Multiple large bowel resections: Potential risk factor for anastomotic leak

Abstract

Objectives Identify risk factors of anastomotic leak (AL) after large bowel resection (LBR) for ovarian cancer (OC) and compare outcomes between AL and no AL. Methods All cases of AL after LBR for OC between 01/01/1994-05/20/2011 were identified and matched 1:2 with controls for age (+/−5years), sub-stage (IIIA/IIIB;IIIC;IV), and date of surgery (+/−4years). Patient-specific and intraoperative risk factors, use of protective stomas, and outcomes were abstracted. A stratified conditional logistic regression model was fit to determine the association between each factor and AL. Results 42 AL cases were evaluable and matched with 84 controls. Two-thirds of the AL had stage IIIC disease and >90% of both cases and controls were cytoreduced to <1cm residual disease. No patient-specific risk factors were associated with AL (pre-operative albumin was not available for most patients). Rectosigmoid resection coupled with additional LBR was associated with AL (OR=2.73, 95%CI 1.13–6.59, P=0.025), and protective stomas were associated with decreased risk of AL (0% vs. 10.7%, P=0.024). AL had longer length of stay (P<0.001), were less likely to start chemotherapy (P=0.020), and had longer time to chemotherapy (P=0.007). Cases tended to have higher 90-day mortality (P=0.061) and were more likely to have poorer overall survival (HR=2.05, 95%CI 1.18–3.57, P=0.011). Conclusions Multiple LBRs appear to be associated with increased risk of AL and protective stomas with decreased risk. Since AL after OC cytoreduction significantly delays chemotherapy and negatively impacts survival, surgeons should strongly consider temporary diversion in selected patients (poor nutritional status, multiple LBRs, previous pelvic radiation, very low anterior resection, steroid use).

Predictive and Prognostic Implication of Bowel Resections During Primary Cytoreductive Surgery in Advanced Epithelial Ovarian Cancer

“…This is in line with previous studies. 11,14 With respect to the prognostic implication of AL, it has to be kept in mind that the number of events, that is, patients with AL (n = 9), was limited in the present study. Anastomotic leakage was associated with shortened PFS and OS in univariate analysis.…”

Rectosigmoidian Involvement in Advanced-stage Ovarian Cancer – Intraoperative Decisions

“…The author demonstrated that the addition of another large bowel resection to rectosigmoidian resection associated with a significantly higher risk of anastomotic leak (p=0.025) while the decision of performing a protective ileostomy significantly decreased the risk of anastomotic leak (p=0.024). In the same study, other factors such as BMI value, ASA score, diabetes mellitus or smoking did not significantly influence the apparition of anastomotic leaks (23).…”

Ghost Ileostomy in Advanced Ovarian Cancer: A Reliable Option

“…5,7 Additional risk factors such prior pelvic radiation, anastomosis of less than 6 cm from the anal verge, failed leak test, or contamination of the pelvis with stool have been also reported. 13 In an effort to identify the indications for DI in the context of primary debulking surgery for ovarian cancer, only 2 factors were found to be associated with the decision of performing a DI: extended operating time and increased length of rectosigmoid resection.…”

“…5,7,12,14 Nonetheless, because of the lack of prognostic scores of AL, there is no clear indication regarding which cases would and would not benefit from DI. Ultimately, the surgeon has the choice to selectively perform a DI in case of colorectal anastomosis.…”