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Lago V, Albert MM, Cruz MA, Guijarro Campillo RA, Padilla-Iserte P, Matute L, Gurrea M, Flor B, Domingo S. A restrictive stoma policy after colorectal anastomosis in ovarian cancer based on ghost ileostomy use. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108325. [PMID: 38636248 DOI: 10.1016/j.ejso.2024.108325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/31/2024] [Accepted: 04/06/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The incidence of anastomotic leak after colorectal anastomosis in ovarian cancer has been reported to be much lower than that in colorectal cancer patients. Regarding the use of protective manoeuvres (diverting ileostomy) as suggested by clinical guidelines, the goal should be the implementation of a restrictive stoma policy for ovarian cancer patients, given the low rate of anastomotic leakage in this population. MATERIAL AND METHODS Patients who underwent cytoreduction surgery in a single centre (University Hospital La Fe, Valencia Spain) due to ovarian cancer between January 2010 and June 2023 were classified according to two groups: a non-restrictive stoma policy group (Group A) and a restrictive stoma policy group (Group B). RESULTS A total of 256 patients were included in the analysis (group A 52 % vs group B 48 %). The use of protective diverting ileostomy was lower in the restrictive stoma policy group (14 % vs 6.6 %), and the use of ghost ileostomy was 32 % vs 87 % in groups A and B, respectively (p < 0.00001). No differences were found in the anastomotic leak rate, which was 5.2 % in the non-restrictive group and 3.2 % in the restrictive stoma policy group (p = 0.54). CONCLUSION The use of a restrictive stoma policy based on the use of ghost ileostomy reduces the rate of diverting ileostomy in patients with ovarian cancer after colorectal resection and anastomosis. Furthermore, this policy is not associated with an increased rate of anastomotic leakage nor with an increased rate of morbi-mortality related to the leak.
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Affiliation(s)
- Víctor Lago
- Gynecologic Oncology Unit, University Hospital La Fe, Valencia, Spain; CEU Cardenal Herrera University, Valencia, Spain.
| | | | - Marta Arnaez Cruz
- Gynecologic Oncology Unit, University Hospital La Fe, Valencia, Spain
| | | | | | - Luis Matute
- Gynecologic Oncology Unit, University Hospital La Fe, Valencia, Spain
| | - Marta Gurrea
- Gynecologic Oncology Unit, University Hospital La Fe, Valencia, Spain
| | - Blas Flor
- Colorectal Surgery Unit, University Hospital La Fe, Valencia, Spain
| | - Santiago Domingo
- Gynecologic Oncology Unit, University Hospital La Fe, Valencia, Spain
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Navarro Santana B, Garcia-Torralba E, Viveros-Carreño D, Rodriguez J, Pareja R, Martin A, Forte S, Krause KJ, González-Martín JM, Ramirez PT. Complications of HIPEC for ovarian cancer surgery: evaluation over two time periods. Int J Gynecol Cancer 2023:ijgc-2023-004658. [PMID: 37669829 DOI: 10.1136/ijgc-2023-004658] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVE Cytoreductive surgery in conjunction with hyperthermic intraperitoneal chemotherapy (HIPEC) is being explored in the upfront, interval, and recurrent setting in patients with ovarian cancer. The objective of this systematic review was to assess the rate of complications associated with HIPEC in epithelial ovarian cancer surgery over two time periods. METHODS This study was registered in PROSPERO (CRD42022328928). A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Ovid/Medline, Ovid/Embase, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials were searched from January 2004 to April 2022. We included studies reporting on patients with advanced primary or recurrent epithelial ovarian cancer who underwent cytoreductive surgery and HIPEC. We evaluated two different time periods: 2004-2013 and 2014-2022. A random-effects meta-analysis was used to produce an overall summary. Subgroup analyses were planned according to recruited period for each specific complication type. Heterogeneity was assessed using the I2 statistic. RESULTS A total of 4928 patients were included from 69 studies for this systematic review; 19 published from 2004-2013, and 50 published from 2014-2022. No significant differences were found between the two time periods in terms of blood transfusions (33% vs 51%; p=0.46; I2=95%) overall gastrointestinal complications (15% vs 21%; p=0.36; I2=98%), infectious diseases (16% vs 13%; p=0.62; I2=93%), overall respiratory complications (12% vs 12%; p=0.88; I2=91%), overall urinary complications (6% vs 12%; p=0.06; I2=94%), or thromboembolic events (5% vs 3%; p=0.25; I2=63%). Also, no differences were found in intensive care unit (ICU) admissions (89% vs 28%; p=0.06; I2=99%), reoperations (8% vs 7%; p=0.50; I2=37%), or deaths (3% vs 3%; p=0.77; I2=57%). CONCLUSIONS Our review showed that overall complications have not changed over time for patients undergoing HIPEC in the setting of primary or recurrent ovarian cancer. There was no decrease in the rates of ICU admissions, reoperations, or deaths.
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Affiliation(s)
| | | | - David Viveros-Carreño
- Gynecologic Oncology, Instituto Nacional de Cancerologia, Bogota, Colombia
- Gynecologic Oncology, Clínica Universitaria Colombia and Centro de Tratamiento e Investigación sobre Cáncer Luis Carlos Sarmiento Angulo-CTIC, Bogotá, Colombia
| | | | - Rene Pareja
- Gynecologic Oncology, Instituto Nacional de Cancerologia, Bogota, Colombia
| | - Alicia Martin
- Insular University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Canarias, Spain
| | - Sara Forte
- Azienda USL Toscana centro, Prato, Italy
| | - Kate J Krause
- The University of Texas MD Anderson Cancer Center Research Medical Library, Houston, Texas, USA
| | - J M González-Martín
- Insular University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Canarias, Spain
| | - Pedro T Ramirez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas, USA
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Kofoed NG, Falconer H, Vanky H, Johansson H, Abraham-Nordling M, Salehi S. Survival and chance of reversal after intestinal stoma formation during cytoreductive surgery for advanced ovarian cancer; a population-based cohort study. Gynecol Oncol 2023; 170:259-265. [PMID: 36738484 DOI: 10.1016/j.ygyno.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Our objective was to examine oncologic outcome in women with advanced epithelial ovarian cancer (aEOC) receiving an intestinal stoma (IS) at the time of cytoreductive surgery (CRS), probability of stoma reversal (SR) and variables affecting odds of SR. METHODS This population-based cohort study included all women diagnosed with aEOC between 2009 and 2018 in the Stockholm/Gotland Region of Sweden. The association between IS formation at CRS and survival was analyzed with proportional hazards regression yielding hazard ratios (HR) with 95% confidence intervals (CI), adjusted for predefined confounders. Cumulative incidence functions, with death or recurrence as competing risk, were used to estimate chance of SR. The association between clinical factors and SR was analyzed with logistic regression yielding odds ratios (OR) with 95% CI. RESULTS The final analysis included 888 women undergoing CRS for aEOC. Of these, 129 (14,5%) received an IS of which 74% (n = 95) were defunctioning and 26% (n = 34) permanent. IS was associated with an increased hazard of death (HR 1.30, CI 95%, 1.05-1.61; p = 0.02) in the univariate analysis, however not in the adjusted analysis. The probability of SR of defunctioning IS within 2 years was 48% (95% CI, 38-58). Median time to SR was 10 months. High surgical complexity score (SCS) was associated with increased odds of reversal (OR 3.43, 95% CI, 1.06-11.05; p = 0.04). CONCLUSIONS IS formation does not seem to affect prognosis in women with aEOC. We could not identify any factor, known at time of CRS, that may predict the odds of SR except a high SCS.
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Affiliation(s)
- Nina Groes Kofoed
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Department of Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden.
| | - Henrik Falconer
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Department of Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Hanna Vanky
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Department of Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Hemming Johansson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Mirna Abraham-Nordling
- Department of Molecular medicine and Surgery Karolinska Institutet and Department of Pelvic Cancer, Theme Cancer Karolinska University Hospital, Stockholm, Sweden
| | - Sahar Salehi
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Department of Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden; Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Sweden
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Fornasiero M, Geropoulos G, Kechagias KS, Psarras K, Katsikas Triantafyllidis K, Giannos P, Koimtzis G, Petrou NA, Lucocq J, Kontovounisios C, Giannis D. Anastomotic Leak in Ovarian Cancer Cytoreduction Surgery: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14215464. [PMID: 36358882 PMCID: PMC9653973 DOI: 10.3390/cancers14215464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/10/2022] Open
Abstract
Simple Summary Bowel resection is often required to obtain complete removal of ovarian cancer. A major complication of this operation is anastomotic leakage, which has been shown to increase morbidity and mortality in this population. Numerous original research studies have assessed the risk factors for anastomotic leaks. We aimed to conduct a systematic review and meta-analysis to identify statistically significant risk factors. This meta-analysis identified multiple bowel resections as the only significant risk factor. With further research to identify additional risk factors, new management guidelines could be implemented to minimize the risk of anastomotic leaks and improve patient outcomes. Abstract Introduction: Anastomotic leaks (AL) following ovarian cytoreduction surgery could be detrimental, leading to significant delays in commencing adjuvant chemotherapy, prolonged hospital stays and increased morbidity. The aim of this study was to investigate risk factors associated with anastomotic leaks after ovarian cytoreduction surgery. Material and methods: The MEDLINE (via PubMed), Cochrane Library, EMBASE and Scopus bibliographical databases were searched. Original clinical studies investigating risk factors for AL in ovarian cytoreduction surgery were included. Results: Eighteen studies with non-overlapping populations reporting on patients undergoing cytoreduction surgery for ovarian cancer (n = 4622, including 344 cases complicated by AL) were included in our analysis. Patients undergoing ovarian cytoreduction surgery complicated by AL had a significantly higher rate of 30-day mortality but no difference in 60-day mortality. Multiple bowel resections were associated with an increased risk of postoperative AL, while no association was observed with body mass index (BMI), American Society of Anesthesiologists (ASA) score, age, smoking, operative approach (primary versus interval cytoreductive, stapled versus hand-sewn anastomoses and formation of diverting stoma), neoadjuvant chemotherapy and use of hyperthermic intraperitoneal chemotherapy (HIPEC). Discussion: Multiple bowel resections were the only clinical risk factor associated with increased risk for AL after bowel surgery in the ovarian cancer population. The increased 30-day mortality rate in patients undergoing ovarian cytoreduction complicated by AL highlights the need to minimize the number of bowel resections in this population. Further studies are required to clarify any association between neoadjuvant chemotherapy and decreased AL rates.
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Affiliation(s)
| | - Georgios Geropoulos
- 2nd Propaedeutic Department of Surgery, Aristotle University School of Medicine, Hippokration General Hospital, 546 42 Thessaloniki, Greece
- Department of General and Upper GI Surgery, Victoria Hospital Kirkcaldy, Kirkcaldy KY2 5AH, UK
- Correspondence:
| | - Konstantinos S. Kechagias
- Society of Meta-Research and Biomedical Innovation, London W12 0FD, UK
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
| | - Kyriakos Psarras
- 2nd Propaedeutic Department of Surgery, Aristotle University School of Medicine, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | | | - Panagiotis Giannos
- Society of Meta-Research and Biomedical Innovation, London W12 0FD, UK
- Department of Life Sciences, Faculty of Natural Sciences, Imperial College London, London SW7 2AZ, UK
| | | | - Nikoletta A. Petrou
- Department of General Surgery, The Royal Marsden Hospital, London SW3 6JJ, UK
| | - James Lucocq
- Department of Hepaticopancreaticobiliary Surgery, University of Edinburgh, Edinburgh EH8 9YL, UK
| | | | - Dimitrios Giannis
- Department of Surgery, North Shore University Hospital/Long Island Jewish Medical Center, Northwell Health, Manhasset, NY 11030, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
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Lago V, Segarra-Vidal B, Cappucio S, Angeles MA, Fotopoulou C, Muallem MZ, Manzanedo I, Iglesias JLS, Chacón E, Padilla-Iserte P, Fagotti A, Ferron G, Kluge L, Vargiu V, Del M, Scambia G, Minig L, Tejerizo Á, Segovia MG, Cascales-Campos PA, Hervás D, Domingo S. OVA-LEAK: Prognostic score for colo-rectal anastomotic leakage in patients undergoing ovarian cancer surgery. Gynecol Oncol 2022; 167:22-27. [PMID: 36058743 DOI: 10.1016/j.ygyno.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/31/2022] [Accepted: 08/07/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of the present study was to define and validate an anastomotic leak prognostic score based on previously described and reported anastomotic leak risk factors (OVA-LEAK: https://n9.cl/ova-leakscore) and to establish if the use of OVA-LEAK score is better than clinical criteria (surgeon's choice) selecting anastomosis to be protected with a diverting ileostomy. MATERIAL & METHODS This is a retrospective, multicentre cohort study that included patients who underwent cytoreductive surgery for primary advanced or relapsed ovarian cancer with colorectal resection and anastomosis between January 2011 and June 2021. Data from patients already included in the previous predictive model were not considered in the present analysis. To validate the performance of our logistic regression model, we used the OVA-LEAK formula (Annex I: https://n9.cl/ova-leakscore) for estimating leakage probabilities in a new independent cohort. Then, receiver operating characteristic (ROC) analysis was performed and area under the curve (AUC) was used to measure the performance of the model. Additionally, the Brier score was also estimated. 95% confidence intervals (CI) for each of the estimated performance measures were also calculated. RESULTS 848 out of 1159 recruited patients were finally included in the multivariable logistic regression model validation. The AUC of the new cohort was 0.63 for predicting anastomotic leak. Considering a cut-off point of 22.1% to be 'positive' (to get a leak) this would provide a sensitivity of 0.45, specificity of 0.80, positive predictive value of 0.09 and negative predictive value of 0.97 for anastomotic leak. If we consider this cut-off point to select patients at risk of leak for bowel diversion, up to 22.5% of the sampled patients would undergo a diverting ileostomy and 47% (18/40) of the anastomotic leaks would be 'protected' with the stoma. Nevertheless, if we consider only the 'clinical criteria' for performing or not a diverting ileostomy, only 12.5% (5/40) of the leaks would be 'protected' with a stoma, with a rate of diverting ileostomy of up to 24.3%. CONCLUSIONS Compared with subjective clinical criteria, the use of a predictive model for anastomotic leak improves the selection of patients who would benefit from a diverting ileostomy without increasing the rate of stoma use.
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Affiliation(s)
- Víctor Lago
- Department of Gynecologic Oncology Department, University Hospital La Fe, Valencia, Spain; CEU Cardenal Herrera, Spain.
| | - Blanca Segarra-Vidal
- Department of Gynecologic Oncology Department, University Hospital La Fe, Valencia, Spain
| | - Serena Cappucio
- Fondazione Policlinico Universitario A. Gemelli, IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Martina Aida Angeles
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Christina Fotopoulou
- Department of Gynecologic Oncology, Imperial College London, London, United Kingdom
| | - Mustafa Zelal Muallem
- Department of Gynecology with Centre for Oncological Surgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Virchow Campus Clinic, Charité Medical University, Berlin, Germany
| | - Israel Manzanedo
- Department of General and Digestive Surgery, Peritoneal Carcinomatosis Unit, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | - Enrique Chacón
- Department of Obstetrics and Gynecology, University Clinic of Navarra, Madrid, Navarre, Spain
| | - Pablo Padilla-Iserte
- Department of Gynecologic Oncology Department, University Hospital La Fe, Valencia, Spain
| | - Anna Fagotti
- Fondazione Policlinico Universitario A. Gemelli, IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gwenael Ferron
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Luisa Kluge
- Department of Gynecology with Centre for Oncological Surgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Virchow Campus Clinic, Charité Medical University, Berlin, Germany
| | - Virginia Vargiu
- Fondazione Policlinico Universitario A. Gemelli, IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mathilde Del
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli, IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lucas Minig
- Department of Gynecology, IMED Hospitales, Valencia, Spain
| | - Álvaro Tejerizo
- Department of Obstetrics and Gynecology, Hospital 12 de Octubre, Madrid, Spain
| | | | | | | | - David Hervás
- Department of Applied Statistics and Operational Research and Quality, Universitat Politècnica de València, Valencia, Spain
| | - Santiago Domingo
- Department of Gynecologic Oncology Department, University Hospital La Fe, Valencia, Spain
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