- Email: [email protected]
Laparoscopic Colostomy in Gynecologic Cancer
Laparoscopic Colostomy in Gynecologic Cancer Danielle D. Jandial, MD, Pamela T. Soliman, MD, Brian M. Slomovitz, MD, Kathleen M. Schmeler, MD, Charles Levenback, MD, Robert L. Coleman, MD, and Pedro T. Ramirez, MD* From the Moores University of California San Diego Cancer Center, La Jolla (Dr. Jandial); Department of Gynecologic Oncology, University of Texas M.D. Anderson Cancer Center, Houston (Drs. Soliman, Schmeler, Levenback, Coleman, and Ramirez); and Department of Gynecologic Oncology, Weill Medical College of Cornell University New York Presbyterian Hospital, New York (Dr. Slomovitz).
ABSTRACT Study Objective: The purpose of our study was to report on our case series of 7 patients with gynecologic cancer who underwent laparoscopic colostomy for elective fecal diversion. Our aim was to retrospectively estimate feasibility, safety, and efficacy of the laparoscopic approach in the setting of gynecologic malignancy, given the high incidence of earlier abdominal surgery and pelvic radiation treatment in this select population. Design: Retrospective chart review (Canadian Task Force classification I). Setting: University of Texas, M.D. Anderson Cancer Center. Patients: All patients with a history of gynecologic cancers who underwent laparoscopic colostomy during the study period. Interventions: We retrospectively reviewed all patients who underwent elective laparoscopic diverting colostomy in our department of gynecologic oncology. Surgical indications, medical history, operative and stomal complications, estimated blood loss, return of bowel function, and length of hospital stay were collected. Measurements and Main Results: Seven patients underwent laparoscopic colostomy during the study period. Six of these patients underwent an end descending colostomy, and 1 patient underwent a loop colostomy. Indications included rectovaginal fistula (n 5 5), colonic/pelvic fistula (n 5 1), or large bowel obstruction (n 5 1). No intraoperative or postoperative complications occurred, nor did any conversions to laparotomy. The median blood loss was 50 mL (range 10–75). Median operative time was 102 minutes (range 69–159). Six (86%) patients had a history of pelvic radiation. In addition, 3 (43%) patients had a history of laparotomy. The median patient weight was 59.8 kg (range 47.1–82.2). The median time to tolerance of a regular diet was 2 days (range 1–3) and the median length of hospital stay was 3 days (range 2–4). No immediate or delayed stomal complications were noted with a median follow-up of 6 months (range 1–15). Conclusion: Laparoscopic colostomy in advanced gynecologic cancer may be a safe and feasible technique with minimal morbidity, rapid return of bowel function, and short hospital stay. Journal of Minimally Invasive Gynecology (2008) 15, 723–728 Ó 2008 AAGL. All rights reserved. Keywords:
Gynecologic cancer; Laparoscopy; Colostomy; Rectovaginal fistula
Laparoscopic surgical indications in the field of gynecologic oncology continue to be defined. Surgical management of early cervical cancer, endometrial cancer staging, and pelvic and para-aortic lymphadenectomy are among the more common indications for laparoscopy in gynecologic The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Pedro T. Ramirez, MD, Department of Gynecologic Oncology, University of Texas M.D. Anderson Cancer Center, PO Box 301439, Unit 1362, Houston, TX 77230-1439. E-mail: [email protected] Submitted March 27, 2008. Accepted for publication August 9, 2008. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2008 AAGL. All rights reserved. doi:10.1016/j.jmig.2008.08.007
oncology. When intestinal diversion is indicated, data in the general surgical literature suggest that the use of laparoscopic diverting colostomy may be a viable treatment approach [1–9]. In patients with gynecologic cancer, however, several characteristics of this population must be considered. These patients tend to have a significant tumor burden, poor nutrition, earlier abdominal surgery, and frequent history of pelvic irradiation. A number of small retrospective studies have looked at the feasibility and outcomes of laparoscopic colostomy in patients with a variety of benign and malignant indications. These indications range from fistulas as a result of inflammatory bowel disease, fecal incontinence, perineal sepsis, or advanced colorectal cancer. Results of these studies reveal
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decreased postoperative morbidity, quicker return of bowel function, and shorter hospital stay [2–4]. The stomal complication rates vary but in general parallel or are less than those seen in open colostomy [2–4,10–12]. The purpose of this study was to report our technique and the surgical outcomes of 7 patients who underwent laparoscopic diverting colostomy performed in our department of gynecologic oncology. Material and Methods After institutional review board approval was obtained, the medical records of patients who underwent elective diverting colostomy by a gynecologic oncologist at our institution were identified from June 2005 through November 2006. Age, weight, tumor history, indication for colostomy, operative outcomes, time to tolerance of a regular diet, length of hospital stay, and stomal complications were obtained from the medical record. Blood loss was defined as the total volume of suctioned fluids minus the volumes of irrigation fluids used at the completion of surgery. Surgical Technique All patients underwent a laparoscopic colostomy under general endotracheal anesthesia after consultation with an enterostomal nurse. Preoperative bowel preparations were given routinely except to patients with bowel obstruction. All patients received perioperative antibiotics. The patient was placed in the supine position, arms tucked at the side. The initial entry was made at the level of the umbilicus under direct visualization with a 10-mm bladeless trocar that incorporates the zero-degree laparoscope. In 1 patient with central obesity, the primary access was made through a supraumbilical midline port (approximately 5 cm superior to the umbilicus) to avoid injury to pelvic and vascular structures. The patient was then placed in Trendelenburg position and 10mm right and left lower quadrant bladeless trocars were
Fig. 1. Recommended trocar placement.
Fig. 2. Transection of bowel with endoscopic stapler.
placed under direct visualization, with the left lower quadrant port placed at the previously marked stoma site. An additional 5-mm bladeless trocar was then placed in the midline above the pubic symphysis (Fig. 1). After exploration of the abdomen for tumor burden and identification of appropriate anatomic structures, the lateral peritoneal reflection was dissected using electrosurgical techniques to mobilize the sigmoid colon. Once the appropriate bowel segment was selected and adequately mobilized, a window was then made in the mesentery using blunt dissection and coagulation. For the end colostomy, an endoscopic stapling device was then introduced and the bowel transected intracorporeally (Fig. 2). Once the bowel was transected, we used the Harmonic ACE (Ethicon Endosurgery, Cincinnati, OH) to transect the bowel mesentery and thus allow for ease of mobilization of the bowel. An Endo-Babcock clamp (Ethicon Endosurgery) was then introduced through the left lower
Fig. 3. Grasping of proximal bowel segment with delivery through left lower quadrant port site.
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Results
Fig. 4. Confirmation of tension-free colostomy.
quadrant port and the proximal limb identified and grasped (Fig. 3). It was then elevated to the anterior abdominal wall to determine whether further mobilization was required for a tension-free colostomy. Attention was then turned externally, where the left lower quadrant trocar site incision was circumferentially enlarged and the fascia incised to allow comfortable passage of the descending bowel limb through the defect. The clamp, proximal limb of bowel, and trocar sleeve were then exteriorized as a unit. Correct orientation of the mesentery and assessment of tension was then confirmed laparoscopically (Fig. 4). Hemostasis was confirmed before completion of the procedure. Pneumoperitoneum was then released and attention redirected externally. After excision of the staple line, the distal colon was then anchored to the underlying fascia with 4 everting sutures in each quadrant. These were placed through the edge of the bowel, the seromuscular layer of the bowel 1 cm below the edge, and finally through the dermis of the skin. Between these sutures the bowel edge was reapproximated with the skin edge using interrupted absorbable suture. The remaining trocar sites were closed with a subcuticular closure.
From June 2005 through November 2006, 7 patients underwent elective fecal diversion (Table 1). Indications included rectovaginal fistula (n 5 5), colonic/pelvic fistula (n 5 1), or palliation of distal bowel obstruction (n 5 1). Six of these patients underwent a laparoscopic end descending colostomy, and 1 underwent loop colostomy. The median age was 48 years (range 34–61). The median weight was 59.8 kg (range 47.1–82.2) and the median body mass index was 22.3 kg/m2 (range 19.6–35.1). All patients had a gynecologic cancer (3 with cervical cancer, 1 with cancer of the rectovaginal septum, 1 with vaginal cancer, 1 with ovarian cancer, and 1 with cancer arising from endometriosis). Six (86%) patients had received earlier pelvic radiation and 3 (43%) patients had a history of laparotomy. All of the procedures were completed laparoscopically. The median estimated blood loss was 50 mL (range 10–75). Median operative time was 102 minutes (range 69–159). Median time to tolerance of a regular diet was 2 days (range 1–3) and median length of hospital stay was 3 days (range 2–4). No intraoperative or postoperative complications occurred. No immediate or delayed stomal complications were noted. Patients were followed up for a median of 6 months (range 1.3–15.0).
Discussion Patients with gynecologic cancer requiring fecal diversion are a distinct population of women. They typically have multiple medical comorbidities. They may have a significant tumor burden, and are often in the late stages of their disease. Many patients have had previous abdominal surgery, pelvic irradiation, or both. The most common indication for fecal diversion in this population is colovaginal fistula or distal bowel obstruction. The traditional approach to fecal diversion in this population was either exploratory laparotomy through a midline vertical incision or a loop colostomy through a trephine approach in which the abdominal wall is opened only at the selected stomal site. Data in the gynecologic cancer population regarding colostomy approach, however, are limited.
Table 1
Demographic characteristics and results Patient
Age (yrs)
BMI
Earlier laparotomy
Earlier pelvic XRT
Surgical indication
Operative time (min)a
EBL (mL)a
Hospital stay (days)a
Complicationsb
1 2 3 4 5 6 7
48 55 41 58 61 38 34
24.0 35.1 22.5 22.3 19.6 21.8 20.9
No No No No Yes Yes Yes
Yes Yes Yes Yes Yes Yes No
Rectovaginal fistula Rectovaginal fistula Rectovaginal fistula Rectovaginal fistula Colonic/pelvic fistula Complex rectovesicovaginal fistula Distal bowel obstruction
87 116 159 69 129 102 94
20 75 50 10 50 50 50
3 3 3 2 4 4 4
None None None None None None None
BMI 5 body mass index; EBL 5 estimated blood loss; XRT 5 radiation therapy. Median values reported. b Includes perioperative and stomal complications. a
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One study [13] compared open-end colostomy with loop colostomy in 75 patients with colonic fistulae. A significantly increased rate of delayed stomal complications occurred in 26% of patients who underwent a loop colostomy. This included incomplete fecal diversion in 5 patients, stomal prolapse in 1 patient, and stomal retraction in 3 patients. No survival advantages were offered by either method. They concluded that loop colostomy, although routinely performed, was not preferred for management of fistulas in patients with gynecologic cancer. To date, no randomized prospective studies were performed to address this question, but frequent problems were reported with loop colostomy [14–16]. In patients with malignant bowel obstruction, the use of open surgical modalities including colostomy for treatment or palliation were well documented in the setting of recurrent ovarian cancer [17–20]. One study [21] provided an analysis of pooled data from more than 700 patients in 15 studies looking at surgical outcomes in the setting of advanced ovarian cancer and obstruction. Significant morbidity was seen in 32% of patients and perioperative mortality was 15.5%, emphasizing the need for careful patient selection. These risks must be weighed against the potential survival benefit that is conferred if successful palliation is achieved [21]. The use of laparoscopy for intestinal diversion in this setting will likewise require great care in choosing surgical candidates most likely to benefit from this approach while minimizing surgical risk. Although previously believed to be a contradiction to laparoscopy, several studies in the general surgery literature showed that intestinal obstruction can be successfully and safely managed with the laparoscopic approach [22–24]. One study [25] reported the largest case series to date of 167 patients
with intestinal obstruction, including 23 (13%) patients with malignant large bowel obstruction from colon carcinoma. Successful identification and treatment of the obstruction was achieved in 92.2% of cases, and perioperative morbidity was minimal. Conversion to laparotomy was required in 7.8% of patients, most commonly as a result of the massively dilated loops of bowel obstructing the operative view. Specific to the patient with ovarian cancer, malignant bowel obstruction more commonly involves multiple sites of obstruction. When considering the use of laparoscopy in this setting, this approach may offer the potential benefit over the trephine approach of identifying and treating other sites of obstruction that may increase the chance for successful palliation. A number of published reports exist on the laparoscopic approach for elective diverting colostomy in the general population. The indications and patient populations in such studies, however, are very heterogeneous. Table 2 includes reported cases of laparoscopic colostomy in patients with cancer (predominantly anorectal carcinoma). In these published series, the conversion rate to laparotomy ranged from 0% to 25%. The most common reasons cited for conversion to laparotomy were significant pelvic and abdominal adhesions, inability to adequately mobilize the colon, obesity, and ascites [1–4,11,12,26]. Overall, however, the procedures were well tolerated. Furthermore, only 3 series have compared the laparoscopic with an open approach [3,4,26]. These each reported lower analgesic requirements, earlier return of bowel function, and shorter hospital stays after laparoscopic colostomy. Stomal and postoperative complications were comparable between the 2 groups. Additional advantages of the laparoscopic approach over the traditional laparotomy approach include the ability to
Table 2
Literature review of laparoscopic colostomy in cancer patients Conversion to laparotomy
Hospital stay (days)
24/4 (4 with colorectal cancer) 80/36 (20 with colorectal cancer, 16 with prostate or gynecologic cancer)
1/16 (6.3%) 1/80 (1.3%)
6 10.3
Hollyoak et al [3]
40/29 (29 with anal or rectal cancer)
2/40 (5%)
7.4
Young et al [4]
19/3 (3 with colorectal cancer)
3/19 (15.8%)
8
Hallfeldt et al [11]
14/9 (7 with ovarian cancer, 2 with rectal cancer)
2/14 (14.3%)
Jugool et al [12]
18/8 (8 with colorectal, anal, or prostate cancer)
0
Boike and Lurain [26]
4/4 (4 with cervical cancer)
Study
No. (total/pelvic malignancy)
Ludwig et al [1] Liu et al [2]
1/4 (25%)
Not reported
9
Not reported
Perioperative morbidity and mortality 1 death caused by pulmonary embolus 6.3% Reoperation rate because of postoperative hemorrhage (1), parastomal abscess (1), stomal retraction (1), small bowel obstruction (2), port site hernia repair (1) 1 death caused by aspiration, 8 minor complications including small bowel obstruction (1), wound infection (1), prolonged ileus (2) 1 death caused by postoperative myocardial infarction, 1 anastomotic stricture (postclosure) Conversion to laparotomy in 2/7 patients with ovarian cancer because of obstructive ascites 2 deaths caused by postoperative myocardial infarction and advanced anorectal cancer with liver metastasis, 1 reoperation for stomal malorientation None
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Laparoscopic Colostomy in Gynecologic Cancer
explore the abdomen for tumor burden or adhesions, to ensure appropriate selection of the stomal site, and to ensure proper orientation of the stoma. Cases of exteriorizing the distal limb during a trephine approach also were reported [27]. One presumed advantage of a loop colostomy is the ease of reversibility. Although colostomy reversal may be a common option for patients in the general surgery population undergoing colostomy, this is less common in women with gynecologic cancers. One study [28] reviewed 111 patients with gynecologic cancer who underwent colostomy. In this series only 11 (10%) patients went on to have their colostomy reversed. Of these, 2 patients required a repeated colostomy. Therefore, the benefit of a straightforward colostomy closure offered by an open loop colostomy may be less important in the gynecologic cancer population where the most common indication for diversion is radiation-induced or tumor-related fistula. When addressing the surgical risks of the gynecologic cancer population, it is important to consider earlier laparotomy or history of pelvic radiation. Previous abdominal surgery increases the risk for significant adhesions, which was the most common indication for conversion to laparotomy in previously published studies [1–4,8]. In addition, patients who have undergone previous irradiation may have changes associated with obliterative endarteritis resulting in tissue fibrosis, local ischemia, and poor healing. One study [29] reported a series of 97 patients who underwent open-end sigmoid colostomy for fistulae management. Of their patients, 80% had previous irradiation for cervical cancer. They had a 15% stomal complication rate with 10 of 14 patients ultimately requiring surgical revision. They concluded that the use of irradiated sigmoid may have accounted for their observed complications. In our series, we did not find a high incidence of postoperative or stomal complications in patients who underwent laparoscopic colostomy. This information on postoperative complications may be limited by the small number of patients and the short follow-up because of disease progression and patients succumbing to their disease. This is consistent with data in patients with colorectal conditions who also underwent pelvic irradiation before laparoscopic colorectal resection, where morbidity and mortality were comparable with open procedures, and no conversions to laparotomy were required in those patients undergoing stoma creation [30]. However, in our subset of patients, and in the gynecologic cancer population in general, assessing delayed stomal complications in particular requires a much larger series of patients, given that the length of follow-up is frequently limited by these patients succumbing to their advanced disease. This case series of 7 women who underwent laparoscopic diverting colostomy shows the feasibility of a minimally invasive approach to diverting colostomy in patients with gynecologic cancers. Our patients who underwent laparoscopic colostomy had minimal blood loss, short hospital stay, and rapid return of bowel function, with a limited number of complications. All these are of specific importance in patients
727
with gynecologic cancer who commonly have advanced disease and thus a limited lifespan whereby such benefits are of particular value. At our institution, not all patients requiring colostomy for the indications specified had their procedure performed laparoscopically. Patients in this series were collected from a small group of surgeons in our department experienced in laparoscopic surgery. Exclusive of surgical preference, we think that a good candidate for this approach is a patient undergoing an end colostomy that can safely be performed through minimal access points. Caution must be exercised in patients with obstructive disease, pre-existing hernia, or earlier colostomy, as injury with trocar placement and enterotomy may be higher. In all cases, the abdomen was entered via direct trocar insertion, under laparoscopic guidance with a bladeless trocar, although an open approach is an alternative. Primary access through the left upper quadrant is also routinely performed for patients with earlier midline laparotomy, to avoid areas at high risk for adhesions. Similarly, patients with extensive intraperitoneal (particularly omental or abdominal wall) disease and ascites may provide a significant barrier to visualization and dissection via laparoscopy. Careful case selection can optimize operator experience and minimize potential complications. Our results, in conjunction with the studies reviewed, indicate that laparoscopic diverting colostomy is a safe, feasible option with an acceptable rate of stomal complications. This approach should be considered for patients with gynecologic cancers needing fecal diversion.
References 1. Ludwig KA, Milsom JW, Garcia-Ruiz A, Fazio VW. Laparoscopic techniques for fecal diversion. Dis Colon Rectum. 1996;39:285–288. 2. Liu J, Bruch HP, Farke S, Nolde J, Schwander O. Stomal formation for fecal diversion: a plea for the laparoscopic approach. Tech Coloproctol. 2005;9:9–14. 3. Hollyoak MA, Lumley J, Stitz RW. Laparoscopic stoma formation for fecal diversion. Br J Surg. 1998;85:226–228. 4. Young CJ, Eyers AA, Solomon MJ. Defunctioning the anorectum: historical controlled study of laparoscopic vs open procedures. Dis Colon Rectum. 1998;41:190–194. 5. Romero CA, James KM, Cooperstone LM. Laparoscopic sigmoid colostomy for perianal Crohn’s disease. Surg Laparosc Endosc. 1992;2: 148–151. 6. Fuhrman GM, Ota DM. Laparoscopic intestinal stomas. Dis Colon Rectum. 1994;37:444–449. 7. Lyerly HK, Mault JR. Laparoscopic ileostomy and colostomy. Ann Surg. 1994;219:317–322. 8. Oliviera L, Reissman P, Nogueras J, Wexner SD. Laparoscopic creation of stomas. Surg Endosc. 1997;11:285–288. 9. Roe AM, Barlow AP, Durdey P. Indications for laparoscopic formation of intestinal stomas. Surg Laparosc Endosc. 1994;4:345–347. 10. Carne PW, Frye JN, Robertson GM, Frizelle FA. Parastomal hernia following minimally invasive stoma formation. Aust N Z J Surg. 2003;73: 843–845. 11. Hallfeldt K, Schmidbaeur S, Trupka A. Laparoscopic loop colostomy for advanced ovarian cancer, rectal cancer, and rectovaginal fistulas. Gynecol Oncol. 2000;76:380–382.
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12. Jugool S, McKain ES, Swarnkar K, Vellacott KD, Stephenson BM. Laparoscopic or trephine fecal diversion: is there a preferred approach and why? Colorectal Dis. 2004;7:156–158. 13. Segreti EM, Levenback C, Morris M, Lucas KR, Gershenson DM, Burke TW. A comparison of end and loop colostomy for fecal diversion in gynecologic cancer patients with colonic fistulas. Gynecol Oncol. 1996;60:49–53. 14. Winkler MJ, Volpe PA. Loop transverse colostomy–the case against. Dis Colon Rectum. 1982;25:321–326. 15. Allen-Mersh TG, Thompson JPS. Surgical treatment of colostomy complications. Br J Surg. 1988;75:416–418. 16. Phillips R, Pringle W, Evans MA, Keighley MRB. Analysis of a hospital based stoma therapy service. Ann R Coll Surg Engl. 1985;67:37–40. 17. Clarke-Pearson DL, Chin N, DeLong ER, Rice R, Creasman WT. Surgical management of intestinal obstruction in ovarian cancer. Gynecol Oncol. 1987;26:11–18. 18. Rubin SC, Hoskins WJ, Benjamin I, Lewis JL. Palliative surgery for bowel obstruction in advanced ovarian cancer. Gynecol Oncol. 1989; 34:16–19. 19. Bartels CJ, Reed E, Sindelar WF. Intestinal obstruction due to advanced ovarian cancer: results of surgical intervention. Surg Forum. 1995;46: 564–566. 20. Zoetmulder A, Helmerhorst TJ, van Coevorden F, Wolfs PE, Leyer JP, Hart AA. Management of bowel obstruction in patients with advanced ovarian cancer. Eur J Cancer. 1994;30A:1625–1628.
21. Pothuri B, Vaidya A, Aghajanian C, Vankatraman E, Barakat RR, Chi DS. Palliative surgery for bowel obstruction in recurrent ovarian cancer: an updated series. Gynecol Oncol. 2003;89:306– 313. 22. Reissman P, Wexner SD. Laparoscopic surgery for intestinal obstruction. Surg Endosc. 1995;9:865–868. 23. Agresta F, Michelet I, Coluci G, Bedin N, Sartori CA. Small bowel obstruction: laparoscopic approach. Surg Endosc. 2000;14:154–156. 24. Fischer CP, Doherty D. Laparoscopic approach to small bowel obstruction. Semin Laparosc Surg. 2002;9:40–45. 25. Franklin ME Jr, Gonzalez JJ Jr, Miter DB, Glass L, Paulson D. Laparoscopic diagnosis and treatment of intestinal obstruction. Surg Endosc. 2004;18:26–30. 26. Boike GM, Lurain JR. Laparoscopic descending colostomy in three patients with cervical carcinoma. Gynecol Oncol. 1994;54:381–384. 27. Loder PB, Thompson JP. Trephine colostomy: a warning. Ann R Coll Surg Engl. 1995;77:462. 28. Hoffman MS, Barton DPJ, Gates J, et al. Complications of colostomy performed on gynecologic cancer patients. Gynecol Oncol. 1992;44: 231–234. 29. Kimose HH, Fischer L, Spjeldnaes N, Wara P. Late radiation injury of the colon and rectum–surgical management and outcome. Dis Colon Rectum. 1989;32:684–689. 30. Geisler D, Marks J, Marks G. Laparoscopic colorectal surgery in the irradiated pelvis. Am J Surg. 2004;188:267–270.
ABSTRACT Study Objective: The purpose of our study was to report on our case series of 7 patients with gynecologic cancer who underwent laparoscopic colostomy for elective fecal diversion. Our aim was to retrospectively estimate feasibility, safety, and efficacy of the laparoscopic approach in the setting of gynecologic malignancy, given the high incidence of earlier abdominal surgery and pelvic radiation treatment in this select population. Design: Retrospective chart review (Canadian Task Force classification I). Setting: University of Texas, M.D. Anderson Cancer Center. Patients: All patients with a history of gynecologic cancers who underwent laparoscopic colostomy during the study period. Interventions: We retrospectively reviewed all patients who underwent elective laparoscopic diverting colostomy in our department of gynecologic oncology. Surgical indications, medical history, operative and stomal complications, estimated blood loss, return of bowel function, and length of hospital stay were collected. Measurements and Main Results: Seven patients underwent laparoscopic colostomy during the study period. Six of these patients underwent an end descending colostomy, and 1 patient underwent a loop colostomy. Indications included rectovaginal fistula (n 5 5), colonic/pelvic fistula (n 5 1), or large bowel obstruction (n 5 1). No intraoperative or postoperative complications occurred, nor did any conversions to laparotomy. The median blood loss was 50 mL (range 10–75). Median operative time was 102 minutes (range 69–159). Six (86%) patients had a history of pelvic radiation. In addition, 3 (43%) patients had a history of laparotomy. The median patient weight was 59.8 kg (range 47.1–82.2). The median time to tolerance of a regular diet was 2 days (range 1–3) and the median length of hospital stay was 3 days (range 2–4). No immediate or delayed stomal complications were noted with a median follow-up of 6 months (range 1–15). Conclusion: Laparoscopic colostomy in advanced gynecologic cancer may be a safe and feasible technique with minimal morbidity, rapid return of bowel function, and short hospital stay. Journal of Minimally Invasive Gynecology (2008) 15, 723–728 Ó 2008 AAGL. All rights reserved. Keywords:
Gynecologic cancer; Laparoscopy; Colostomy; Rectovaginal fistula
Laparoscopic surgical indications in the field of gynecologic oncology continue to be defined. Surgical management of early cervical cancer, endometrial cancer staging, and pelvic and para-aortic lymphadenectomy are among the more common indications for laparoscopy in gynecologic The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Pedro T. Ramirez, MD, Department of Gynecologic Oncology, University of Texas M.D. Anderson Cancer Center, PO Box 301439, Unit 1362, Houston, TX 77230-1439. E-mail: [email protected] Submitted March 27, 2008. Accepted for publication August 9, 2008. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2008 AAGL. All rights reserved. doi:10.1016/j.jmig.2008.08.007
oncology. When intestinal diversion is indicated, data in the general surgical literature suggest that the use of laparoscopic diverting colostomy may be a viable treatment approach [1–9]. In patients with gynecologic cancer, however, several characteristics of this population must be considered. These patients tend to have a significant tumor burden, poor nutrition, earlier abdominal surgery, and frequent history of pelvic irradiation. A number of small retrospective studies have looked at the feasibility and outcomes of laparoscopic colostomy in patients with a variety of benign and malignant indications. These indications range from fistulas as a result of inflammatory bowel disease, fecal incontinence, perineal sepsis, or advanced colorectal cancer. Results of these studies reveal
724
Journal of Minimally Invasive Gynecology, Vol 15, No 6, November/December 2008
decreased postoperative morbidity, quicker return of bowel function, and shorter hospital stay [2–4]. The stomal complication rates vary but in general parallel or are less than those seen in open colostomy [2–4,10–12]. The purpose of this study was to report our technique and the surgical outcomes of 7 patients who underwent laparoscopic diverting colostomy performed in our department of gynecologic oncology. Material and Methods After institutional review board approval was obtained, the medical records of patients who underwent elective diverting colostomy by a gynecologic oncologist at our institution were identified from June 2005 through November 2006. Age, weight, tumor history, indication for colostomy, operative outcomes, time to tolerance of a regular diet, length of hospital stay, and stomal complications were obtained from the medical record. Blood loss was defined as the total volume of suctioned fluids minus the volumes of irrigation fluids used at the completion of surgery. Surgical Technique All patients underwent a laparoscopic colostomy under general endotracheal anesthesia after consultation with an enterostomal nurse. Preoperative bowel preparations were given routinely except to patients with bowel obstruction. All patients received perioperative antibiotics. The patient was placed in the supine position, arms tucked at the side. The initial entry was made at the level of the umbilicus under direct visualization with a 10-mm bladeless trocar that incorporates the zero-degree laparoscope. In 1 patient with central obesity, the primary access was made through a supraumbilical midline port (approximately 5 cm superior to the umbilicus) to avoid injury to pelvic and vascular structures. The patient was then placed in Trendelenburg position and 10mm right and left lower quadrant bladeless trocars were
Fig. 1. Recommended trocar placement.
Fig. 2. Transection of bowel with endoscopic stapler.
placed under direct visualization, with the left lower quadrant port placed at the previously marked stoma site. An additional 5-mm bladeless trocar was then placed in the midline above the pubic symphysis (Fig. 1). After exploration of the abdomen for tumor burden and identification of appropriate anatomic structures, the lateral peritoneal reflection was dissected using electrosurgical techniques to mobilize the sigmoid colon. Once the appropriate bowel segment was selected and adequately mobilized, a window was then made in the mesentery using blunt dissection and coagulation. For the end colostomy, an endoscopic stapling device was then introduced and the bowel transected intracorporeally (Fig. 2). Once the bowel was transected, we used the Harmonic ACE (Ethicon Endosurgery, Cincinnati, OH) to transect the bowel mesentery and thus allow for ease of mobilization of the bowel. An Endo-Babcock clamp (Ethicon Endosurgery) was then introduced through the left lower
Fig. 3. Grasping of proximal bowel segment with delivery through left lower quadrant port site.
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Results
Fig. 4. Confirmation of tension-free colostomy.
quadrant port and the proximal limb identified and grasped (Fig. 3). It was then elevated to the anterior abdominal wall to determine whether further mobilization was required for a tension-free colostomy. Attention was then turned externally, where the left lower quadrant trocar site incision was circumferentially enlarged and the fascia incised to allow comfortable passage of the descending bowel limb through the defect. The clamp, proximal limb of bowel, and trocar sleeve were then exteriorized as a unit. Correct orientation of the mesentery and assessment of tension was then confirmed laparoscopically (Fig. 4). Hemostasis was confirmed before completion of the procedure. Pneumoperitoneum was then released and attention redirected externally. After excision of the staple line, the distal colon was then anchored to the underlying fascia with 4 everting sutures in each quadrant. These were placed through the edge of the bowel, the seromuscular layer of the bowel 1 cm below the edge, and finally through the dermis of the skin. Between these sutures the bowel edge was reapproximated with the skin edge using interrupted absorbable suture. The remaining trocar sites were closed with a subcuticular closure.
From June 2005 through November 2006, 7 patients underwent elective fecal diversion (Table 1). Indications included rectovaginal fistula (n 5 5), colonic/pelvic fistula (n 5 1), or palliation of distal bowel obstruction (n 5 1). Six of these patients underwent a laparoscopic end descending colostomy, and 1 underwent loop colostomy. The median age was 48 years (range 34–61). The median weight was 59.8 kg (range 47.1–82.2) and the median body mass index was 22.3 kg/m2 (range 19.6–35.1). All patients had a gynecologic cancer (3 with cervical cancer, 1 with cancer of the rectovaginal septum, 1 with vaginal cancer, 1 with ovarian cancer, and 1 with cancer arising from endometriosis). Six (86%) patients had received earlier pelvic radiation and 3 (43%) patients had a history of laparotomy. All of the procedures were completed laparoscopically. The median estimated blood loss was 50 mL (range 10–75). Median operative time was 102 minutes (range 69–159). Median time to tolerance of a regular diet was 2 days (range 1–3) and median length of hospital stay was 3 days (range 2–4). No intraoperative or postoperative complications occurred. No immediate or delayed stomal complications were noted. Patients were followed up for a median of 6 months (range 1.3–15.0).
Discussion Patients with gynecologic cancer requiring fecal diversion are a distinct population of women. They typically have multiple medical comorbidities. They may have a significant tumor burden, and are often in the late stages of their disease. Many patients have had previous abdominal surgery, pelvic irradiation, or both. The most common indication for fecal diversion in this population is colovaginal fistula or distal bowel obstruction. The traditional approach to fecal diversion in this population was either exploratory laparotomy through a midline vertical incision or a loop colostomy through a trephine approach in which the abdominal wall is opened only at the selected stomal site. Data in the gynecologic cancer population regarding colostomy approach, however, are limited.
Table 1
Demographic characteristics and results Patient
Age (yrs)
BMI
Earlier laparotomy
Earlier pelvic XRT
Surgical indication
Operative time (min)a
EBL (mL)a
Hospital stay (days)a
Complicationsb
1 2 3 4 5 6 7
48 55 41 58 61 38 34
24.0 35.1 22.5 22.3 19.6 21.8 20.9
No No No No Yes Yes Yes
Yes Yes Yes Yes Yes Yes No
Rectovaginal fistula Rectovaginal fistula Rectovaginal fistula Rectovaginal fistula Colonic/pelvic fistula Complex rectovesicovaginal fistula Distal bowel obstruction
87 116 159 69 129 102 94
20 75 50 10 50 50 50
3 3 3 2 4 4 4
None None None None None None None
BMI 5 body mass index; EBL 5 estimated blood loss; XRT 5 radiation therapy. Median values reported. b Includes perioperative and stomal complications. a
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One study [13] compared open-end colostomy with loop colostomy in 75 patients with colonic fistulae. A significantly increased rate of delayed stomal complications occurred in 26% of patients who underwent a loop colostomy. This included incomplete fecal diversion in 5 patients, stomal prolapse in 1 patient, and stomal retraction in 3 patients. No survival advantages were offered by either method. They concluded that loop colostomy, although routinely performed, was not preferred for management of fistulas in patients with gynecologic cancer. To date, no randomized prospective studies were performed to address this question, but frequent problems were reported with loop colostomy [14–16]. In patients with malignant bowel obstruction, the use of open surgical modalities including colostomy for treatment or palliation were well documented in the setting of recurrent ovarian cancer [17–20]. One study [21] provided an analysis of pooled data from more than 700 patients in 15 studies looking at surgical outcomes in the setting of advanced ovarian cancer and obstruction. Significant morbidity was seen in 32% of patients and perioperative mortality was 15.5%, emphasizing the need for careful patient selection. These risks must be weighed against the potential survival benefit that is conferred if successful palliation is achieved [21]. The use of laparoscopy for intestinal diversion in this setting will likewise require great care in choosing surgical candidates most likely to benefit from this approach while minimizing surgical risk. Although previously believed to be a contradiction to laparoscopy, several studies in the general surgery literature showed that intestinal obstruction can be successfully and safely managed with the laparoscopic approach [22–24]. One study [25] reported the largest case series to date of 167 patients
with intestinal obstruction, including 23 (13%) patients with malignant large bowel obstruction from colon carcinoma. Successful identification and treatment of the obstruction was achieved in 92.2% of cases, and perioperative morbidity was minimal. Conversion to laparotomy was required in 7.8% of patients, most commonly as a result of the massively dilated loops of bowel obstructing the operative view. Specific to the patient with ovarian cancer, malignant bowel obstruction more commonly involves multiple sites of obstruction. When considering the use of laparoscopy in this setting, this approach may offer the potential benefit over the trephine approach of identifying and treating other sites of obstruction that may increase the chance for successful palliation. A number of published reports exist on the laparoscopic approach for elective diverting colostomy in the general population. The indications and patient populations in such studies, however, are very heterogeneous. Table 2 includes reported cases of laparoscopic colostomy in patients with cancer (predominantly anorectal carcinoma). In these published series, the conversion rate to laparotomy ranged from 0% to 25%. The most common reasons cited for conversion to laparotomy were significant pelvic and abdominal adhesions, inability to adequately mobilize the colon, obesity, and ascites [1–4,11,12,26]. Overall, however, the procedures were well tolerated. Furthermore, only 3 series have compared the laparoscopic with an open approach [3,4,26]. These each reported lower analgesic requirements, earlier return of bowel function, and shorter hospital stays after laparoscopic colostomy. Stomal and postoperative complications were comparable between the 2 groups. Additional advantages of the laparoscopic approach over the traditional laparotomy approach include the ability to
Table 2
Literature review of laparoscopic colostomy in cancer patients Conversion to laparotomy
Hospital stay (days)
24/4 (4 with colorectal cancer) 80/36 (20 with colorectal cancer, 16 with prostate or gynecologic cancer)
1/16 (6.3%) 1/80 (1.3%)
6 10.3
Hollyoak et al [3]
40/29 (29 with anal or rectal cancer)
2/40 (5%)
7.4
Young et al [4]
19/3 (3 with colorectal cancer)
3/19 (15.8%)
8
Hallfeldt et al [11]
14/9 (7 with ovarian cancer, 2 with rectal cancer)
2/14 (14.3%)
Jugool et al [12]
18/8 (8 with colorectal, anal, or prostate cancer)
0
Boike and Lurain [26]
4/4 (4 with cervical cancer)
Study
No. (total/pelvic malignancy)
Ludwig et al [1] Liu et al [2]
1/4 (25%)
Not reported
9
Not reported
Perioperative morbidity and mortality 1 death caused by pulmonary embolus 6.3% Reoperation rate because of postoperative hemorrhage (1), parastomal abscess (1), stomal retraction (1), small bowel obstruction (2), port site hernia repair (1) 1 death caused by aspiration, 8 minor complications including small bowel obstruction (1), wound infection (1), prolonged ileus (2) 1 death caused by postoperative myocardial infarction, 1 anastomotic stricture (postclosure) Conversion to laparotomy in 2/7 patients with ovarian cancer because of obstructive ascites 2 deaths caused by postoperative myocardial infarction and advanced anorectal cancer with liver metastasis, 1 reoperation for stomal malorientation None
Jandial et al.
Laparoscopic Colostomy in Gynecologic Cancer
explore the abdomen for tumor burden or adhesions, to ensure appropriate selection of the stomal site, and to ensure proper orientation of the stoma. Cases of exteriorizing the distal limb during a trephine approach also were reported [27]. One presumed advantage of a loop colostomy is the ease of reversibility. Although colostomy reversal may be a common option for patients in the general surgery population undergoing colostomy, this is less common in women with gynecologic cancers. One study [28] reviewed 111 patients with gynecologic cancer who underwent colostomy. In this series only 11 (10%) patients went on to have their colostomy reversed. Of these, 2 patients required a repeated colostomy. Therefore, the benefit of a straightforward colostomy closure offered by an open loop colostomy may be less important in the gynecologic cancer population where the most common indication for diversion is radiation-induced or tumor-related fistula. When addressing the surgical risks of the gynecologic cancer population, it is important to consider earlier laparotomy or history of pelvic radiation. Previous abdominal surgery increases the risk for significant adhesions, which was the most common indication for conversion to laparotomy in previously published studies [1–4,8]. In addition, patients who have undergone previous irradiation may have changes associated with obliterative endarteritis resulting in tissue fibrosis, local ischemia, and poor healing. One study [29] reported a series of 97 patients who underwent open-end sigmoid colostomy for fistulae management. Of their patients, 80% had previous irradiation for cervical cancer. They had a 15% stomal complication rate with 10 of 14 patients ultimately requiring surgical revision. They concluded that the use of irradiated sigmoid may have accounted for their observed complications. In our series, we did not find a high incidence of postoperative or stomal complications in patients who underwent laparoscopic colostomy. This information on postoperative complications may be limited by the small number of patients and the short follow-up because of disease progression and patients succumbing to their disease. This is consistent with data in patients with colorectal conditions who also underwent pelvic irradiation before laparoscopic colorectal resection, where morbidity and mortality were comparable with open procedures, and no conversions to laparotomy were required in those patients undergoing stoma creation [30]. However, in our subset of patients, and in the gynecologic cancer population in general, assessing delayed stomal complications in particular requires a much larger series of patients, given that the length of follow-up is frequently limited by these patients succumbing to their advanced disease. This case series of 7 women who underwent laparoscopic diverting colostomy shows the feasibility of a minimally invasive approach to diverting colostomy in patients with gynecologic cancers. Our patients who underwent laparoscopic colostomy had minimal blood loss, short hospital stay, and rapid return of bowel function, with a limited number of complications. All these are of specific importance in patients
727
with gynecologic cancer who commonly have advanced disease and thus a limited lifespan whereby such benefits are of particular value. At our institution, not all patients requiring colostomy for the indications specified had their procedure performed laparoscopically. Patients in this series were collected from a small group of surgeons in our department experienced in laparoscopic surgery. Exclusive of surgical preference, we think that a good candidate for this approach is a patient undergoing an end colostomy that can safely be performed through minimal access points. Caution must be exercised in patients with obstructive disease, pre-existing hernia, or earlier colostomy, as injury with trocar placement and enterotomy may be higher. In all cases, the abdomen was entered via direct trocar insertion, under laparoscopic guidance with a bladeless trocar, although an open approach is an alternative. Primary access through the left upper quadrant is also routinely performed for patients with earlier midline laparotomy, to avoid areas at high risk for adhesions. Similarly, patients with extensive intraperitoneal (particularly omental or abdominal wall) disease and ascites may provide a significant barrier to visualization and dissection via laparoscopy. Careful case selection can optimize operator experience and minimize potential complications. Our results, in conjunction with the studies reviewed, indicate that laparoscopic diverting colostomy is a safe, feasible option with an acceptable rate of stomal complications. This approach should be considered for patients with gynecologic cancers needing fecal diversion.
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