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

Anastomotic leakage after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer

BACKGROUND

Anastomotic leakage (AL) after colorectal surgery is well-researched, yet the effect of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) after Cytoreductive Surgery (CRS) is unclear. Assessment of risk factors in these patients may assist surgeons during perioperative decision making.

METHODS

This was a single-center, retrospective study of patients who underwent CRS-HIPEC for colorectal peritoneal metastases. Main outcome measures were anastomotic leakage and associated morbidity.

RESULTS

AL was observed in 17 of the 234 (7.3%) anastomoses in 17 of the total of 165 (10.3%) of patients. No association was observed between the number and location of anastomoses and AL, although only one in 87 small bowel anastomoses showed leakage. The only factor associated with AL was administration of bevacizumab within 60 days prior to surgery with an odds ratio (OR) of 6.13 (1.32-28.39), P = 0.03. Deviating stomata were not statistically protective of increased morbidity, although more AL occurred in the patients with colocolic and colorectal anastomoses when no concomitant deviating stoma was created. Deviation stomata were reversed in 52.6%, and no AL was observed after stoma reversal.

CONCLUSION

The overall AL rate of CRS-HIPEC is comparable to colorectal surgery, and there is no cumulative risk of multiple anastomoses - especially in the case of small bowel anastomoses. Deviating stomata should be considered in patients with colocolic or colorectal anastomosis, although there is a significant chance that the stoma will not be reversed in these patients. Due to increased AL-risk surgeons should be aware of previous bevacizumab treatment, and plan the CRS-HIPEC at least 60 days after the treatment-day.

Evaluating the outcomes of primary anastomosis with hand-sewn full-circular reinforcement in managing perforated left-sided colonic diverticulitis

Background

It is a challenge to avoid stoma formation in emergency surgery of perforated left-sided diverticulum. The hand-sewn full-circular reinforcement of the colorectal anastomosis is used during complete pelvic peritonectomy to avoid a diverting ileostomy. This study examined the effect of applying the reinforcement method to perforated left-sided colonic diverticulitis with respect to the permanent stoma rate and cost-effectiveness.

Materials and methods

This historical cohort study examined all patients who underwent emergency surgery for perforation of a left-sided diverticulum at the Hyogo Prefectural Amagasaki General Medical Center between July 2015 and September 2019. The cohort was divided into two groups: those who underwent conventional method (Group F) and those for whom the hand-sewn full-circular reinforcement method was actively performed (Group L).

Results

The number of patients who underwent emergency surgery which did not lead to an ostomy increased significantly from 12% (3/25) in Group F to 42% (11/26) in Group L (P = 0.0015). The rate of permanent stoma decreased from 80% in Group F to 27% in Group L (P < 0.001). Total treatment costs for patients under the age of 80 in Group L were significantly lower than those in Group F (2170000 ± 1020000 vs 3270000 ± 1960000 JPY; P = 0.018).

Conclusions

In emergency surgery for left-sided perforated colonic diverticulitis, applying the hand-sewn full-circle reinforcement of the anastomotic site may reduce stoma formation at the initial surgery and consequently decrease permanent stoma rate and contribute to cost-effectiveness without increasing complications such as anastomotic leakage.

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Primary anastomosis was used as an emergency approach to perforated diverticulitis.

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Primary anastomosis was reinforced by a hand-sewn serosal suture.

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Full-circle reinforcement of the anastomosis may decrease the permanent stoma rate.

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Full-circle reinforcement of the anastomosis may be cost effective in approach to perforated diverticulitis.

Systemic Chemotherapy for High-Grade Mucinous Appendiceal Cancer with Peritoneal Spread After Unsuccessful CRS/HIPEC

BACKGROUND

The best management of patients who have unresectable mucinous appendiceal cancer (MAC) with peritoneal spread after a failed attempt at cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is unclear. This study aimed to assess outcomes after systemic chemotherapy (SCT) for patients with unresectable peritoneal metastases from high-grade MAC.

METHODS

A single-center retrospective cohort study was conducted using a prospective CRS/HIPEC database. The study included high-grade MAC patients with peritoneal carcinomatosis who were deemed surgical candidates, but had an aborted CRS/HIPEC or only palliative HIPEC due to unresectable disease. Overall survival (OS) was compared.

RESULTS

Of 72 identified patients, 20 received SCT and 52 did not (NoCT). The groups were balanced by age (p = 0.299), sex (p = 0.930), histopathologic subtype (p = 0.096), preoperative chemotherapy (p = 0.981), and postoperative major complication rates (p = 0.338). Both groups had extensive disease (median peritoneal cancer index at exploration, 39 vs 39). The median number of cycles was 12 (interquartile range [IQR], 6-15), and the median time between the procedure and SCT was 7 weeks (IQR, 5-10 weeks). The median follow-up period was 65 months. The median OS was significantly higher for the SCT group (26 months; 95 % confidence interval [CI], 10.8-41.5 months) than for the NoCT group (12 months; 95 % CI, 9.6-14.4 months) (p < 0.001), with hazard ratio (HR) of 0.22 (95 % CI, 0.08-0.66; p = 0.007) after adjustment for other factors.

CONCLUSION

Systemic chemotherapy is associated with improved OS for high-grade MAC patients with unresectable peritoneal metastases who are deemed surgical candidates but underwent an unsuccessful CRS/HIPEC attempt. Further prospective studies with a larger sample are required to identify patient subgroups who benefit the most from SCT.

Safe Anastomoses without Ostomies in Cytoreductive Surgery with Heated Intraperitoneal Chemotherapy: Technical Considerations and Modifications

BACKGROUND

Gastrointestinal complications, predominantly anastomotic leak (AL), are the most frequent source of severe morbidity after cytoreductive surgery (CRS).

OBJECTIVE

The aim of this study was to present the technical standards for colorectal anastomoses developed and systematically applied to all patients undergoing CRS in a high-volume tertiary center, and the associated AL rates.

METHODS

This was a descriptive study reporting the technical characteristics of a standardized protocol for three types of colorectal anastomoses (colorectal, ileorectal, and ileocolic) in CRS with heated intraperitoneal chemotherapy (HIPEC), and a retrospective analysis of prospectively collected data on anastomotic outcomes. All patients (1172) undergoing CRS with HIPEC from September 2006 to September 2020 were included. The anastomotic complications were classified according to the International Study Group of Rectal Cancer Surgery (ISGRCS) classification.

RESULTS

Overall, 1172 patients underwent 1300 procedures and 1359 gastrointestinal anastomoses. An ileocolic anastomosis was performed in 408 patients, colorectal anastomosis in 469 patients, and ileorectal anastomosis in 16 patients, none with diverting ileostomy; 345 other gastrointestinal reconstructions and 82 urinary reconstructions were performed in these patients. The AL rate was 1% (4/408) for the ileocolic anastomosis, 0.85% (4/469) for the colorectal anastomosis, and 0% (0/16) for the ileorectal anastomosis. One patient died postoperatively due to AL.

CONCLUSIONS

Systematic application of standardized techniques adapted to ensure optimal tissue healing (stapled anastomoses avoiding overlap, accurate staple deployment, and hand-sewn reinforcement) are associated with a very high level of anastomotic safety in a large cohort of patients undergoing CRS and HIPEC.