activities, compared with healthy women, whereas social functioning and financial status did deteriorate. Prospective cohort studies are needed.

Cytoreductive surgery in primary advanced epithelial ovarian cancer

Epithelial ovarian cancer is one of the most common malignancy and one of the principal causes of death among gynaecological neoplasm. The majority of patients (about 70%) present with an advanced International Federation of Gynaecology and Obstetrics stage disease. The current standard treatment for these patients consists of complete cytoreduction and combined systemic chemotherapy (CT). An increasing proportion of patients undergoing complete cytoreduction to no gross residual disease (RD) is associated with progressively longer overall survival. As a counterpart, some authors hypothesized the improving in survival could be due more to a less diffused initial disease than to an increase in surgical cytoreduction rate. Moreover the biology of the tumor plays an important role in survival benefit of surgery. It’s still undefined how the intrinsic features of the tumor make intra-abdominal implants easier to remove. Adjuvant and hyperthermic intraperitoneal CT could play a decisive role in the coming years as the completeness of macroscopic disease removal increases with advances in surgical techniques and technology. The introduction of neo-adjuvant CT moreover will play a decisive role in the next years Anyway cytoreduction with no macroscopic residual of disease should always be attempted. However the definition of RD is not universal. A unique and definitive definition is needed.

Advanced ovarian cancer: omental bursa, lesser omentum, celiac, portal and triad nodes spread as cause of inaccurate evaluation of residual tumor

OBJECTIVE

We evaluated the role of omental bursa (OB), surface of the pancreas, lesser omentum, caudate lobe, celiac nodes (CNs), portal nodes and triad nodes spread in advanced ovarian cancer (AOC). We investigated if the exploration and cleaning up of these areas can lead to a more complete cytoreduction and to a more realistic assessment of residual tumor in AOC.

METHODS

We prospectively recruited patients diagnosed with AOC, who underwent a complete cytoreduction. Demographics, surgical procedures, morbidities, pathologic findings and correlations with OB spread were assessed.

RESULTS

A total of 37 patients had an optimal debulking including OB evaluation and peritonectomy. The OB area procedure required in mean 65 min with an estimated blood loss of 250 ml. OB involvement was found in 67% (25/37) of cases. Peritoneal disease was found in 22 cases including 18 supragastric lesser sac and 4 porta hepatis peritoneum. CNs metastases were found in 5 cases, of which 3 cases are with bulky nodes, all presented also bulky nodes in the para-aortic area. Only in the case of a macroscopic involvement of the diaphragm OB was positive for disease. When adhesions occluding the Winslow foramen were present, no OB peritoneum involvement was found. OB resection related complications were low (2 out 25).

CONCLUSIONS

The data of this prospective study demonstrate the high rate of OB, surface of the pancreas, lesser omentum, caudate lobe, CNs, portal and triad nodes involvement and the value of investigating the dissemination and cytoreduction in these sites to obtain a real optimal debulking.

Intraoperative image-guided surgery for ovarian cancer

Approximately two thirds of the ovarian cancer is diagnosed at late stage with peritoneal seeding. The most important prognostic factor is the residual tumor size after surgery. The better survival outcome from minimizing tumor has been established well from several institutional reports, clinical trials for chemotherapy, and meta-analyses. The current standard treatment for such advanced ovarian cancer is to resect all visible and palpable ovarian cancer as much as possible and postoperative chemotherapy. But, even after complete resection of all visible and palpable tumors, a significant percentage of the patients have recurrence usually in the peritoneal cavity in advanced ovarian cancer. Recurrence likely stems from microscopic residual tumor not resected at time of the initial surgery. Currently, advanced technology for intraoperative tumor detection has been reported. Although the current clinical outcome is at an early stage definitively, clinical benefit could be expected from the future in-depth basic research and clinical trials in this area. If all residual microscopic disease, especially chemotherapy-resistant cancer cells, could be removed or treated using new technology, groundbreaking advance for treating ovarian cancer will be realized.

Surgical management of epithelial ovarian cancer

Ovarian cancer affects approximately 21,880 women and accounts for over 13,000 deaths annually in the United States. Although survival rates have improved over the past several decades, directly as a result of advances in chemotherapy and surgery, ovarian cancer continues to have high mortality rates. Understanding the multiple roles of surgery throughout the disease course is the focus of this review.

Evolution of surgical treatment paradigms for advanced-stage ovarian cancer: redefining 'optimal' residual disease

Over the past 40 years, the survival of patients with advanced ovarian cancer has greatly improved due to the introduction of combination chemotherapy with platinum and paclitaxel as standard front-line treatment and the progressive incorporation of increasing degrees of maximal cytoreductive surgery. The designation of "optimal" surgical cytoreduction has evolved from residual disease ≤ 1 cm to no gross residual disease. There is a growing body of evidence that patients with no gross residual disease have better survival than those with optimal but visible residual disease. In order to achieve this, more radical cytoreductive procedures such as radical pelvic resection and extensive upper abdominal procedures are increasingly performed. However, some investigators still suggest that tumor biology is a major determinant in survival and that optimal surgery cannot fully compensate for tumor biology. The aim of this review is to outline the theoretical rationale and historical evolution of primary cytoreductive surgery, to re-evaluate the preferred surgical objective and procedures commonly required to achieve optimal cytoreduction in the platinum/taxane era based on contemporary evidence, and to redefine the concept of "optimal" residual disease within the context of future surgical developments and analysis of treatment outcomes.

Extended cytoreduction of tumor at the porta hepatis by an interdisciplinary team approach in patients with epithelial ovarian cancer

OBJECTIVE

The objective of this study was to describe the development and experience in resection of tumor at the porta hepatis in patients with ovarian cancer by an interdisciplinary team approach.

METHODS

From August 2007 to June 2009, 11 women (2 primary and 9 recurrent ovarian cancers) underwent extended cytoreductive surgery including resection of tumor at the porta hepatis by hepatobiliary surgeons.

RESULTS

Tumor resection at the porta hepatis was required in 7.1% of the patients (11/155) during the study period. The median tumor size of the porta hepatis was 2.0cm (range, 0.7-4cm). All visible tumors at the porta hepatis were completely resected with co-operation of hepatobiliary surgeons. Optimal cytoreduction was achieved in all patients. There was no significant morbidity related to tumor resection of the porta hepatis and mortality associated with surgery. Five of 11 patients had recurrent disease at median 8months (range, 1-13) after the surgery with a median follow-up of 8months (range, 3-21months).

CONCLUSION

Tumor resection at the porta hepatis is feasible with acceptable morbidities in patients with ovarian cancer by an interdisciplinary team approach with hepatobiliary surgeons. Long term follow up is needed to know the impact on survival.

Region-based diagnostic performance of multidetector CT for detecting peritoneal seeding in ovarian cancer patients

PURPOSE

To determine the accuracy of multi-detector CT (MDCT) compared with the surgical findings, such as peritoneal seeding and metastatic lymph nodes, in ovarian cancer patients.

METHODS

Fifty-seven FIGO stage IA-IV ovarian cancer patients, who underwent MDCT before primary surgery, were included in this study. Two radiologists evaluated the following imaging findings in consensus: the presence of nodular, plaque-like or infiltrative soft-tissue lesions in peritoneal fat or on the serosal surface; presence of ascites; parietal peritoneal thickening or enhancement; and small bowel wall thickening or distortion. We also evaluated the presence of lymph node metastases. To allow region-specific comparisons, the peritoneal cavity was divided into 13 regions and retroperitoneal lymph nodes were divided into 3 regions. Descriptive statistical data were thus obtained.

RESULTS

The MDCT sensitivity, specificity, positive predictive values, and negative predictive values were 45, 72, 46, and 72%, respectively, for detecting peritoneal seeding and 21, 90, 52, and 69%, respectively, for detecting lymph node metastasis.

CONCLUSIONS

MDCT is moderately accurate for detecting peritoneal metastasis and lymph node metastasis in ovarian cancer patients.