DISCUSSION
This is the first report for the surgical procedures for early ovarian
cancer as far as we know. The objective of this study is to know the
surgical effort to remove all suspicious metastatic lesions and the
pathological outcomes in the surgical management of early epithelial
ovarian cancer. Resection of the rectosigmoid colon with accompanying
pelvic peritonectomy was required in approximately one-third patients
with early epithelial ovarian cancer for complete removal of all
suspicious metastatic lesions.
In advanced ovarian cancer, the benefits of resection of the
rectosigmoid colon as part of cytoreductive surgery was reported by
several investigators.11-14 The rate of leakage and
fistula was 1.7-3.1% and 0-3.3% after resection of the rectosigmoid
colon and primary anastomosis in patients with advanced ovarian
cancer.11, 13, 14 In the current study, no leakage and
fistula were identified.
Resection of the rectosigmoid colon and primary anastomosis could be
easily and safely performed in early ovarian cancer compared to advanced
ovarian cancer. First, tension-free anastomosis was more easily
performed in early ovarian cancer patients. Because cancer invasion of
the colon was limited to the pelvis and the descending colon was free of
tumour which permits easier taking off the proximal colon for
anastomosis. Second, a more favoruable environment for postoperative
recovery after complete cytoreduction was allowed in patients with early
ovarian cancer. More than half of the patients with advanced ovarian
cancer had still peritoneal seeding after cytoreductive surgery in our
previous report.11 In the current study, complete
cytoreduction was possible in all patients with early ovarian cancer.
Third, adjuvant chemotherapy was skipped or minimized in patients with
early ovarian cancer compared to advanced ovarian cancer.
In the current study, endometriosis is the second common cause to
perform resection of the rectosigmoid colon in patients with early
ovarian cancer. It is not surprising because more than half of the
patient with stage I ovarian cancer has
endometriosis.1 In the surgical field, the
differentiation of endometriosis from metastatic ovarian cancer is
difficult. Many epidemiologic, histologic, and molecular studies
revealed that endometriosis is a precursor lesion of ovarian
cancer.15-17 Endometriosis at the rectum could cause
pain on defecation and the most effective surgical treatment is
full-thickness excision of the anterior rectal wall or segmental
resection of the rectum.8 Therefore, we can raise the
potential benefit of resection of the rectosigmoid colon in early
ovarian cancer patients.
Special consideration was required to minimize the resection of cancer
or endometriosis free rectum. We did not split between the rectum and
uterus to avoid possible disrupt and seeding of cancer during surgical
procedures. If there is adhesion between the rectum and uterus, we
remove them en bloc. Four patients who underwent resection of the
rectosigmoid colon had neither cancer nor endometriosis. Two patients
had endometriosis-related adhesion between the rectum and uterus because
they had no previous operation history and revealed peri-adnexal
endometriosis. And another two patients had a previous history of
abdominal operation.
Selection bias and other confounders found in retrospective studies were
also possibilities in this study, and we made an effort to minimize the
selection bias and confounders as much as possible. The incidence of
co-existing endometriosis was obtained from a retrospective review.
Therefore, the incidence of endometriosis may increase if more sections
to identify endometriosis are obtained from the tumours in a prospective
setting.
In conclusion, resection of the rectosigmoid colon with adjacent pelvic
peritonectomy is required in 28.8% of the patients with early ovarian
cancer for complete removal of all suspicious metastatic lesions in the
pelvis. Cancer invasion, endometriosis, and fibrosis and/or adhesion are
the cause to perform resection of the rectosigmoid colon in such
patients.
Contribution to authorship :
Conception: MC Lim, SY Park
Planning: MC Lim
Carrying out, analysing and writing up of the work: Myong Cheol Lim,
Sang-Soo Seo, Sokbom Kang, Sun Ho Kim, Chong Woo Yoo, Sang-Yoon Park