Complications after double-barreled wet colostomy compared to separate urinary and fecal diversion during pelvic exenteration: Time to change back?

doi:10.1016/j.ygyno.2012.08.004

Gynecologic Oncology

Volume 128, Issue 1, January 2013, Pages 60-64

https://doi.org/10.1016/j.ygyno.2012.08.004 Get rights and content

Abstract

Objective

To assess complications associated with double-barreled wet colostomy (DBWC) in the first six months after pelvic exenteration as compared to separate urinary and fecal diversion (SUD).

Methods

A single institution retrospective chart review was conducted of all patients who underwent a pelvic exenteration between 2000 and 2011. Patients were included if the procedure involved at least a urinary diversion and a perineal phase. Patient demographics and complications in the first 6 months after surgery were recorded.

Results

Thirty-three patients met inclusion criteria (12 DBWC and 21 SUD). The majority of patients had recurrent cervical cancer (58%) followed by vaginal, vulva, and endometrial cancer. All patients had previously received radiation. 10/12 patients with a DBWC and 67% of SUD had pelvic reconstruction. Median length of stay (LOS) was shorter for DBWC (14.5 vs. 20 days, p = .01). Median operating times were shorter for DBWC (610 vs. 702 minutes, p = .04). No urinary conduit or anastomotic bowel leaks occurred in the DBWC group compared to 5 (24%) and 2 (9.5%), respectively, in the SUD group (p = .06 for any leak). 58% of the DBWC and 62% of the SUD group required re-operation, and there were no 30-day peri-operative deaths.

Conclusions

DBWC can be performed safely at the time of pelvic exenteration. We found reduced operating times, shorter LOS, and a trend toward fewer urinary conduit and/or bowel anastomotic leaks in DBWC exenteration patients. DBWC may be favorable over more technically challenging SUD in this heavily radiated population that generally has a limited overall survival.

Highlights

► Double-barreled wet colostomy is a safe option at the time of pelvic exenteration. ► We found a trend towards fewer conduit and anastomotic leaks than seen with separate urinary and fecal diversions. ► It decreases the length of stay, reduces operating times, and allows for time for pelvic reconstruction.

Introduction

Pelvic exenteration is an extensive, ultra-radical operation that consists of multiple complicated procedures. Even in the modern days the peri-operative mortality is still 0–12% and complications occur in 50–85% of patients [1], [2], [3], [4], [5], [6]. A significant component of the wide constellation of complications possible in a patient undergoing pelvic exenteration is associated with urinary diversion and includes anastomotic breakdown, infection, ureteric stricture, pouch leak, stone formation, incontinence, and renal dysfunction [1], [2], [3], [4], [7]. Candidates for a curative pelvic exenteration for gynecologic malignancies are almost always heavily radiated, and may even need a laterally extended endopelvic resection (LEER) to clear all disease [8]. Both extensive surgery and prior radiation may further increase morbidity [5], [8], [9]. In order to reduce postoperative complications several experts have advocated that pelvic reconstruction become a standard component of exenteration with the goal of filling empty space, enhancing vascularity and reducing adhesive disease and fistula formation [10], [11], [12], [13]. The meticulous dissection required for a radiated pelvis and/or LEER and pelvic reconstruction are of utmost importance, but also time consuming. In search of a relatively fast and easy option for urinary diversion with a potentially lower rate of complications we started offering our patients double-barreled wet colostomy (DBWC) in 2006, encouraged by one of our local urologists (RB).

The wet colostomy was first described by Brunschwig in 1948 [14]. In the original description the ureters were implanted proximal to the colostomy. This technique fell out of favor due to frequent urinary tract infections, metabolic abnormalities (hyperchloremic and hypocalcemic acidosis), kidney disease, and large volumes of watery malodorous stool [15]. In 1989 Carter et al. [16] reported a modification of the wet colostomy, the double barreled wet colostomy (DBWC), which includes the construction of a loop colostomy with division of the colon approximately 10 to 15 cm distal to the ostomy. The segment of colon distal to the stoma, the urinary limb, acts as a urinary conduit in which the ureters are reimplanted (Fig. 1). Carters initial experience with the first 11 patients was favorable and complications were minor [17]. The technique was readily adopted by colorectal surgeons and urologists and was found to be safe and simple. Postoperative mortality for pelvic exenterations with DBWC, in patients with a variety of pelvic malignancies varied from 0–11.5%, but morbidity is still high at 53.8–78% [18], [19], [20]. The objective of this study was to describe our experience and assess the surgical outcomes associated with double-barreled wet colostomy versus separate urinary (and fecal) diversion at the time of pelvic exenteration for gynecologic malignancies.

Section snippets

Methods

The Ohio State University and James Cancer Hospital institutional review board approved of this study. A single institution retrospective chart review was conducted of all patients who underwent a pelvic exenteration with curative intent between 2000 and 2011. We started offering our patients double-barreled wet colostomy (DBWC) in 2006, encouraged by one of our local urologists (RB). Sine 2009 we have solely performed DBWCs if a conduit was required per surgeon preference.

Patients were

Results

Thirty-three patients were identified between 2000 and 2011. Twelve had a DBWC and 21 had a separate urinary diversion (SUD) with or without a separate intestinal diversion (Table 1). The majority of patients had recurrent cervical cancer (58%) followed by vaginal, vulva, and endometrial cancer (Table 2). All patients had received full dose pelvic radiation. Patients with a uterus in place received intercavitary or interstitial brachytherapy in addition to external beam radiation. Patients with

Discussion

Pelvic exenteration is a very extensive and long operation that is associated with a high rate of peri-operative morbidity and even mortality. Several techniques of pelvic reconstruction and urinary and fecal diversions have been reported. This review provides the first comparison of peri-operative outcomes after double-barreled wet colostomy as compared to separate urinary and fecal diversion performed at the time of pelvic exenteration for gynecologic malignancies. We found reduced operating

Conflict of interest statement

None of the authors have reported a conflict of interest, except Dr Bahnson who is a principal investigator for a kidney cancer clinical trial with Aveo Pharmaceuticals.

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Pelvic exenteration is a radical procedure used to treat locally advanced and/or recurrent pelvic malignancies. Different reconstruction options exist, the most popular being the end colostomy with ileal conduit. The double barrel wet colostomy (DBWC) offers concomitant fecal and urinary diversion through a single stoma, but is infrequently utilized. We aim to review the evidence base of the postoperative complications, long-term oncologic risks and quality of life following creation of a double barrel wet colostomy.
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