ABSTRACT
PURPOSE: To ease anesthesia and inpatient strain during the COVID-19 pandemic, our institution's policy for hybrid intracavitary-interstitial brachytherapy (IC/ISBT) for cervical cancer (CC) was modified from multiple applications (MA) treated over 2 separate weeks (7 Gy × 4) to a single-application (SA), treated within 1 week (8 Gy × 3). Here, we assessed dosimetric quality of the SA hybrid IC/ISBT approach and report our early outcomes. MATERIAL AND METHODS: This was an IRB-approved retrospective review of CC patients treated with magnetic resonance imaging (MRI)-guided hybrid IC/ISBT between April 1, 2020 and December 31, 2020 (COVID cohort). Treatment parameters and quality indicators were compared to hybrid IC/ISBT cases treated in 2 years prior (pre-COVID cohort). Differences between cohorts were evaluated with the Mann-Whitney U-test. RESULTS: In the COVID compared to pre-COVID cohort, median high-risk clinical target volume (HR-CTV) was similar: 33.3 vs. 33.9 cc, as was cumulative HR-CTV D90%: 81.2 vs. 80.9 Gy. Organ-at-risk D2cc values and recto-vaginal point doses were similar. Median number of channels loaded was increased to 6 vs. 4 (p = 0.002), but percentage of total dwell time allocated to needles remained similar: 13% vs. 15%. Median implant HR-CTV D90% was higher: 107.8% vs. 98.4% (p = 0.001), and there was a trend toward reduced overall treatment time (OTT): 44 days vs. 53 days (p = 0.1). Local control was achieved in all patients, but mucosal toxicity was higher in the COVID group, with grade 2 or higher vaginal, genitourinary, or gastrointestinal events recorded in 56% of the patients. CONCLUSIONS: The SA hybrid IC/ISBT approach utilized during the COVID-19 pandemic maintained similar plan characteristics as pre-pandemic MA hybrid cases, while simultaneously reducing anesthesia, inpatient resources, and OTT. Local control outcomes demonstrate the regimen was effective; however, given the increased risk of mucosal toxicity, we conclude that the SA regimen should be considered only when a MA schedule is not feasible.
ABSTRACT
STUDY OBJECTIVE: To demonstrate a surgical video wherein a robot-assisted colostomy takedown was performed with anastomosis of the descending colon to the rectum after reduction of ventral hernias and extensive lysis of adhesions. DESIGN: Case report and a step-by-step video demonstration of a robot-assisted colostomy takedown and end-to-side anastomosis. SETTING: Tertiary referral center in New Haven, Connecticut. A 64-year-old female was diagnosed with stage IIIA endometrioid endometrial adenocarcinoma in 2015 when she underwent an optimal cytoreductive surgery. In addition, she required resection of the sigmoid colon and a descending end colostomy with Hartmann's pouch, mainly secondary to extensive diverticulitis. After adjuvant chemoradiation, she remained disease free and desired colostomy reversal. Body mass index at the time was 32 kg/m2. Computed tomography of her abdomen and pelvis did not show any evidence of recurrence but was notable for a large ventral hernia and a parastomal hernia. She then underwent a colonoscopy, which was negative for any pathologic condition, except for some narrowing of the distal rectum above the level of the levator ani. INTERVENTIONS: Enterolysis was extensive and took approximately 2 hours. The splenic flexure of the colon had to be mobilized to provide an adequate proximal limb to the anastomosis site. An anvil was then introduced into the distal descending colon through the colostomy site. A robotic stapler was used to seal the colostomy site and detach it from the anterior abdominal wall. Unfortunately, the 28-mm EEA sizer (Covidien, Dublin, Ireland) perforated through the distal rectum, caudal to the stricture site. A substantial length of the distal rectum had to be sacrificed secondary to the perforation, which mandated further mobilization of the splenic flexure. The rectum was then reapproximated with a 3-0 barbed suture in 2 layers. This provided us with approximately 6- to 8-cm distal rectum. An end-to-side anastomosis of the descending colon to the distal rectum was performed. Anastomotic integrity was confirmed using the bubble test. Because of the lower colorectal anastomosis, a protective diverting loop ileostomy was performed. The patient had an uneventful postoperative course. A hypaque enema performed 3 months after the colostomy takedown showed no evidence of anastomotic leak or stricture. The ileostomy was then reversed without any complications. CONCLUSION: Robot-assisted colostomy takedown and anastomosis of the descending colon to rectum were successfully performed. Although there is a paucity of literature examining this technique within gynecologic surgery, the literature on general surgery has supported laparoscopic Hartmann's reversal and has demonstrated improved rates of postoperative complications and incisional hernia and reduced duration of hospitalization [1]. Minimally invasive technique is a feasible alternative to laparotomy for gynecologic oncology patients who undergo colostomy, as long as the patients are recurrence free.