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Is Fecal Diversion Needed in Pelvic Anastomoses During Hyperthermic Intraperitoneal Chemotherapy (HIPEC)?
Matthew D Whealon1, John V Gahagan1, Sarath Sujatha-Bhaskar1
1Department of Surgery, University of California Irvine, Orange, CA, USA.
Insights
Fecal diversion with a diverting ileostomy significantly reduces anastomotic leaks in patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). While reversal may require laparotomy, it is associated with a reduced leak rate.
Area of Science:
- Surgical Oncology
- Gastroenterology
- Oncologic Surgery
Background:
- The role of fecal diversion in pelvic anastomosis during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) remains unclear.
- Defining optimal surgical strategies for CRS and HIPEC is crucial for patient outcomes.
Purpose of the Study:
- To evaluate the impact of fecal diversion, specifically a diverting ileostomy, on anastomotic leak rates in patients undergoing CRS and HIPEC with pelvic anastomosis.
- To assess the outcomes and complications associated with ileostomy reversal in this patient cohort.
Main Methods:
- A retrospective review was conducted on 73 patients who underwent CRS and HIPEC between 2009 and 2016.
- Patients with a pelvic anastomosis were categorized into groups with and without a diverting ileostomy.
- Anastomotic leak rates, 90-day mortality, hospital stay, and complication rates were analyzed.
Main Results:
- The anastomotic leak rate was significantly lower in the diverting ileostomy group (0%) compared to the no-diversion group (22%) (p < 0.01).
- The 90-day mortality rate was 7.1% in the no-diversion group.
- Ileostomy reversal was performed in 68% of patients, with 18% requiring laparotomy and experiencing a 50% complication rate.
Conclusions:
- Diverting ileostomies are associated with a significantly reduced anastomotic leak rate in patients undergoing CRS and HIPEC with pelvic anastomosis.
- While ileostomy reversal can necessitate laparotomy and carries morbidity, the protective effect against anastomotic leaks is substantial.
Background:
The role of fecal diversion with pelvic anastomosis during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is not well defined.
Methods:
A retrospective review of patients who underwent CRS and HIPEC between 2009 and 2016 was performed to identify those with a pelvic anastomosis (colorectal, ileorectal, or coloanal anastomosis).
Results:
The study identified 73 patients who underwent CRS and HIPEC at three different institutions between July 2009 and June of 2016. Of these patients, 32 (44%) underwent a primary anastomosis with a diverting ileostomy, whereas 41 (56%) underwent a primary anastomosis without fecal diversion. The anastomotic leak rate for the no-diversion group was 22% compared with 0% for the group with a diverting ileostomy (p < 0.01). The 90-day mortality rate for the no-diversion group was 7.1%. The hospital stay was 14.1 ± 8.0 days in the diversion group compared with 17.9 ± 12.5 days in the no-diversion group (p = 0.12). Of those patients with a diverting ileostomy, 68% (n = 22) had their bowel continuity restored, 18% of which required a laparotomy for reversal. Postoperative complications occurred for 50% of those who required a laparotomy and for 44% of those who did not require a laparotomy (p = 0.84).
Conclusion:
Diverting ileostomies in patients with a pelvic anastomosis undergoing CRS and HIPEC are associated with a significantly reduced anastomotic leak rate. Reversal of the diverting ileostomy in this patient population required a laparotomy in 18% of the cases and had an associated morbidity rate of 50%.