Visceral segmental serosectomy during debulking surgery for advanced ovarian and fallopian tubal cancer

Abstract

Objectives: To evaluate the effect and safety of conservatively ablative operation as an alternative to low anterior resection (LAR) on postoperative outcomes and survival in patients with advanced ovarian cancer. Methods: We collected data of patients with stage IIB to IVB ovarian cancer who underwent conservatively ablative operation or LAR from January 2013 to May 2020. Visceral segmental serosectomy (VSS) was conducted as conservatively ablative operation when tumors were not involved in the descending colon over the rectosigmoid colon and did not invade the mucosal layer of the rectosigmoid colon. The extent of surgery and all procedures were performed by a single gynecologic oncologist for minimizing the selection bias, based on total parietal peritonectomy and ultra-radical surgery. Especially, VSS was preferred when tumors involved the rectosigmoid colon within 18 cm because it was considered safe without tension increasing postoperative leakage. Results: A total of 83 patients were divided into the following three groups: VSS (n=44); LAR1 including patients with the rectosigmoid colon involved by tumors within 18 cm (n=18); LAR2 including patients with the rectosigmoid colon involved by tumors over 18 cm (n=21), which showed no difference in clinico-pathologic characteristics. Left diaphragm peritonectomy, right paracolic peritonectomy, and left paracolic peritonectomy were more frequently performed in VSS, LAR2 than in LAR1 (45.5% and 61.9% vs 22.2%; 68.2% and 66.7% vs 27.8%; 25% and 42.9% vs 22.2%; p<0.05). Splenectomy, cholecystectomy, portal triad stripping were more frequently performed in LAR2 and VSS than in LAR1 (81% and 61.4% vs 38.9%; 47.6% and 31.8% vs 11.1%; 42.9% and 25% vs 5.6%; p<0.05), whereas small bowel resection and anastomosis was more common tendency in LAR1 and LAR2 than in VSS (22.2% and 33.3% vs 9.1%; 11.1; p=0.052). Moreover, LAR2 showed longer operation time (median, 440 vs 300 and 343 mins; p=0.008), and more estimated blood loss (median, 2800 vs 1450 and 1615 mL; p=0.007) than VSS and LAR. VSS was a favorable prognostic factor affecting overall survival (adjusted HR 0.157; 95% confidence interval 0.035-0.696; p=0.015). Conclusions: Conservatively ablative operations such as VSS can be performed safely in AOC patients with tumors involving the rectosigmoid colon within 18 cm. Moreover, extensive involvement of the rectosigmoid colon over 18 cm may represent tumor biology affecting poor prognosis. To evaluate the effect and safety of conservatively ablative operation as an alternative to low anterior resection (LAR) on postoperative outcomes and survival in patients with advanced ovarian cancer. We collected data of patients with stage IIB to IVB ovarian cancer who underwent conservatively ablative operation or LAR from January 2013 to May 2020. Visceral segmental serosectomy (VSS) was conducted as conservatively ablative operation when tumors were not involved in the descending colon over the rectosigmoid colon and did not invade the mucosal layer of the rectosigmoid colon. The extent of surgery and all procedures were performed by a single gynecologic oncologist for minimizing the selection bias, based on total parietal peritonectomy and ultra-radical surgery. Especially, VSS was preferred when tumors involved the rectosigmoid colon within 18 cm because it was considered safe without tension increasing postoperative leakage. A total of 83 patients were divided into the following three groups: VSS (n=44); LAR1 including patients with the rectosigmoid colon involved by tumors within 18 cm (n=18); LAR2 including patients with the rectosigmoid colon involved by tumors over 18 cm (n=21), which showed no difference in clinico-pathologic characteristics. Left diaphragm peritonectomy, right paracolic peritonectomy, and left paracolic peritonectomy were more frequently performed in VSS, LAR2 than in LAR1 (45.5% and 61.9% vs 22.2%; 68.2% and 66.7% vs 27.8%; 25% and 42.9% vs 22.2%; p<0.05). Splenectomy, cholecystectomy, portal triad stripping were more frequently performed in LAR2 and VSS than in LAR1 (81% and 61.4% vs 38.9%; 47.6% and 31.8% vs 11.1%; 42.9% and 25% vs 5.6%; p<0.05), whereas small bowel resection and anastomosis was more common tendency in LAR1 and LAR2 than in VSS (22.2% and 33.3% vs 9.1%; 11.1; p=0.052). Moreover, LAR2 showed longer operation time (median, 440 vs 300 and 343 mins; p=0.008), and more estimated blood loss (median, 2800 vs 1450 and 1615 mL; p=0.007) than VSS and LAR. VSS was a favorable prognostic factor affecting overall survival (adjusted HR 0.157; 95% confidence interval 0.035-0.696; p=0.015). Conservatively ablative operations such as VSS can be performed safely in AOC patients with tumors involving the rectosigmoid colon within 18 cm. Moreover, extensive involvement of the rectosigmoid colon over 18 cm may represent tumor biology affecting poor prognosis.