Chapter 14: Colorectal Anastomosis, Colostomy, and Small Bowel Anastomosis

BACKGROUND

The first step in understanding any surgery is achieving a clear overall picture of the patient. If the patient is healthy enough medically, nutritionally, and mentally to undergo debulking surgery, then the surgeon must have a concrete understanding of the anatomy involved.¹ Without a thorough understanding of the anatomy, many pitfalls and complications may occur. The anatomy of the entire abdomen needs to be under the purview of the gynecologic oncologist. Because gynecologic cancers do not remain confined to the pelvis, our anatomic knowledge cannot remain confined to the pelvis.

Morrow and Curtin² have previously elegantly illustrated that certain conditions must be met prior to creating any bowel anastomosis. First, healthy tissue with good blood supply needs to be used in both the afferent and efferent bowel limbs. If blood supply is questionable, then fluorescein dye with a wood’s lamp can be used to visualize the blood supply.³ Second, an adequate, nonstrictured, water-tight, hemostatic lumen must be created. Third, the anastomosis should be free of tension. Fourth, an anastomosis should not be created in the presence of established peritonitis. Applying these guidelinesto any bowel anastomosis is crucial.

INDICATIONS AND APPLICATIONS

The stomach at the proximal end of the small bowel is a site frequently involved with disease extending over from the lesser or greater omentum. Infrequently, disease is large enough to require wedge resection for complete cytoreduction or gastrojejunostomy for palliation secondary to a large node or mass obstructing the pylorus or proximal duodenum.^4,5 Hoffman et al⁶ described cases in which en bloc resection of the left upper quadrant intra-abdominal contents (including 2 cases of partial gastrectomy), was able to leave the patient with minimal residual disease. In a larger series, Walter et al⁴ have shown that partial gastrectomy (or wedge resection) can be safely performed in radical debulking of ovarian cancer.

The most common surgery performed on the small bowel (jejunum and ileum) in gynecologic oncology is small bowel resection with primary reanastomosis. This can be performed for a variety of reasons by gynecologic oncologists. The resection may be for obstruction by cancer, debulking of cancer, radiation damage causing fistula or stricture, or for dead or damaged bowel as a complication of therapy.

Bristow et al⁷ demonstrated the safety and utility of colorectal resection and reanastomosis in women with ovarian cancer. Three years later, Hoffman⁸ built upon their study and echoed the safety of similar procedures. Both of these papers showed that large resections of the colon could be safely performed to aid in cytoreduction. Silver and Walter separately have shown that subtotal colectomies can be safely performed in achieving complete cytoreduction.^9,10 These extensive resections with pouches (Figure 14-1) are associated with complications but are tolerated well by patients.¹¹ Once the protective ostomy is reversed, patients will ...