EP647 - Use Of Double-Barrel Wet Colostomy As Part Of Pelvic Exenteration: A Case Series

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Purpose/Background: Pelvic exenteration is a highly morbid operation employed for locally advanced or recurrent pelvic malignancies. It frequently requires simultaneous urinary and fecal diversion to facilitate oncologic resection with en bloc removal of pelvic organs. Creation of separate stomas for diversion of urine and stool is currently the most popular technique employed. Use of a single stoma double-barrel wet colostomy (DBWC), however, is a technique unfamiliar to many surgeons participating in these operations that has several distinct advantages, including patient preference to manage a single stoma, cost of stoma supplies with limitations in insurance coverage, preservation of unilateral rectus abdominis muscle for perineal myocutaneous flap reconstruction, and simplicity, particularly in palliative cases as this approach avoids creation of an anastomosis and a second stoma. We present a case series including outcomes of four patients with complex pelvic malignancies who underwent DBWC during pelvic exenteration.

Methods/Interventions: Consecutive patients undergoing pelvic exenteration with DBWC at our rural tertiary referral institution between 2023 and 2024 were identified. Management decisions were made by a multidisciplinary team including colorectal surgery, urologic oncology, gynecologic oncology, and plastic surgery. DBWC was created by three surgeons with no prior experience with this technique. Post-operative outcomes including return of bowel function, duration of urinary stents, post-operative renal function, overall and stoma-specific complications, hospital length of stay, readmission and mortality were recorded.

Results/Outcomes: Four patients who underwent urinary and fecal diversion DBWC were followed. Indications for surgery included rectal cancer with bladder invasion, recurrent cervical cancer with vesicovaginal fistula, recurrent vulvar carcinoma with chronic radiation-induced pelvic osteomyelitis, and recurrent anal cancer with post-radiation rectourethral fistula. In three cases DBWC was pursued due to anticipated need for perineal rectus abdominis flap reconstruction and one was for patient preference and associated cost of stoma supplies. Post-operative length of stay was five, 12, 25, and 26 days. Ureteral stents were removed between 24 and 33 days in all patients. One patient had no complications, three had minor complications (Clavien-Dindo ≤2) including superficial wound abscess, DVT, and pyelonephritis requiring IV antibiotics. No ostomy-related complications were identified, and no patients have required reoperation. Three patients have had stable kidney function and one patient with a notable decline. There were no mortalities at 90-days and one patient succumbed of metastatic disease 10-months following surgery. The associated table details post-operative outcomes.

Conclusion/Discussion: With improvement of oncologic outcomes in complex pelvic malignancies, careful consideration for fecal and urinary diversion techniques become increasingly important. We present promising outcomes of four patients who underwent pelvic exenteration with DBWC. This approach is safe and feasible, enabling myocutaneous flap reconstruction of perineal defects and long-term patient management of a single stoma. Importantly, creation of a DBWC was performed by surgeons with no prior experience with the technique, suggesting a simple learning curve for utilization in appropriately selected patients.