Stoma Creation and Reversal After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

INTRODUCTION: Cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC) often includes stoma creation. We evaluated the indications, morbidity, and mortality associated with stoma creation and reversal after CRS/HIPEC. METHODS: Retrospective analysis of a prospective database of 1149 CRS-HIPEC procedures was performed. Patient demographics, type of malignancy, comorbidities, Clavien-graded morbidity, mortality, indications for stoma creation, and outcomes of subsequent reversal were abstracted. RESULTS: Sixteen percent (186/1149) of CRS/HIPEC procedures included stoma creation, whereas 1.1 % (11/963) of patients without initial stoma creation developed anastomotic leaks requiring stoma. Patients who required a stoma had worse preoperative performance status (ECOG 0/1: 77.2 vs. 86.1 %, p = 0.002), greater burden of disease (PCI 17.6 vs. 12.9, p < 0.0001), and were more likely to have R2 resections (74.5 vs. 48.8 %, p < 0.0001) than those without stoma creation. Stomas were intended to be permanent in 17.5 % (35/199). Of 164 patients with potentially reversible ostomies, only 26.2 % (43/164) underwent reversal. Disease progression (43/164, 26.2 %) and death (40/164, 24.3 %) most commonly precluded reversal. After reversal, 27.9 % (12/43) suffered a Clavien I/II morbidity, 27.9 % (12/43) suffered Clavien III/IV morbidity, and 30-day mortality was 4.7 % (2/43). Anastomotic leak occurred after 9 % (3/33) of ileostomy and 10 % (1/10) of colostomy reversals. CONCLUSIONS: Stomas are more common among CRS/HIPEC patients with a high burden of disease and poor functional status. Reversal is uncommon and is associated with significant major morbidity. Preoperative counseling for those with high disease burden and poor functional status should include the risk of permanent stoma.

Postinflammatory changes of the diaphragmatic stomata.

Numerous investigations concerning the fine morphology of diaphragmatic stomata have been performed, but its ultrastructural changes in experimental conditions remain unclear. The present study demonstrates the peritoneal side of the diaphragm in adult Wistar rats by transmission electron microscopy. Ten experimental animals were observed 5 and 8 days after Pseudomonas aeuriginosa instillation (PI) into the peritoneal cavity. A control group of 6 rats showed flat mesothelial covering on basal lamina (BL) and connective tissue layer, as well as cubic mesothelial cells, single stomata over underlying lymphatic lacunae (LL). Five days after PI the mesothelial cells had more numerous microvilli, microvesicles, vacuoles, lysosomes and a lesser number of specialized contacts. The multiplication of the extravasal cells and larger intercellular spaces lead to thickenings of the connective tissue around LL. LL were larger and located in close proximity of the mesothelium. Intercellular spaces in the mesothelial layer and different types of contacts between mesothelial cells and endothelial protrusions of LL (with common BL or without BL) were encountered. Eight days after PI the mesothelium, endothelium of LL, their BL and surrounding connective tissue were interrupted and structurally modified to form typical new channels--stomata. The larger portion of the channels were formed of mesothelial cells, while the endothelial cells participated in the submesothelial part. LL were more numerous than in the previous period, and were arranged in groups. LL increased their vertical (50.59 microm) and horizontal (155.57 microm) diameter, as compared with control animals (respectively 12.37 microm and 74.08 microm). Neighbouring LL were separated by thin or thick septae. Peristomatal mesothelial cells or more rarely endothelium formed valve- or bridge-like structures. Valves on the opposite side of LL were observed. Groups of electron-dense bodies characterized some tall endothelial cells of LL. Cubic mesothelium, endothelium of the LL, both BL, the cell connections that formed new stomata, LL and surrounding connective tissue underwent rapid and parallel changes after PI. Among these elements of the lymphatic regions mentioned above, the mesothelium and endothelium of LL had a main role in experimental conditions.