IS IT SAFE TO PERFORM A NON-DERIVED ANASTOMOSIS IN MALIGNANT COLONIC OBSTRUCTION WITH PERITONEAL CARCINOMATOSIS

Mseddi Mohamed Ali | Frikha Mohamed Taieb | Zahaf Bechir | Abdelmalek Mokhtar | Sassi Karim | Ben Slima Mohamed |

La tunisie chirurgicale - 2022 ; Vol 2022

Resumé

Anastomotic loosening is a potentially lethal complication. In the setting of a peritoneal carcinomatosis (PC), this unfortunate event may jeopardize the carcinological prognosis due to delayed palliative chemotherapy. Thus, this raises the question of safety of digestive anastomosis in the situation of intestinal obstruction with PC. Through this clinical case and literature review, we are hoping to provide guidance to assist clinician’s decision making when facing with an occlusive colonic tumor with PC.

Mots Clés

peritoneal carcinomatosis

Introduction :

Case-report:

A 44-year-old hypertensive woman was referred to us for management of a moderately differentiated adenocarcinoma of the colon with a double location in the sigmoidal and hepatic flexure resulting in iterative sub-occlusive syndromes. On examination, she was light-colored but with a compensated hemodynamic state, there were no features of extracellular dehydration. Abdominal examination revealed no abnormalities apart from a melena stained finger. On biology she presented an anemia of 7.6 g/dL. She had a correct nutritional status. She was operated on after a short pre-operative optimization with transfusion of erythrocyte units compatible with a controlled hemoglobinemia of 10.1 g/dL. She was approached by a generous midline incision. Exploration showed scattered peritoneal implants in all quadrants with two colonic indurations of the sigmoid loop and the hepatic flexure not invading the adjacent planes. She had a total colectomy with mechanical ileorectal end-to-end anastomosis. On fourth postoperative day, she reported diarrhea with asthenia, a biological control showed a hypokalemia at 2.1 mmol/L. After correction of the ion disturbances and in view of the recovery of her overall condition, she was discharged at D05 postoperatively (PO). On D12 PO, she reconsulted our casualty for abdominal pain and shivering. On examination, the operative dressing was wet and the pressure of the wound edges brought a stream of fecal matter. The biology showed a biological inflammatory syndrome with 19000 white blood cells (WBC)/mm3 and C-reactive protein (CRP) at 210 mg/L. The abdominal scan with contrast enema showed a large hydroaeric collection of 19cm occupying the pelvis fed by an anastomotic breach, certified by an extradigestive contrast leak. Echo-guided drainage and antibiotic therapy were started. The drainage brought back 800cc on the first day. On the following days the drainage flow decreased and the patient's fever flared up again. Biology showed anemia at 8.2 g/dL, hypokaliemia at 2.4mmol/L, CRP=190mg/L and 9000 WBC/mm3. She was re-operated on D15 PO. Access to the abdominal cavity was risky in front of an abdomen riddled with rugged adhesions and the digestive tract bathed in a feco-purulent liquid. The decision was to suspend any digestive procedure and to leave tubulated drains that would be used for irrigation and aspiration. The drainage system brought back 3000cc per day. The patient succumbed on day 11 of the revision operation.

Article

Discussion:

The obstructive event implies a poor outcome and suggests a disease that cannot be resected. This is more accurate in the case of a finding of a wide spread and high-volume peritoneal disease especially with extensive involvement of small bowel and small bowel mesentery, more than one bowel stenosis/obstructions, which are suggestive of aggressive biologic behavior [1].Even when 30 % to 40 % of patients with inoperable malignant bowel obstruction (MBO) achieve spontaneous resolution of the obstructive episode [2], we shouldn't hold out high hopes on spontaneous resolution considering it might occurs within 7 days for only one third of patients, and relapse of obstructive symptoms occurs in roughly 72%[3]. The question of intervention thus becomes unavoidable; this is the purpose of our work to assist the clinician in resolving this therapeutic issue.

How does surgery fit in therapeutic armamentarium of malignant bowel obstruction?

A recent literature review, dating back to 2016, covering 122 articles and totaling 548 patients, resection has the best outcomes in terms of relief of obstructive symptoms as well as survival, and  achieved less incidence of re-obstruction than other surgical techniques [1]. Median survival was doubled  in surgical patients than in those receiving conservative treatments (8–34 vs 4–5 weeks) [1]. By the end of this study, surgery has been recognized as the treatment of choice enabling to remedy the occlusion even in overwhelmed state. Any time surgery is technically feasible, it should be considered as the first treatment option in patients with good performance status [1]. Consideration for surgical palliation should then be undertaken in situations where the patients are not actively dying and reversal of enteral failure could make therapeutic options viable, gastrostomy tubes are placed in patients not suitable for palliation by surgery [4]. However, in debilitated patients, clinical guidelines recommendations by the French National Authority for Health in 2014 regarding the treatment of malignant intestinal obstructions, preconise the step up approach: the reassessment is established every three days except for the emergence of signs of severity necessitating recourse to surgery. After the first 3 days of usual conditioning for symptomatic purposes, the introduction of somatostatin analogues is permissible in the event of non-relief. If this step fails after a further 3 days, gastrostomy is sought [5]. Cognitive impairment, cachexia, dyspnea at rest, palpable abdominal tumors, liver failure, upper bowel obstruction, and dehydration have been reported to be factors associated with non-resolution of MBOs [2]. It is crucial to acknowledge the risk factors for failure of conservative treatment in order to operate on the patient for the purpose to abbreviate his evolution in the presence of the above-mentioned elements.

What is the best surgical procedure in surgically selected patients?

Given the plethora of surgical procedures on the offering, the selection of the best surgical procedure becomes difficult. In view of deciding on the most appropriate surgical procedure, a review of palliative surgery in which the tumor burden is the highest will assist in selecting the best surgical procedure. A review of the literature in 2014, covering 64 articles and involving 249 patients, was carried out in an effort to select the most effective surgical procedure for intestinal obstruction in PC, with an interest in evaluating the overall survival after each surgical procedure. The resection has held the leading spot with a better overall survival with 7.2 months,comparing to 3.4 months if ostomy or 2.7 months if enteral bypass [4]. 

Is a diversion ostomy an imperative when carrying an anastomosis?

In order to properly evaluate the risk of anastomotic leakage (AL) in surgery for occlusive colonic tumors in the setting of peritoneal miliary, and in the lack of a study in this perspective, it is therefore appropriate to estimate the risk of AL in the case of cytoreductive surgery (CRS) and hyperthermicintraperitoneal chemotherapy (HIPEC). In fact, considering that the latter is a long-lasting procedure requiring a large-volume fluid of resuscitation and operative transfusions due to the hypothetical risk of anemization accompanying peritoneal stripping and multiple visceral resections, colonic surgery in a controlled situation is more likely to fail than in an occlusive situation because the operating time will be shortened and no additional gestures will be devoted to the malignant peritoneal surface.

A recently published, in 2020, retrospective study [6] investigated the safety of pelvic anastomosis in CRS and HIPEC. The anastomosis was made under adverse conditions. Indeed, peritoneal dissemination was extensive (median peritoneal carcinomatosis index (PCI) was 29) and clearance of macroscopic tumor deposits was achieved in 91%. This suggests a time-consuming and cumbersome surgery, with the median lowest intraoperative hemoglobin dropping from 12.7 to 9.4 g/dL, requiring intraoperative blood transfusion in 51% of the patients. Of the 274 patients with low anterior resection, 243 (89%) had immediate restoration of the digestive tract, and 11 (4%) were protected by a diverting ostomy. Among the 232 patients with non-derived anastomosis, only 2 developed an AL.

At equal age (61.1 vs 57.2 years), equal transfusion requirement (21 vs 20.4%) and despite the high proportion of males (16.6 vs 37.2%), the adjunction of HIPEC only resulted in one (1/275) anastomotic dehiscence, thus exculpating HIPEC in terms of anastomotic safety [7].

 

 

Another recent retrospective study [8] focused in the interest of a derivation during a colorectal anastomosis made after a CRS and HIPEC. Only 3 risk factors were identified: diabetes, male sex and obesity. The operative time was without significance, even the low level of anastomosis was without relevance as 85.5% of patients have a low or medium colorectal anastomosis with a 8.6% rate of anastomotic leakage.

In a study [9], the risk factors for anastomotic leakage in CRS and HIPEC were identified. Older age > 65 years was not statistically significant: 9.5% of the elderly developed AL while 7.5% of younger people developed the same complication with p=0.35. On the other hand, the male sex is characterized by a propensity to develop anastomotic leaks, whose risk doubles from 5.76% to 10.9%; p<0.01. Also, the number of anastomosis is a parameter to be considered during the elaboration of digestive anstomosis because of the risk of anastomotic leakage in proportion to the number of structures joined. This risk doubles from 11.6% to 6.53% if the number >=2 with p<0.01. Extensive resectional surgery does not affect the integrity of the anastomosis. Indeed, in case of lengthy surgery the risk increases very little from 9.43% if >=60 min to 8.16% if <60 minutes. Also, a laborious surgery evidenced by a total macroscopic clearance,completeness of cytoreduction(CCR)=0, has only a 6.82% chance of being complicated by a fistula p=0.14.

This implies that an additionnal diversion procedure does not confer any benefit in terms of reduction of the risk of AL. But it is prudent to consider the additional morbidity brought by the stoma. In addition to the traditional risk of hydroelectrolytic loss and invalidating skin irritation, these patients may not be able to successfully connect the alimentary tract because of the increased hypothetical difficulty. Indeed patients undergoing cytoreductive surgery with HIPEC develop diffuse postoperative intraabdominal adhesions, as a result of extensive peritonectomies and use of HIPEC. This increases the risk of adhesions that may generate fibrous bands retracting the stomal orifice, making its release and the preparation of anastomosis by the elective route laborious. Re-establishment by the median route will then be a necessity despite the increased morbidity that is related to it.

But a study [10] was devoted to the influence of the ostomy derivation on anastomotic integrity. The parameters that could influence the success of the anastomosis were similar in the two study groups. Age was equal (56.5 vs 54.9 years), no male preponderance (sex-ratio=1 vs 1.27), equal general status: ASA 3-4 (75% vs 66%), equal bodymass index (28.1 vs 26.5kg/m2), no difference in tumor burden (PCI=15 vs 16) neither in number of anstomosis (1.6 vs 1. 9), almost majority of anstomosis were low (93.8% vs 100%). And despite longer operative time in the diversion arm (666.1 vs 606 minutes), the no diversion group had a significantly higher rate of anastomotic leak (22 vs. 0%; p=0.01). Considering the burden of an anastomotic fistula in this population and that 57% of the patients will require a surgical or radiological draining procedure [8], a derivation is to be considered each time the patient is frail and cannot endure a second operative procedure or limited-resource institutions.

 

Conclusions:

Although the literature review states that the risk of anastomotic fistula is not increased in case of colonic obstruction in the atmosphere of peritoneal carcinomatosis, it is prudent tofavour a colonic derivation or resection with protected anastomosis in frail patients or under-equipped institutions.

Références

 

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