The effects of the intraperitoneal administration of oxaliplatin and 5-FU on the healing of colonic anastomoses: an experimental study

Healing of colonic anastomosis in rats under obstructive ileus conditions

BACKGROUND

The anastomosis leak in colon resections is a crucial post-operative complication with significant morbidity and mortality.  Methods: Forty (40) Wistar rats were allocated in two groups. In SHAM group only anastomosis was performed. In ILEUS group anastomosis was performed following one day of ileus. Animals in both groups were subdivided in two groups according to the day they were sacrificed, 4th or 8th post-operative day. A number of variables between the groups were estimated.

RESULTS

Body weight loss was higher following obstructive ileus on both days. Adhesion score in 4th and 8th post-operative day was higher in ILEUS1, ILEUS2 groups compared to SHAM1, SHAM2 groups respectively (p<0.001 for both). Neovascularization decreased following obstructive ileus compared to control on the 4th day (ILEUS1 vs. SHAM1, p=0.038). Bursting pressure was lower in ILEUS2 group than SHAM2 group (p<0.001). The number of fibroblasts decreased following obstructive ileus compared to control on the 4th and 8th day (ILEUS1 vs. SHAM1, p=0.001, ILEUS2 vs SHAM2, p=0.016). Hydroxyproline concentration was decreased in ILEUS2 group compared to SHAM2 group (p<0.001).

CONCLUSIONS

The balance of collagenolysis and collagenogenesis plays a decisive role in the healing of anastomoses following bowel obstruction. Under those circumstances, anastomosis' bursting pressure is reduced owning to decreased neovascularization, reduced fibroblast presence and lower hydroxyproline concertation. In our study, local inflammation, neocollagen concentration and collagenase activity were not associated with this adverse effect. However, further research should delineate the mechanisms of healing of colonic anastomoses and identify those factors that can improve our outcomes.

The Role of Hyperthermic Intraperitoneal Chemotherapy in Pseudomyxoma Peritonei After Cytoreductive Surgery

Importance

Studies on the prognostic role of hyperthermic intraperitoneal chemotherapy (HIPEC) in pseudomyxoma peritonei (PMP) are currently not available.

Objectives

To evaluate outcomes after cytoreductive surgery (CRS) and HIPEC compared with CRS alone in patients with PMP.

Design, Setting, and Participants

This cohort study analyzed data from the Peritoneal Surface Oncology Group International (PSOGI) registry, including 1924 patients with histologically confirmed PMP due to an appendiceal mucinous neoplasm. Eligible patients were treated with CRS with or without HIPEC from February 1, 1993, to December 31, 2017, and had complete information on the main prognostic factors and intraperitoneal treatments. Inverse probability treatment weights based on the propensity score for HIPEC treatment containing the main prognostic factors were applied to all models to balance comparisons between the CRS-HIPEC vs CRS-alone groups in the entire series and in the following subsets: optimal cytoreduction, suboptimal cytoreduction, high- and low-grade histologic findings, and different HIPEC drug regimens. Data were analyzed from March 1 to June 1, 2018.

Interventions

HIPEC including oxaliplatin plus combined fluorouracil-leucovorin, cisplatin plus mitomycin, mitomycin, and other oxaliplatin-based regimens.

Main Outcomes and Measures

Overall survival, severe morbidity (determined using the National Cancer Institute Common Terminology for Adverse Events, version 3.0), return to operating room, and 30- and 90-day mortality. Differences in overall survival were compared using weighted Kaplan-Meier curves, log-rank tests, and Cox proportional hazards multivariable models. A sensitivity analysis was based on the E-value from the results of the main Cox proportional hazards model. Differences in surgical outcomes were compared using weighted multivariable logistic models.

Results

Of the 1924 patients included in the analysis (997 [51.8%] men; median age, 56 [interquartile range extremes (IQRE), 45-65] years), 376 were in the CRS-alone group and 1548 in the CRS-HIPEC group. Patients with CRS alone were older (median age, 60 [IQRE, 48-70] vs 54 [IQRE, 44-63] years), had less lymph node involvement (14 [3.7%] vs 119 [7.7%]), received more preoperative systemic chemotherapy (198 [52.7%] vs 529 [34.2%]), and had higher proportions of high-grade disease (179 [47.6%] vs 492 [31.8%]) and suboptimal cytoreduction residual disease (grade 3, 175 [46.5%] vs 117 [7.6%]). HIPEC was not associated with a higher risk of worse surgical outcomes except with mitomycin, with higher odds of morbidity (1.99; 95% CI, 1.25-3.19; P = .004). HIPEC was associated with a significantly better overall survival in all subsets (adjusted hazard ratios [HRs], 0.60-0.68, with 95% CIs not crossing 1.00). The weighted 5-year overall survival was 57.8% (95% CI, 50.8%-65.7%) vs 46.2% (95% CI, 40.3%-52.8%) for CRS-HIPEC and CRS alone, respectively (weighted HR, 0.65; 95% CI, 0.50-0.83; P < .001; E-value, 2.03). Such prognostic advantage was associated with oxaliplatin plus fluorouracil-leucovorin (HR, 0.42; 95% CI, 0.19-0.93; P = .03) and cisplatin plus mitomycin (HR, 0.57; 95% CI, 0.42-0.78; P = .001) schedules.

Conclusions and Relevance

In this cohort study, HIPEC was associated with better overall survival when performed after CRS in PMP, generally without adverse effects on surgical outcomes.

A Retrospective Study of Risk Factors for Symptomatic Anastomotic Leakage after Laparoscopic Anterior Resection of the Rectal Cancer without a Diverting Stoma

Background

Anastomotic leakage (AL) is a common and devastating postoperative issue for patients who have undergone anterior resection of rectal carcinoma and can lead to increased short-term morbidity and mortality. Moreover, it might be associated with a worse oncological prognosis of tumors. This study is aimed at exploring the risk factors for symptomatic AL after laparoscopic anterior resection (LAR) for rectal tumors without a preventive diverting stoma.

Materials and Methods

This case control study retrospectively reviewed the data of 496 consecutive patients who underwent LAR of the rectum without a preventive diverting stoma at the Cancer Hospital, Chinese Academy of Medical Sciences between September 2016 and September 2017. All patients were divided into an AL group and a control group based on the occurrence of postoperative symptomatic AL. Factors regarding patient-related variables, operation-related variables, and tumor-related variables were collected and assessed between the two groups through univariate and multivariate logistic regression analyses to identify independent risk factors for AL.

Results

In total, 18 (3.6%) patients developed postoperative symptomatic AL. Univariate analysis showed that a synchronous primary malignancy of the left hemicolon (P = 0.047), intraoperative chemotherapy (P = 0.003), and level of anastomosis (P = 0.033) were significantly related with AL. Multivariate analysis was subsequently performed to adjust for confounding biases and confirmed that a synchronous primary malignancy of the left hemicolon (odds ratio (OR), 12.225; 95% confidence interval (CI), 1.764-84.702; P = 0.011), intraoperative chemotherapy (OR, 3.931; 95% CI, 1.334-11.583; P = 0.013), and level of anastomosis (OR, 3.224; 95% CI, 1.124-9.249; P = 0.030) were independent risk factors for symptomatic AL for patients who received LAR for rectal neoplasms without a preventive diverting stoma.

Conclusions

Synchronous primary malignancy of the left hemicolon, intraoperative chemotherapy, and a low anastomotic level can increase the risks of postoperative symptomatic AL after LAR of the rectum without a protective diverting stoma.

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 albumin/glutaraldehyde glue on healing of colonic anastomosis in rats

AIM

To evaluate the effect of local surgical adhesive glue (albumin/glutaraldehyde-Bioglue) on the healing of colonic anastomoses in rats.

METHODS

Forty Albino-Wistar male rats were randomly divided into two groups, with two subgroups of ten animals each. In the control group, an end-to-end colonic anastomosis was performed after segmental resection. In the Bioglue group, the anastomosis was protected with extraluminar application of adhesive glue containing albumin and glutaraldehyde. Half of the rats were sacrificed on the fourth and the rest on the eighth postoperative day. Anastomoses were resected and macroscopically examined. Bursting pressures were calculated and histological features were graded. Other parameters of healing, such as hydroxyproline and collagenase concentrations, were evaluated. The experimental data were summarized and computed from the results of a one-way ANOVA. Fisher’s exact test was applied to compare percentages.

RESULTS

Bursting pressures, adhesion formation, inflammatory cell infiltration, and collagen deposition were significantly higher on the fourth postoperative day in the albumin/glutaraldehyde group than in the control group. Furthermore, albumin/glutaraldehyde significantly increased adhesion formation, inflammatory cell infiltration, neoangiogenesis, and collagen deposition on the eighth postoperative day. There was no difference in fibroblast activity or hydroxyproline and collagenase concentrations.

CONCLUSION

Albumin/glutaraldehyde, when applied on colonic anastomoses, promotes their healing in rats. Therefore, the application of protective local agents in colonic anastomoses leads to better outcomes.

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.

Impact of electrocautery and hyperthermic intraperitoneal chemotherapy on intestinal microvasculature in a murine model

BACKGROUND

Electrocautery (EC) is used during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Using a murine model, we studied the effect of HIPEC on small bowel EC lesions and surrounding normal tissues.

METHODS

Thirty-two rats were divided into five groups: a control group with EC lesions; EC plus intraperitoneal heated 5% dextrose (D5W); EC plus oxaliplatin (OXA, 460 mg/m(2)); EC plus mitomycin C 10 mg/m(2) (MMC10); EC plus MMC 35 mg/m(2) (MMC35). EC lesions and surrounding tissue microvasculature were analysed after intravenous injection of fluorescein.

RESULTS

In the ileum OXA significantly reduced EC lesions microvasculature compared with the control group; MMC10 caused greater reduction than the control, D5W and MMC35 groups. Surrounding tissue microvasculature was significantly reduced by MMC35 exposure when compared to the control, OXA or MMC10 groups. In the jejunum EC injuries exposed to OXA or MMC10 had significantly reduced microvasculature compared to the control, heated D5W and MMC35 groups. Surrounding tissue microvasculature was significantly reduced by MMC35 exposure when compared to the OXA group. There was no significant microvasculature difference between the EC lesions made before or after HIPEC.

CONCLUSION

HIPEC with OXA and MMC10 potentiates small bowel wall EC injuries. MMC35 reduces surrounding unharmed tissue microvasculature. There was no effect of hyperthermia alone on microvasculature.

Effects of TachoSil and 5-fluorouracil on colonic anastomotic healing

BACKGROUND

The administration of intraperitoneal (IP) 5-fluorouracil (5-FU) during the early postoperative period after cytoreductive surgery can decrease local cancer recurrence but may also cause impairment of the anastomotic healing. This study examined the effects of the use of this therapy and of the anastomotic sealing with TachoSil, a fibrin-thrombin coated sealant (FTCS), on the healing of colon anastomoses.

MATERIALS AND METHODS

Forty male rats were divided into four groups (1-4, 10 rats each) that underwent transection and anastomosis of the left colon. The anastomoses were covered with FTCS in groups 2 and 4. Saline solution (2 mL/d-groups 1 and 2) or 5-FU (20 mg/kg/d; groups 3 and 4) was administered IP once daily for 3 d. Bursting pressure (BP) was recorded, and the anastomoses were examined macroscopically and graded histologically.

RESULTS

The relative weight loss was significantly higher in group 3 than in the other groups (P = 0.0004). Anastomotic dehiscence, postoperative adhesion formation, perianastomotic collections, and preanastomotic dilatation did not differ significantly among groups. BP was significantly lower in group 3 compared with all other groups (P = 0.001). Neoangiogenesis was significantly lower in group 3 compared with groups 1 and 2 (P = 0.05). Fibroblastic activity was significantly higher in group 1 compared with group 3 (P = 0.035). Inflammatory cell infiltration and collagen deposition did not differ significantly among groups.

CONCLUSIONS

Our results shown that the early postoperative IP chemotherapy with 5-FU impaired the healing of colon anastomoses. However, anastomotic sealing with FTCS reversed some of the negative effects of this therapy.