Douglas peritonectomy compared to recto-sigmoid resection in optimally cytoreduced advanced ovarian cancer patients: Analysis of morbidity and oncological outcome
Introduction
Advanced ovarian cancer (AOC) commonly spreads along the peritoneal surfaces in the abdomen and often involves the serosa of the rectosigmoid colon by direct extension or implantation. In most cases, tumors can twist pelvic anatomy and the cul de sac can be completely involved by carcinomatosis implants. Maximal cytoreductive surgery to remove all visible areas of cancerous lesions followed by taxol-platinum combination chemotherapy is the current standard treatment in AOC. In fact, post-operative residual tumor (RT) and chemosensitivity remain the only proved prognostic factors of such disease.1, 2, 3
Two different surgical approaches have been described to remove tumor from the pelvis: pelvic peritonectomy (PP), if only the peritoneum of the Douglas pouch is involved, or rectosigmoid resection (RR), in the case of bowel wall infiltration. Some published data support an association between improved survival and optimal residual disease status in patients undergoing bowel resection during ovarian cancer cytoreduction.4, 5, 6, 7, 8, 9, 10, 11 Nevertheless, the collective bowel-related morbidity from these studies, although acceptable, is certainly not inconsequential, ranging from 2% to 30.5%.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 Moreover, some studies have suggested that other factors related to “innate tumor biology” may influence prognosis and consequently the use of bowel resection and aggressive surgery would not improve survival.33, 34, 35, 36
In the present study we report our experience with these two different surgical approaches (RR and PP) in optimally cytoreduced AOC patients, in order to identify a recommended surgical procedure to remove tumor from the pelvis with respect to: 1) oncological outcomes, in terms of incidence of pelvic recurrence, disease-free survival (DFS) and overall survival (OS); 2) morbidity and the rate of short-term complications. In addition, histopathological prognostic factors influencing surgical and clinical outcome have been investigated.
Section snippets
Methods
All women with a diagnosis of primary epithelial AOC referred to the Division of Gynaecological Oncology of the Catholic University of Rome and Campobasso between January 2004 and December 2009, were identified. An Institutional Review Board approval was obtained for the study.
Surgical and clinical records were reviewed retrospectively for demographic and clinical data, surgical-pathological characteristics, type of surgery (primary cytoreduction (PC) or interval debulking surgery (IDS) after
Results
During the study period, we identified 187 advanced AOC patients, fitting the inclusion criteria: 71 (38%) were submitted to RR and 116 (62%) were managed with PP. Complete clinico-pathological characteristics of these patients are shown in Table 1. 129 women (69%) were submitted to PC and 58 (31%) to IDS.
Colonoscopy was performed in 40 (21.4%) cases, and showed rectal mucosa infiltration in four patients.
Surgical procedures for debulking included: 182 (97.3%) hysterectomies ± bilateral
Discussion
RR with primary anastomosis or PP are often part of an optimal en bloc tumor resection12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 in AOC patients with contiguous extension to or encasement of the reproductive organs, peritoneum of the cul-de-sac and sigmoid colon. However, percentages of RR in the literature range widely from 16 to 58% of AOC patients,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 and whether RR is
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Neo-adjuvant chemotherapy does not reduce surgical complexity nor the accuracy of intra-operative visual assessment of disease in advanced ovarian cancer
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Risk factors of major intraoperative blood loss at primary debulking surgery for ovarian cancer
2022, Gynecology and Obstetrics Clinical MedicineCitation Excerpt :In their study, the degree of surgical complexity was related to the severity of postoperative complications and the degree of postoperative hemoglobin decline. Since surgical complexity is a crucial independent risk factor for MBL, in order to prepare an appropriate amount of blood, it is very important to assess the extent of resection before surgery, such as bowel resection, hepatectomy, splenectomy, and upper abdominal lymph node resection.21,22 The most important prognostic factor at PDS is complete gross resection.
Risks factors for anastomotic leakage in advanced ovarian cancer: A systematic review and meta-analysis
2022, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :Thirty-one studies were retrospective [1,8–12,14,17,23–40,42,43,46,47], one was a case-control study [16] and four were prospective study [5,41,44,45]. Twenty-nine studies were single-centre [1,5,10–12,14,16,17,24–27,29–42,44,45,47] while six were multi-centre studies [8,9,23,28,43,46]. Hartmann’s procedure is listed only in the table and not reported into the count [10,24,30,41].
En-bloc resection of the pelvis (EnBRP) in patients with stage IIIC–IV ovarian cancer: A 10 steps standardised technique. Surgical and survival outcomes of primary vs. interval surgery
2017, Gynecologic OncologyCitation Excerpt :Mainly because these patients usually have significant ascites, nutritional compromise or even early bowel obstruction, a trend towards bowel diversion was predominant. However more recent studies have demonstrated low anastomotic breakdown rates (0–8%) for patients who had recto-sigmoid resection and primary anastomosis [17–21, 24–35] This data therefore supports the contention that protective intestinal diversion is unwarranted in the majority of patients [35]. Two recent studies [36–37] suggested a therapeutic benefit to EnBRP with recto-sigmoid colectomy, when performing primary cytoreductive surgery for patients with advanced ovarian cancer.