A. N. Doud1, N. Fitzgerald2, E. Levine1, P. Shen1, J. Stewart1, K. Votanopoulos1 1Wake Forest University,Department Of General Surgery, Surgical Oncology Service,Winston-Salem, NC, USA 2Wake Forest University,Division Of Public Health Sciences, Department Of Biostatistical Sciences,Winston-Salem, NC, USA
Introduction:
Stoma creation is often included as a part of Cytoreductive Surgery with Heated Intraperitoneal Chemotherapy (CRS/HIPEC). Herein, we evaluate the indications for stoma creation during CRS/HIPEC procedures as well as the morbidity and mortality associated with stoma reversal after CRS/HIPEC procedures.
Methods:
A retrospective analysis of a prospective database of 1149 CRS/HIPEC procedures was performed. Patient demographics, type of malignancy, comorbidities, Clavien-graded morbidity, mortality and overall survival were abstracted. Patients were grouped into those with and without stoma creation and documented indications for stoma creation and reversal were recorded and analyzed.
Results:
16% (186/1149) of CRS/HIPEC procedures included stoma creation, while 1.1% (11/963) of patients without stoma creation during CRS/HIPEC developed anastomotic leaks requiring reoperation with stoma formation. This resulted in 197 stomas after CRS/HIPEC, of which 37.6% (74/197) were end ileostomies, 27.9% (55/197) were loop ileostomies, 23.9% (47/197) were end colostomies and 8.6% (17/197) were loop colostomies. Patients requiring stoma at initial operation had worse preoperative performance status (ECOG 0/1: 77.2% vs 86.11%, p=0.002), worse preoperative nutrition (mean albumin 3.69 vs 3.78, p=0.03), greater burden of disease (PCI 18.57 vs. 12.90, p<0.0001) and were more likely to have R2 resections (74.19% vs 48.69%, p<0.0001) than those without stoma creation. 18.6% (36/197) of the stomas were intended to be permanent. Of the 161 patients with potentially reversible ostomies, only 26.7% (43/161) had their ostomies reversed. Patients undergoing reversal were more likely to have complete cytoreductions than those not undergoing reversal (41.9% vs 23.7%, p=0.0007). The most common reasons for failure to reverse were disease progression (43/161, 26.7%) and death (40/161, 24.8%). After reversal, 27.9% (12/43) suffered a Clavien I/II minor morbidity, 27.9% (12/43) suffered Clavien III/IV major morbidity, and 30 day mortality was 4.7% (2/43). Anastomotic leak occurred after 9% (3/33) of ileostomy and 10% (1/10) of colostomy reversals.
Conclusion:
Stoma creation during CRS/HIPEC is more common in patients with higher burden of disease, incomplete CRS and poor functional status. Less than half of the patients with complete CRS will have their stomas reversed. Stoma reversal after CRS/HIPEC has a significant risk of major morbidity that should be taken into consideration especially if postoperative systemic chemotherapy is part of the treatment strategy. Patients with high burden of disease and poor functional status should be counseled prior to CRS/HIPEC as to their increased risk of stoma creation and their low likelihood of successful reversal.