Low colorectal anastomosis after radical pelvic surgery: A risk factor analysis

OBJECTIVE: This study was conducted to analyze our experience with low (8-1 2 cm above the anal verge) and very low (<6 cm above the anal verge) colore ctal resection and primary anastomosis at the time of radical en bloc resec tion of pelvic malignancies. STUDY DESIGN: A retrospective review of 77 patients undergoing supralevator pelvic exenteration with low colorectal resection and primary anastomosis in our gynecologic oncology service was carried out. Data were obtained fro m patient medical records and from the tumor registry. Univariate statistic al analysis of the data was used. RESULTS: The distribution of primary malignancies in this cohort was as fol lows: 33 (43%) recurrent or primary cervical carcinomas, 27 (35%) primary o r recurrent ovarian carcinomas, 7 (9%) recurrent vaginal carcinomas, 4 (5%) endometrial carcinomas, 3 (4%) colon carcinomas, and 3 (4%) cases of stage IV endometriosis. Forty patients underwent total pelvic exenteration, and 37 patients underwent posterior exenteration. Thirty-six patients in the to tal pelvic exenteration group had a history of pelvic irradiation. Twelve ( 30%) of these patients had development of breakdown or fistulas of the anas tomosis. Six of the 12 patients (50%) had undergone protective colostomy. T hirty-seven patients underwent posterior exenteration with primary anastomo sis for ovarian cancer, endometrial cancer, colon cancer, or endometriosis, and only 1 of these had received pelvic irradiation. This patient did not have a protective colostomy, and a rectovaginal fistula developed. in addit ion, there were 3 other breakdowns in the posterior exenteration group. Fin ally, the presence of preoperative ascites did not appear to alter the brea kdown rate of the anastomosis among the patients with ovarian cancer who un derwent cytoreductive surgery. CONCLUSION: Radical resection of pelvic tissue remains a crucial part of th e armamentarium of the gynecologic oncologist. Previous pelvic irradiation appears to be a major risk factor (35% vs 7.5%) for anastomotic breakdown a nd fistulas, independent of the presence of a protective colostomy. The ove rall results appear to be better for patients undergoing this procedure as part of a posterior exenteration.