The integrity of colonic anastomoses following the intraperitoneal administration of oxaliplatin

Surgical management after Oxaliplatin extravasation: A case report and literature review

This case report describes a unique case of chronic reaction after extravasation of oxaliplatin. The pain and extensive subcutaneous induration did not resolve after 9 months of conservative treatment. Surgical debridement with removal of the totally implantable venous access device (TIVAD) resulted in immediate resolution of the symptoms. Oxaliplatin has both irritant and vesicant properties that are difficult to distinguish at initial clinical presentation. In most literature cases complaints resolve within 3 months with conservative treatment yet surgical debridement should be considered if complaints persist beyond this period.

Predictors of Anastomotic Failure After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Does Technique Matter?

BACKGROUND

Anastomotic failure (AF) after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) remains a dreaded complication. Whether specific factors, including anastomotic technique, are associated with AF is poorly understood.

METHODS

Patients who underwent CRS-HIPEC including at least one bowel resection between 2000 and 2017 from 12 academic institutions were reviewed to determine factors associated with AF (anastomotic leak or enteric fistula).

RESULTS

Among 1020 patients who met the inclusion criteria, the median age was 55 years, 43.9% were male, and the most common histology was appendiceal neoplasm (62.3%). The median Peritoneal Cancer Index was 14, and 93.2% of the patients underwent CC0/1 resection. Overall, 82 of the patients (8%) experienced an AF, whereas 938 (92.0%) did not. In the multivariable analysis, the factors associated with AF included male gender (odds ratio [OR], 2.2; p < 0.01), left-sided colorectal resection (OR 10.0; p = 0.03), and preoperative albumin (OR 1.8 per g/dL; p = 0.02).Technical factors such as method (stapled vs hand-sewn), timing of anastomosis, and chemotherapy regimen used were not associated with AF (all p > 0.05). Anastomotic failure was associated with longer hospital stay (23 vs 10 days; p < 0.01), higher complication rate (90% vs 59%; p < 0.01), higher reoperation rate (41% vs 9%; p < 0.01), more 30-day readmissions (59% vs 22%; p < 0.01), greater 30-day mortality (9% vs 1%; p < 0.01), and greater 90-day mortality (16% vs 8%; p = 0.02) as well as shorter median overall survival (25.6 vs 66.0 months; p < 0.01).

CONCLUSIONS

Among patients undergoing CRS-HIPEC, AF is independently associated with postoperative morbidity and worse long-term outcomes. Because patient- and tumor-related, but not technical, factors are associated with AF, operative technique may be individualized based on patient considerations and surgeon preference.

Intraoperative intraperitoneal chemotherapy increases the incidence of anastomotic leakage after anterior resection of rectal tumors

BACKGROUND

Intraoperative intraperitoneal chemotherapy is an emerging treatment modality for locally advanced rectal neoplasms. However, its impacts on postoperative complications remain unknown. Anastomotic leakage (AL) is one of the most common and serious complications associated with the anterior resection of rectal tumors. Therefore, we designed this study to determine the effects of intraoperative intraperitoneal chemotherapy on AL.

AIM

To investigate whether intraoperative intraperitoneal chemotherapy increases the incidence of AL after the anterior resection of rectal neoplasms.

METHODS

This retrospective cohort study collected information from 477 consecutive patients who underwent an anterior resection of rectal carcinoma using the double stapling technique at our institution from September 2016 to September 2017. Based on the administration of intraoperative intraperitoneal chemotherapy or not, the patients were divided into a chemotherapy group (171 cases with intraperitoneal implantation of chemotherapy agents during the operation) or a control group (306 cases without intraoperative intraperitoneal chemotherapy). Clinicopathologic features, intraoperative treatment, and postoperative complications were recorded and analyzed to determine the effects of intraoperative intraperitoneal chemotherapy on the incidence of AL. The clinical outcomes of the two groups were also compared through survival analysis.

RESULTS

The univariate analysis showed a significantly higher incidence of AL in the patients who received intraoperative intraperitoneal chemotherapy, with 13 (7.6%) cases in the chemotherapy group and 5 (1.6%) cases in the control group (P = 0.001). As for the severity of AL, the AL patients who underwent intraoperative intraperitoneal chemotherapy tended to be more severe cases, and 12 (92.3%) out of 13 AL patients in the chemotherapy group and 2 (40.0%) out of 5 AL patients in the control group required a secondary operation (P = 0.044). A multivariate analysis was subsequently performed to adjust for the confounding factors and also showed that intraoperative intraperitoneal chemotherapy increased the incidence of AL (odds ratio = 5.386; 95%CI: 1.808-16.042; P = 0.002). However, the survival analysis demonstrated that intraoperative intraperitoneal chemotherapy could also improve the disease-free survival rates for patients with locally advanced rectal cancer.

CONCLUSION

Intraoperative intraperitoneal chemotherapy can improve the prognosis of patients with locally advanced rectal carcinoma, but it also increases the risk of AL following the anterior resection of rectal neoplasms.

Effects of melatonin on colonic anastomosis healing following chemotherapy in rats

INTRODUCTION

This study aimed to investigate the effects of melatonin on the healing of colon anastomosis following chemotherapy.

METHODS

32 rats were randomised into four groups: (a) control group, which underwent sigmoid colon transection and primary anastomosis; (b) melatonin group, which received melatonin daily following anastomosis; (c) 5-fluorouracil (5-FU) group, which received 5-FU for five days prior to anastomosis; and (d) 5-FU+melatonin group, which received 5-FU for five days prior to anastomosis and melatonin daily following anastomosis. The rats were sacrificed on Postoperative Day 7 and anastomotic bursting pressures were measured. The anastomotic segment was extracted for hydroxyproline, luminol and lucigenin measurement and histopathological examination. Blood samples were obtained from the vena cava for measurement of tumour necrosis factor-alpha (TNF-α) and interleukin-1 beta (IL-1β) plasma levels.

RESULTS

Compared to the 5-FU group, bursting pressures of anastomosis and hydroxyproline levels were significantly higher, while luminol and lucigenin levels were significantly lower, in the control and 5-FU+melatonin groups. In addition, TNF-α and IL-1β plasma levels were significantly lower in the control and 5-FU+melatonin groups than in the 5-FU group. Histopathological examination showed a significant decrease in inflammation and necrosis formation in the melatonin group when compared to the control group. The positive effect of melatonin was also seen in the rats that received 5-FU.

CONCLUSION

Our study results showed that the adverse effects of chemotherapy on the mechanical, biochemical and histopathological parameters of anastomosis healing were attenuated through melatonin treatment.

The effects of hyperthermic intraperitoneal chemoperfusion on colonic anastomosis: an experimental study in a rat model

INTRODUCTION

Cytoreductive surgery (CRS) with subsequent hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising modality to treat and prevent peritoneal metastases. However, this treatment is associated with signficant morbidity and mortality. Whether or not CRS with HIPEC interferes with anastomotic healing has also been debated. This study was designed to investigate the effects of mitomycin C, cisplatin, oxaliplatin, and doxorubicin used in HIPEC treatment on colonic anastomosis healing in a rat model.

METHODS

Sixty Wistar albino rats were employed in the study. Sigmoid resection and end-to-end colorectal anastomosis was performed in all rats. Group 1 rats underwent the surgical procedure alone, while group 2 rats were given hyperthermic intraperitoneal lavage with heated saline following surgery. Groups 3, 4, 5, and 6 had surgery with concomitant HIPEC treatment with mitomycin C, cisplatin, oxaliplatin, and doxorubicin, respectively. Anastomotic bursting pressures and hydroxyproline levels were evaluated.

RESULTS

Regarding the hydroxyproline levels, groups 1 and 2 showed significantly higher values than other groups (p<0.001). However, there was no significant difference between the HIPEC treatment groups (groups 3, 4, 5, and 6) (p>0.05). When groups were compared regarding bursting pressure values, no significant differences were observed (p = 0.81).

CONCLUSIONS

This study demonstrated that the HIPEC procedure with mitomycin C, cisplatin, oxaliplatin and doxorubicin had negative effects on hydroxyproline levels, but had no detrimental effect on anastomotic bursting pressure in a rat model.

Optimal timing of intraperitoneal chemotherapy with oxaliplatin in rats after colonic anastomosis

AIM: To investigate the effect of intraperitoneal oxaliplatin administration at different times postoperatively on colonic wound healing in rats.

METHODS: Forty male Wistar rats underwent end-to-end anastomosis after colonic transection and then were randomly assigned to receive intraperitoneal administration of oxaliplatin or not as follows: group A (n = 30), 25 mg/kg oxaliplatin; control group (n = 10). The former group was sub-divided into three equal subgroups (A1-3) and oxaliplatin was intra-abdominally injected postoperatively as follows: day 3 (A1), day 5 (A2) and day 7 (A3). Abdominal adhesion, anastomotic bursting pressure and histomorphometric parameters were assessed on the postoperative day 10.

RESULTS: All the rats survived throughout the experimental period. Group A1 presented a significantly higher extent of intra-abdominal adherences than the other groups (P < 0.05). The bursting pressure was significantly lower in group A1 than in groups A2, A3 and control group (103.90 mmHg ± 7.97 mmHg vs 167.10 mmHg ± 19.84 mmHg, 178.20 mmHg ± 26.67 mmHg, 184.10 mmHg ± 23.77 mmHg; χ² = 18.64, P = 0.0001). The submucosal thickness in groups A1, A2, A3 and control group were 82.40 µm ± 9.66 µm, 91.50 µm ± 8.74 µm, 96.00 µm ± 7.85 µm and 95.40 µm ± 8.95 µm, respectively. The myenteron thickness in groups A1, A2, A3 and control group were 487.20 µm ± 26.28 µm, 539.30 µm ± 39.46 µm, 521.00 µm ± 35.35 µm and 539.60 µm ± 45.61 µm, respectively. The alterations in submucosal thickness and myenteron thickness were most pronounced in group A1, which were significantly decreased compared to the control group and groups A2 and A3 (F = 5.05, P = 0.0051; F = 4.35, P = 0.0103). There was no significant difference regarding mucosal thickness among the groups (P = 0.0623).

CONCLUSION: Intraperitoneal oxaliplatin administration is safe and feasible on postoperative day 5 after colonic resection, which may be an optimal time point for patients with colorectal carcinoma with unfavorable prognosis to accept early postoperative intraperitoneal chemotherapy.

The use of collagen content as determined by spectral domain polarization-sensitive optical coherence tomography to assess colon anastomosis healing in a rat model

BACKGROUND/PURPOSE

Many studies have been undertaken to prevent anastomosis leakage of the colon, and several methods have been used to assess anastomosis healing, such as measurement of bursting pressure or hydroxyproline (a marker of collagen) content at the anastomosis site. However, these methods are inappropriate for comparing anastomosis healing at two time points in the same animals. In the present study, we measured the collagen level by spectral domain polarization-sensitive optical coherence tomography (SD-PS-OCT) to assess anastomosis healing.

METHODS

Sprague-Dawley rats were divided into groups C (saline-administered controls; study group) and M [a 5-fluorouracil (5-FU)-administered experimental group]. Immediately after end-to-end anastomosis of the colon, SD-PS-OCT images of anastomoses were taken (baseline). Animals were administered saline or 5-FU for 7 days. On the 7th postoperative day, SD-PS-OCT images were acquired, a histopathologic exam was performed, and hydroxyproline levels as well as mRNA expressions of collagen-1 and collagen-3 were measured at the anastomosis site.

RESULTS

Fibroblast proliferation and inflammatory cell infiltration were greater in group C than in group M. The mRNA expressions of collagen-1 and collagen-3 were substantially higher in group C. Hydroxyproline levels were higher in group M than in group C. Though collagen levels measured by SD-PS-OCT at 7 days were elevated compared with baseline in group C, no such changes were observed for group M.

CONCLUSION

Collagen levels at the colon anastomosis site, measured with SD-PS-OCT, were not increased at 7 days postoperatively versus baseline when 5-FU was injected, but were increased in saline-treated controls. The measurement of collagen content by SD-PS-OCT was found to provide a good means of assessing anastomosis healing, because it allows in situ assessment of collagen contents at baseline and during the postoperative period.

Ethyl pyruvate improves healing of colonic anastomosis in a rat model of peritonitis

BACKGROUND

This study was designed to evaluate the effects of ethyl pyruvate (EP) on wound healing in primary colonic anastomoses in intraperitoneal sepsis.

METHODS

Standard left colon resection and end-to-end anastomosis were performed on 30 rats. They were grouped as control (C)--no further treatment; sepsis (S)--received 2 mL Escherichia coli (ATCC 25922) intraperitoneally (IP), and after 5 hours, standard resection and anastomosis were performed; or sepsis-group treated with EP (S-EP)--received 2 mL E coli IP, after 5 hours, standard resection and anastomosis were performed and treated with EP 50 mg/kg IP for 7 days. On the postoperative day 7, the animals were sacrificed.

RESULTS

The anastomosis bursting pressure in group S was significantly lower than in the other groups. There were no differences between groups C and S-EP. Tissue hydroxyproline concentrations in group C were significantly higher than in group S.

CONCLUSIONS

EP administration prevented intraperitoneal sepsis-induced impaired anastomotic healing of colon.

The effect of bevacizumab on colon anastomotic healing in rats

PURPOSE

The aim of the study was to investigate the effect of angiogenesis inhibition by bevacizumab, a monoclonal anti-vascular endothelial growth factor (VEGF) antibody, on the healing process of colonic anastomoses in rats, assessing some specific involved factors. This new agent is used mainly in metastatic colorectal cancer. The angiogenesis plays an important role in both wound healing and metastatic invasion and spread of malignant cells. There has not been any evidence assessing the optimal time for its safe use in operated patients.

MATERIALS AND METHODS

Forty Wistar rats were randomly allocated into four equal groups. A colonic anastomosis was performed in all rats. Half of them received intraoperatively a single dose of bevacizumab 5 mg/body weight and the rest received placebo. The animals were sacrificed on the 7th (Avastin 7th, placebo 7th) and 14th (Avastin 14th, placebo 14th) postoperative day. The anastomosis was resected and sent for histological study and for tissue biochemical assays (VEGF, endothelin-1 (ET-1), C-reactive protein (CRP), pro-oxidant-antioxidant balance (PAB), carbonylated proteins, hydroxyproline) using specific enzyme-linked immunosorbent assay kits. For statistical analysis, the Mann-Whitney U test was used (of statistical significance when P < 0.05).

RESULTS

No complication or anastomotic dehiscence was observed. Histology did not reveal statistically significant differences between groups concerning degree of inflammation, fibroblasts, collagen, and fibrosis. Likewise, hydroxyproline levels did not differ. However, some statistically significant differences were found in VEGF, CRP and carbonyl proteins (Avastin 7th vs placebo 7th, placebo 14th vs placebo 7th), ET-1, and PAB (Avastin 14th vs Avastin 7th), which did not finally affect the collagen synthesis marker hydroxyproline, nor did the anastomotic strength.

CONCLUSIONS

Bevacizumab, when administered intraoperatively, has no significant effect on colon anastomotic healing in rats despite a transient mild ischemia.