Evaluating the Association of Fecal Diversion with Morbidity in Patients Undergoing CRS/HIPEC with Pelvic Anastomoses: A Systematic Review and Meta-analysis

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an established treatment for peritoneal surface malignancies, but is associated with substantial morbidity, particularly when pelvic anastomoses are performed. Diverting ostomies are commonly used to mitigate complications related to anastomotic leak; however, ostomy formation carries its own morbidity, and its benefit in this setting remains controversial. PubMed and Embase were queried for studies of patients undergoing CRS/HIPEC with a pelvic anastomosis, documented use of diverting ostomy, and reported anastomotic leak rates. Eligible studies required combined CRS/HIPEC, explicit reporting of diversion status, and perioperative outcomes stratified by ostomy presence. Abstracts were independently screened by two reviewers, followed by full-text review for final inclusion. A binary odds ratio meta-analysis was performed comparing anastomotic leak between diverted and non-diverted patients. Of 506 studies identified, 10 met inclusion criteria and were combined with our institutional cohort, comprising 1506 patients. Overall, diversion was not associated with a statistically significant reduction in anastomotic leak (OR 0.67, 95% CI 0.32–1.39, p = 0.28). No differences were observed in grade ≥ 3 complications or length of stay. Diversion was associated with increased 60-day readmissions (OR 3.29, 95% CI 1.52–7.11, p < 0.01). Diverting ostomies were not associated with a statistically significant reduction in anastomotic leak in patients undergoing CRS/HIPEC with a pelvic anastomosis. These findings suggest consideration of a selective, rather than routine, diversion strategy in appropriately selected patients.