Stomas in Cytoreductive Surgery and Hyperthermic Intraoperative Peritoneal Chemotherapy for Colorectal and Appendiceal tumors: risk factors and outcomes

Abstract

Background: Cytoreductive surgery/hyperthermic intraperitoneal chemotherapy have evolved as promising treatments for peritoneal carcinomatosis of colorectal and appendiceal origin but are associated with high morbidity and mortality. For concomitant resections, stoma may mitigate against anastomotic leak or its adverse sequelae.
Objective Evaluate factors regarding decision-making and outcomes of stoma during cryoreductive/hyperthermic intraperitoneal chemotherapy.
Design: Retrospective review
Patients: All patients with appendiceal and colorectal neoplasms with peritoneal carcinomatosis who underwent cytoreductive surgery/hyperthermic intraperitoneal chemotherapy between 2009-2018. Patients were divided into those with and without a stoma.
Main outcomes: Surgical outcomes.
Results: 110 consecutive patients were identified. 78 (70.9%) did and 32 (29.1%) did not have a stoma: 46.9% loop ileostomies, 34.4% end ileostomies, 18.7% colostomies. 16.4% had diverting ileostomy. Preoperative factors associated with stoma formation included rectal tumor (p=0.031), body mass index <30 (p=0.023), hypoalbuminemia (p=0.036), and neoadjuvant chemotherapy (p=0.043). Peritoneal cancer index >=10 (p=0.002), greater cytoreduction surgery (p<0.001), residual disease (p=0.002), more blood loss (p < 0.001), more blood transfusions (p<0.001), multiple small bowel resections (p<0.001), and multivisceral resections (p<0.001) also led to more stoma formation. Incidence of complications was 56.2% in patients with and 52.6% without a stoma (p=0.7). Patients with stomas had significantly more surgical site infections (p=0.006), severity of morbidity (Clavien-Dindo class 3/4; p =0.017), longer hospitalization (p=0.028), higher reoperation rate (p=0.010) and higher mortality (p<0.002). 8/32 (25%) patients underwent stoma reversal, one via laparotomy. Mean time to stoma closure was 5.3 +-2.8 months with a 4.5% morbidity rate.
Limitations: Retrospective nature, heterogeneity of pathology/location, high-volume center with quaternary ancillary services leading to better resolution of complications but less generalizable results.
Conclusions: Patient with appendiceal or colorectal neoplasms with higher carcinomatosis burden requiring extensive cytoreductive surgery and blood transfusion are more likely to have a stoma. Only 25% undergo stoma reversal, highlighting the importance of preoperative counselling.