Results from a pilot study demonstrate the feasibility of ghost ileostomy (GI) for the treatment of patients with advanced ovarian cancer, according to investigators from University Hospital La Fe in Valencia, Spain.
GI is an alternative to diverting ileostomy (DI) for colorectal cancer to avoid the morbidity of DI while maintaining its advantages; namely, a reduction in the incidence and consequence of anastomotic leak (AL). The feasibility of the GI technique in ovarian cancer surgery was studied in 26 patients who underwent the procedure after modified posterior pelvic exenteration (n=24) or colorectal resection (n=2) in an effort to achieve optimal cytoreduction.
“To the extent of our knowledge, this is the first study in which ghost ileostomy has been performed for the treatment of patients with ovarian cancer. Ghost ileostomy was successfully performed in 26 patients with any related complication observed in the postoperative course and less than 30 days after surgery,” the investigators wrote in the International Journal of Gynecological Cancer. They added that GI can be swiftly converted into a DI if AL is suspected.
Modified posterior pelvic exenteration was performed in 24 patients with a first diagnosis of ovarian cancer and in two who underwent rectosigmoid resection owing to relapse of disease. Mean age of patients was 53.8 years at diagnosis; 61.5% were postmenopausal.
The tumor histology was serous in 22 cases (84.6%), malignant mixed Müllerian tumor in 2 cases (7.7%), and undifferentiated tumor in 2 cases (7.7%). Three tumors were classified as low grade (11.4%) and 17 as high grade (88.6%). Seven patients were staged as FIGO II (26.6%); 13 patients as FIGO III (50%), and 4 as FIGO IV (15.4%). Staging was not applicable in the two patients with relapsed disease.
GI was performed after modified pelvic exenteration or colorectal resection followed by anastomosis. A portion of terminal ileum distant from the ileocecal valve was identified, and the afferent and efferent portions of the terminal ileum were marked with a long and short stitch, respectively.
A small orifice was dissected in the mesenteric border to pass a vessel loop, which was placed at the point of the theoretical stoma. If no leakage was found, the loop was removed. If leakage was found at the rectoscopy, diverting ileostomy was performed without relaparotomy. If leakage was suspected clinically, the GI was converted into a DI.
Additional procedures were required in most patients to achieve optimal cytoreduction. The most common was omentectomy in 2.3% of cases. Rates of cytoreduction were 69.3% (R0), 19.2% (R1), and 11.5% (R3).
Two major intraoperative complications occurred: one vascular injury that required multiple transfusions during repair, and one small bowel injury in which primary closure was needed. Transfusion was performed in five patients.
Two patients required conversion of the GI to DI. Sixteen patients (61.5%) had grade 2 complications and six (23%) had grade 3 complications. One patient (5%) had a grade 4 complication: complete atrioventricular block associated with noninfective endocarditis.
Fourteen patients had at least one risk factor for AL, which included low serum albumin level (
No patient who underwent GI had clinically apparent AL. No other complication related to the GI or DI was observed during the 30-day postoperative course. Chemotherapy was administered to all patients within 4 weeks after surgery.
“The current study highlights the usefulness of an alternative technique to diverting ileostomy called ghost ileostomy in the context of cytoreductive surgery due to ovarian cancer,” the authors concluded.
To date, neither DI nor GI has demonstrated a reduction of the incidence of AL in patients with ovarian cancer, but both could diminish its severity, according to the authors.
To read more about this study, click here.