Elsevier

Gynecologic Oncology

Volume 99, Issue 3, December 2005, Pages 608-614
Gynecologic Oncology

Morbidity of rectosigmoid resection and primary anastomosis in patients undergoing primary cytoreductive surgery for advanced epithelial ovarian cancer

https://doi.org/10.1016/j.ygyno.2005.07.112Get rights and content

Abstract

Objectives.

Studies from the colorectal literature have shown that factors associated with anastomotic leak after colorectal resection include long surgical time (>2 h), multiple blood transfusions, and short distance to the anal verge. The aim of this study was to assess the morbidity associated with en bloc resection of ovarian carcinoma with low anterior resection and anastomosis in patients undergoing primary cytoreductive surgery for advanced disease.

Methods.

We performed a retrospective chart review of all patients who had undergone primary cytoreduction for advanced epithelial ovarian cancer with rectosigmoid resection followed by low rectal anastomosis between January 1994 and June 2004. Patient characteristics, operative details, and postoperative complications were extracted from patients' charts.

Results.

Seventy patients met the above criteria and form our study group. The median age was 59 years (range, 25–82). There were 52 stage IIIC (74%) and 18 stage IV (26%) cancers. The median operating time was 315 min (range, 120–750) and the median estimated blood loss was 1200 ml (range, 250–8000), with 53 (76%) patients requiring blood transfusion. Twenty-eight patients (40%) underwent major upper abdominal procedures other than omentectomy, and 14 patients (20%) underwent a second bowel resection. Twelve patients (17%) underwent a protective ileostomy while the remainder (83%) did not. Of the 58 patients with no ostomy, the only complications associated with the resection and anastomoses were a pelvic abscess in 3 patients (5%) and an anastomotic leak requiring diverting colostomy in 1 patient (1.7%). Of the 12 patients who had protective ileostomies, 3 (25%) had complications related to their ileostomy short-bowel syndrome requiring early reversal, incarceration of the prolapsed loop requiring surgical correction, and prolapse corrected electively at the time of second-look surgery.

Conclusions.

In women undergoing primary cytoreductive surgery, the morbidity associated with en bloc resection of ovarian carcinoma with low rectosigmoid resection and anastomosis without protective ileostomy was acceptably low, with an anastomotic leak rate of less than 2%. Protective ileostomy is not always necessary and should be used selectively.

Introduction

Optimal cytoreduction is one of the most powerful predictors of disease-free and overall survival in women with advanced-stage epithelial ovarian cancer [1]. Extensive metastatic disease to the neighboring pelvic viscera often results in the need for rectosigmoid resection to achieve optimal cytoreduction. The technique of en bloc resection of pelvic tumor, adjacent rectosigmoid, and pelvic peritoneum with primary anastomosis has been described, with acceptable associated morbidity [2], [3], [4], [5].

Disruption of the anastomosis leading to clinical anastomotic leak is one of the most feared complications after colonic resection. Anastomotic leak is associated with considerable morbidity, including impaired long-term functional outcome [6], and increased mortality [7], [8], [9]. Several studies from the colorectal literature have found that prolonged operating time and blood-product transfusion were important factors associated with anastomotic leak [10], [11]. However, others have suggested that ileostomies should be reserved for those with low anastomoses [10], [12].

We have previously reported that with the incorporation of extensive upper abdominal surgical procedures, optimal cytoreduction rates can be significantly increased [13]. However, the increase in optimal cytoreduction rates was also associated with a significant increase in operating time, intraoperative estimated blood loss (EBL), and the use of blood-product transfusion. Therefore, the objective of this study was to assess the morbidity and mortality associated with low anterior resection (LAR) and primary anastomosis performed for primary cytoreduction in a patient population with extended operating times and significant EBL.

Section snippets

Methods

Our prospectively collected Gynecology Service Database was used to identify all patients with stages IIIC and IV epithelial ovarian cancer who underwent an LAR and primary anastomosis as part of primary cytoreductive surgery between January 1994 and June 2004. Exclusion criteria included the use of neoadjuvant chemotherapy, primary cytoreduction at another institution, the use of an end colostomy at the time of LAR, tumors of low malignant potential, and LAR performed for recurrent disease.

The

Results

Seventy patients that met our inclusion criteria were identified; these patients formed our study cohort. The median age was 59 years (range, 25–82) and the majority of the patients had stage IIIC disease with poorly differentiated tumors of papillary serous histology. Patient and tumor characteristics are presented in Table 2.

Sixty-eight (97%) of the 70 patients underwent preoperative bowel preparation. One of the patients who did not undergo a bowel preparation had a large bowel obstruction;

Discussion

The rectosigmoid is a frequent site of involvement by epithelial ovarian cancer, usually occurring by direct tumor extension and often resulting in obliteration of the cul-de-sac. Gynecologic oncologists frequently perform resection of the rectosigmoid with primary anastomosis as part of an en bloc tumor resection in patients with epithelial ovarian cancer. This results in high rates of optimal cytoreduction with acceptable morbidity [2], [3], [4], [5]. Our series shows LAR to be an effective

Acknowledgments

This work was funded by the Albritton Foundation and the Roy M. Speer Foundation.

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