Ovarian cancer (OC) is the most fatal of all female reproductive cancers (1). The fatality rate of OC is the highest among gynecological malignant tumors. Its main characteristics are insidious onset, high malignancy and strong invasive ability. And most patients are diagnosed only in the middle and late stages of development. Cytoreductive surgery is a common surgical procedure for patients with stage III and above. Residual disease after primary surgery for ovarian cancer is the strongest prognostic factor affecting patient survival (2). More precisely, a 10% increase in the likelihood of achieving maximal or optimal cytoreductive surgery (no gross residual disease) is associated with a 5.5% increase in the average survival rate (3). The metastasis of advanced ovarian cancer is mainly by direct spread and intra-pelvic and abdominal dissemination, which can invade all segments of the intestinal canal. The rectosigmoid colon is anatomically close to the female pelvic organs and is the most commonly involved part of the intestine, accounting for 24-64% (4), followed by the ileocecal colon (5). Therefore, optimal tumor cytoreduction in advanced primary and recurrent disease usually requires radical upper gastrointestinal surgery and bowel segment resection (6). Total mesorectal resection (TME) is a commonly used surgical technique in colorectal surgery (7). It refers to the ligation of the superior rectal artery, through the areolar avascular plane along the mesorectum fascia down to the pelvic floor. Its advantage is that it can reduce the local recurrence rate (8), but increase the risk of local complications (9, 10). However, ovarian cancer cells primarily disseminate within the peritoneal cavity and are superficially invasive in most cases. In specific cases where no lymph node lesions are found at the beginning of the inferior mesenteric artery and the ratio of the length of the left colon to the extent of the colorectal cancer lesions is good, mesorectal-sparing resection with preservation of the superior rectal artery and mesorectal tissue can be performed, thus preserving the rectal mesenteric tissue and vascular supply (11). This method not only reduces the probability of local complications, but also ensures satisfactory tumor reduction. After intestinal surgery, there are usually some intestinal-specific complications. Anastomotic leakage (AL) is one of the most serious complications. In the OC study, the main risk factors were advanced age, low serum albumin level, multiple small bowel resection, manual anastomosis and short distance from anastomosis to anal margin (12). In colorectal surgery, surgeons usually use visual assessment and air leakage test to assess anastomotic rectal perfusion. Recently, gynecologists have found that near-infrared (NIR) angiography via proctoscopy can be used to evaluate rectal perfusion after rectosigmoidectomy and anastomosis. It provides an opportunity to identify poor perfusion, leading to the reinforcement or revision of the anastomosis (13). Transitory protective stoma (TPS) is another commonly used procedure to reduce the incidence of AL. It refers to pulling the small intestine out of the abdominal cavity and making a stoma in the abdominal wall after colorectal resection and anastomosis. It reduces complications by leaving out the intestines at the site of colorectal anastomosis. This article will describe the development for advanced ovarian cancer with digestive tract metastasis and the application status and value of TPS in ovarian cancer surgery.

Initially, gynecologic oncologists often perform end-to-end anastomosis after modified posterior pelvic exenteration (MPE) or colorectal resection to restore continuity of the gastrointestinal tract to achieve optimal cytoreduction (14, 15). An ideal anastomosis requires an adequate blood supply, tension-free serosal apposition, and an uncompromised lumen with a watertight seal (16). The two common methods of constructing an anastomosis are handsewn anastomosis (HA) and stapled anastomosis (SA). HA has been used for more than a century, and over time, various HA techniques have been invented and developed, including single-layer versus double-layer and inverting versus everting sutures. Historically, double-layer sutures were the technique of choice until the late 1970s. However, the double-layer suture is more technically challenging because it requires identifying each layer of the bowel and then separating them appropriately, which makes it more difficult to maintain suture tension. The higher demands on technique result in an increased risk of failure with double-layer sutures. Because it takes longer than single-layer sutures, excessive tissue handling can lead to severe tissue damage and avascular necrosis of the tendon sleeve, which can lead to anastomotic rupture. As an alternative, single-layer sutures became popular in the early 1980s. Single-layer sutures reduce the potential risk previously explained. But several authors have suggested that single-layer sutures also increase the risk of dehiscence because the suturing technique uses a submucosal suture technique with the serosal layer (17). For the use of inverting versus everting sutures, since the publication of Lembert, surgeons have generally advocated inverting sutures because it was thought that mucosal protrusion would lead to anastomotic rupture. However, in the 1960s, two clinical studies (18, 19) showed that good healing could also be achieved with an everting suture. In a series of subsequent studies, there was still no consensus conclusion (20–26). However, regardless of the type of manual suture, it causes a series of inflammatory reactions because dragging the suture through the intestinal wall could damage the tissue (23). Compared to non-absorbable or slowly absorbable sutures, absorbable sutures cause more tissue reactions (27–29), while compromising the strength of the anastomosis by dissolving too quickly. Therefore, non-absorbable sutures may be a better choice.

SA was recommended after validation in relatively small randomized trials conducted between 1970 and 2009 (30). The instrument is similar to a sigmoidoscope with a handle, except that the obturator (nose cone) of the sigmoidoscope protrudes beyond the cylinder. For a low rectal anastomosis, the instrument is inserted through the anus with the nose cone protruding distally. The distal end of the rectum is secured to the staple-carrying cylinder of the instrument with a purse-string suture. And the proximal rectum tied in a purse-string over the anvil-carrying nose cone. The nose cone is then aligned with the cylinder and the two ends of the bowel are anastomosed after excitation of the instrument (31). SA ensures uniformity of the suture and reduces tissue manipulation, so the inflammatory irritation caused is very mild and facilitates the healing of the incision. It also has a shorter operating time and hospital stay (32). The technical requirements are lower than for HA.

Although bowel resection-anastomosis is safe and feasible in PDS, its possible complications still cannot be ignored. AL is a common and serious complication after intestinal anastomosis (33). It has an incidence of 1.26%-9% in patients with ovarian cancer (34). There is no standard definition of AL, and most studies define it as unclean fluid draining from the stoma, incision, or vagina, definitive imaging evidence of anastomotic leakage, or AL confirmed by reoperation (33, 35). AL has now been shown to be an independent risk factor for reduced overall patient survival after cytoreductive surgery for ovarian cancer. Its development has been associated with multiple factors in the perioperative period. Advanced age, multiple bowel resections, low serum albumin levels (≤3 g/dL), and short distance from the anastomosis to the anal verge (<5-6 cm) are independent factors associated with the formation of AL (36–38). Poor postoperative blood supply to the intestinal anastomosis, hypertonicity, and a sharp increase in intestinal pressure during defecation and exhaust are also common causes of AL (39). This surgical complication leads to adverse oncological outcomes due to higher postoperative mortality and delayed duration of adjuvant chemotherapy (33). Adjuvant chemotherapy cannot be initiated in approximately one-third of AL patients (35).

In the field of colorectal surgery, the incidence of AL in the two surgical plans for constructing anastomosis was vary between studies published by different research centers. After analyzing studies of 1125 patients in seven randomized controlled trials published before 2009, Choy et al. found significantly fewer anastomotic leaks in SA compared to HA during ileocolic resection (30). Luglio G et al. updated the systematic review by Choy et al. in 2019 to include 6 trials and 995 patients (825 with cancer), in which SA had significantly less anastomotic leak than HA (1.3% vs. 6.6%; OR 0.28) (40), consistent with previous findings. But in a recent large sample analysis by Nordholm et al. the incidence of AL was found to be two times higher after surgery with SA than with HA, contrary to the results of a previous meta-analysis (41) In their study, Espin noted that the effect of AL on HA patients was much less than that on SA patients, and that HA patients were much less likely to have AL followed by reoperation after surgery and could mostly be cured by conservative treatment (42). Analyzing the results of studies from different centers, it is easy to see that HA is more challenging for the operator and takes longer to perform; SA is suitable for less experienced operators, but is more expensive (43). In low-risk procedures such as elective or laparoscopic surgery, the operator prefers to apply anastomosis, while in high-risk procedures such as emergency surgery and laparotomy, HA is more beneficial to reduce the incidence of AL, but also requires a more qualified operator to operate (44). A recently published study by Enomoto H et al., 2022 evaluated the incidence of anastomosis-related complications associated with the establishment of anastomosis after transanal total mesorectal excision for low rectal cancer using the stapler plus reinforced sutures procedure. All patients using the SA underwent additional HA on each round of the anastomotic line. The incidence of anastomosis-related complications, pelvic abscesses, and anastomotic stenosis was found to be significantly lower in this group of patients compared with HA (P < 0.001, P < 0.048, and P < 0.032) (45). This study provides a new idea for anastomotic construction, combining both anastomotic methods to achieve a reduction in associated complications.

In the field of gynecologic oncology, bowel surgery has become very common in PDS of advanced ovarian cancer. It benefited from the extensive surgical experience in colorectal surgery. But the higher rate of complications, especially AL, has not been fundamentally solved. When serious complications such as AL occur after intestinal anastomosis, they can only be addressed by the use of broad-spectrum antibiotics, placement of pelvic drainage, interventional radiotherapy, or secondary surgery (46, 47). Therefore, gynecologic oncologists urgently need a better approach to reduce the incidence of complications after intestinal anastomosis and to achieve a better prognosis for their patients.

In the past, we were conservative about performing TPS, partly because of the series of stoma-related complications during the stoma period, and partly because of the postoperative psychological changes in the patient and the difficulties in caring for the stoma on their own after discharge.

The incidence of specific complications after stoma surgery is high, about 21%-70% (105), including skin infections, electrolyte imbalance, dehydration, renal failure, parastomal hernia, and stoma retraction or prolapse (39). Of these, dehydration is the most common stoma-related complication and a major factor in rehospitalization of patients (106–109). This is usually associated with decreased small bowel absorption due to the chemotherapy the patient received postoperatively. In patients receiving an ileostomy, the overall fluid balance is very fragile and even small changes caused by less intake or more output (e.g. use of diuretics, etc.) can trigger fluid imbalances that gradually lead to dehydration and the need for readmission and intravenous fluids. Dehydration is a preventable ileostomy-related complication. Optimizing stoma placement through enterostomy treatment counseling, patient education, and using the most terminal small bowel stoma to maximize absorption of intestinal fluids are the primary goals for preventing ileostomy complications. All ileostomy patients should have their stoma outflow and inflow measured daily to achieve a unique fluid balance for each patient (107).

Also, the closure of the stoma is an issue of concern. The evidence on the timing of stoma closure is limited. Surgeons believe that the stoma should close no earlier than 60 to 90 days after sphincter-sparing proctectomy. This timing represents that the patient has recovered from the trauma of the initial surgery, intra-abdominal adhesions are more easily managed, and anastomotic inflammation and edema have resolved (110, 111). Delayed closure of the stoma also exposes patients to a variety of stoma complications, including poor stoma position, dehydration, acute renal failure, the need for parenteral nutrition, peristomal dermatitis, parastomal hernias, prolapse, retraction, and stricture (105). In the field of gynecologic oncology, the optimal timing of reversal remains unclear. Almost all patients undergoing PDS receive adjuvant chemotherapy postoperatively, which can cause the stoma return time to be prolonged accordingly. Therefore, more evidence-based medical evidence is needed to support the time to stoma return in patients with TPS. Most studies currently document a mean stoma reversal time of 6 months (35, 37, 62). The optimal time to stoma reversion is recommended to be 3-6 months (112). Delay in return time beyond 6 months will increase the length of hospital stay and complication rate (113).

Return of stoma is associated with a range of potential surgical complications. Shama et al. drew extensive data from a representative national database and found a major complication rate of 9.3% and a mortality rate of 0.6% for return of the stoma. Patient functional status, ASA classification, and organ dysfunction were independent predictors of complications after ileostomy closure (114). The main causes of morbidity were wound infection, bowel obstruction, incisional hernia and anastomotic leak (115). The choice of anastomotic approach will directly influence the occurrence of postoperative complications. There have been four randomized controlled trials comparing mechanical and manual suture techniques. Overall, the results were similar, with a higher risk of postoperative obstruction and longer operative times with manual sutures (116–119). Surgical site infection is also a common complication after stoma reduction, reported to occur in 2%-41% of patients (120, 121). Wound infection after stoma closure can have serious consequences such as wound dehiscence, incisional hernia, prolonged hospital stay and increased hospital costs. Many surgeons search for suitable sutures to reduce the incidence of surgical site infections. Banerjee first described the technique of subcutaneous suturing of the purse-string to reduce the size of the wound. This is a similar closure to that of the severed end after appendectomy. After placing the reanastomosed bowel back into the abdominal cavity, the rectus is repaired with interrupted sutures. The skin defect is then apposed with subcuticular sutures and purse-string drawn together, leaving a 5-mm gap. Any residual hematoma or exudate can be drained through the gap (122). This type of suture was shown to be superior in subsequent studies. In Milanci’s study, no incisional infection was observed with the purse-string suture method, whereas a 40% incisional infection rate was observed with the conventional linear suture method (P=0.002). Moreover, the long-term follow-up results showed higher patient satisfaction and better postoperative healing and cosmetic outcomes with the purse-string suture (121). Similar conclusions were reached by Daniel et al. 36.67% of patients had postoperative infection with the conventional linear suture method, whereas none were diagnosed in the purse-string group. Also, the healing time was 2.1 week faster in the purse-string suture group than the linear suture group (P < 0.0001) (115). This shows that a more optimal suture protocol results in a more aesthetically pleasing healing wound and a lower chance of infection for the patient.

According to studies, 75.8%-92% of patients with enterostomies after OC surgery undergo a closure program (37, 57, 66, 123), but a proportion of patients still convert to permanent enterostomy due to many reasons such as long-term antiangiogenetic maintenance treatment etc. The main reason for failure to return is recurrence or progression of the disease. For patients with tumor recurrence, the closure plan cannot be implemented, because it may interrupt the continuous treatment of the tumor. Therefore, CT imaging of the abdomen and serum tumor markers should be performed to rule out recurrence or progression of the disease prior to the implementation of the return program (57). The risk of postoperative intestinal obstruction is greatly increased when a closure is performed in patients with progressive ovarian cancer. In patients receiving neoadjuvant chemotherapy, although it is widely accepted that neoadjuvant chemotherapy increases the likelihood of R₀ resection, it is also an important risk factor for anastomotic healing, increasing the risk of anastomosis-related complications, and prolonging the time to stoma closure. While it reduces the probability of bowel resection in interval cytoreductive surgery (IDS), it does not reduce the incidence of enterostomy-related complications (124). In patients receiving cytoreductive surgery with heated intraperitoneal chemotherapy (HIPEC), the possibility of temporary stoma becoming permanent is greatly increased. In the study of Andrea et al., 78% of patients with stoma were converted to permanent stoma. In addition, stoma reversal in this group of patients is associated with significant major morbidity and mortality. This may be due to reduced physiologic reserve due to severe advanced malignancy pretreatment with previous surgery and multiple systemic chemotherapy. Therefore, patients with HIPEC with high disease burden should be carefully considered for stoma application and have a low probability of successful stoma reversal. Different stoma modalities and the patient’s own condition also influence the stoma return. In the study by M. F. Sier et al, independent predictors of non-reversal were terminal ileostomy, preoperative radiotherapy, body mass index and advanced age. Patients with loop ileostomy were 4.3 times more likely to have reversal than patients with terminal ileostomy. Also, the odds of reversal decreased by 3% per year with increasing age. The odds of reversal increased by 7% for each percentage point increase in body mass index (125). In addition, the lack of specialized treatment pathways for patients with TPS (37), cultural choices, and socioeconomic factors may contribute to non-reversal. The return of enterostomy is also often affected by chronic diseases such as diabetes (126). In the colorectal literature, advanced age and comorbidities are the most important risk factors for anastomotic non-reversal (127–129).

In addition to the impact of the surgery itself on the patient, the psychological impact of the stoma on the patient cannot be ignored. Research on the psychosocial problems of patients with stomas began about 50 years ago. For patients who eventually develop a stoma, they must initially deal with severe surgery, loss of important physical functions, image distortion, and significant and important changes in physical functioning and personal care (130–132). During hospitalization, the main stressors that affect patients’ emotions come from difficulty accepting a cancer diagnosis, adjusting to the presence of a stoma, dealing with various related emotions (e.g., shock, disgust, sadness, fear), learning practical skills for stoma self-care, and planning to return to normal activities. Slightly different stressors occurred after discharge, focusing on challenges with self-care and lifestyle adaptations. All of these changes affect aspects of the psychosocial domain of the patient’s life, sexual health, body image, or cultural and religious beliefs (131, 133–137). These physical and psychological stressors play a very important role in the adaptation and prognosis of the disease, as well as in the patient’s perceived quality of life (130, 138). They had a lower overall quality of life, poorer body image, reduced social activity, and significantly higher rates of depression and anxiety than patients without a stoma. Even a few months after discharge, patients had difficulty adjusting to changes in body image. Hortense et al. conducted a cross-sectional correlation study in Portugal to investigate the effects of colorectal cancer on the quality of life of 153 patients 6-8 months after surgery. The researchers found that patients with anastomosis had significantly lower levels of functioning and quality of life in terms of body image and sexual satisfaction, and significantly higher levels of depression compared to patients without anastomosis (139). Therefore, medical treatment of patients with stomas should be accompanied by positive guidance and education about their psychosocial needs, which can have a positive impact on quality of life and prognosis, and can reduce the length of hospitalization, frequency of postoperative complications and re-hospitalization (140).

There is a paucity of gynecologic oncology literature on TPS, and criteria for the use of TPS in the gynecologic oncology research field still rely heavily on subjective operator judgment and lack standardized surgical criteria. Our assumptions and management decisions are largely extrapolated from the colorectal cancer literature. In patients with known high-risk factors, the use of TPS may reduce the severity of postoperative intestinal complications, give patients more opportunities for conservative treatment, and improve their prognosis. However, the complications associated with TPS and the troubles associated with the stoma reversal should not be ignored. At the same time, the use of TPS should be carefully selected considering the complications associated with TPS and the impact on patients’ quality of life and psychosocial well-being. There is no strong evidence to support the routine use of TPS in patients with OC combined with bowel surgery. In the future, more evidence from large prospective trials is needed to support the use of TPS and to clarify the indications for performing TPS surgery. Selection of appropriate patients based on indications is essential and requires a customized postoperative care plan specifically for the stoma population.

LO put forward the proposition. JH drafted the manuscript. JL, BF, LY collected literatures. LO revised the final manuscript. All the authors contributed to this article and approved the submitted version.