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

Abstract

ObjectivesThe aims of this study were to assess anastomotic leakage (AL) rate and risk factors for AL in patients with advanced epithelial ovarian cancer (EOC) undergoing cytoreductive surgery including bowel resections and to evaluate the prognostic implication of AL.MethodsData of 350 consecutive patients with International Federation of Gynecology and Obstetrics EOC stage IIB–IV who underwent cytoreductive surgery at the Department of General Gynecology and Gynecologic Oncology of the General Hospital of Vienna between 2003 and 2017 were collected. Within this cohort, 192 patients (54.9%) underwent at least 1 bowel resection and were further analyzed. Preoperative risk factors for AL were computed using logistic regression models. Prognostic factors for overall survival were evaluated by using log-rank tests and multivariable Cox regression model.ResultsOverall, the AL rate was 4.7% for patients with advanced EOC undergoing cytoreductive surgery with at least 1 bowel resection, including patients with multiple large bowel resections. The AL rate for patients with isolated rectosigmoid resection was 1.9%. In univariate analysis, the number of anastomoses per surgery (P = 0.04) was associated with the occurrence of AL. In multivariable analysis, rectosigmoid resection with additional large bowel resection was associated with a higher risk of AL compared with isolated rectosigmoid resection (P = 0.046; odds ratio, 7.23 [95% confidence interval, 1.04–50.39]). Anastomotic leakage was associated with decreased overall survival (P = 0.04) in univariate but not in multivariable survival analysis.ConclusionsAnastomotic leakage rate after rectosigmoid resection in advanced EOC is acceptably low and outweighs increased perioperative risks when performed in a high-volume institution. Nonetheless, the occurrence of AL is a severe adverse event, which even seems to negatively affect patients’ overall prognosis. As no factor could be identified to clearly predict AL, extensive procedures comprising multiple bowel resections, should be avoided particularly when complete resection cannot be achieved.

Anastomosis Is Possible with an Acceptable Low Rate of Complications Compared to a Diverting Stoma in Surgery for Ovarian Cancer

“…Grimm et al [9] report similar observations, as they could not identify pre-or intraoperative risk factors for leakage of bowel anastomosis, performed in relation to debulking surgery for ovarian cancer. The results in this study are also in agreement with those reported by Bartl et al [10], and indicate that bowel anastomosis may be performed with acceptable leakage rate even in elderly patients, and patients with comorbidity. In case of a leakage, early diagnosis and reoperation is important to minimize the consequences of the complications.…”

“…Based on the routine surveillance in this study, all the patients with a leakage (except for one), had acceptable delay in time to adjuvant chemotherapy which was initiated within 21-45 days after the primary surgery. The data showed a delay in time to chemotherapy within the same range as reported by Bartl et al [10]. The patients in this study had reoperation within 7-11 days after the primary surgery, whereas Bartl et al [10] had 2-17 days to revision.…”

“…The data showed a delay in time to chemotherapy within the same range as reported by Bartl et al [10]. The patients in this study had reoperation within 7-11 days after the primary surgery, whereas Bartl et al [10] had 2-17 days to revision. Unlike Bartl et al [10] there exists a standardized follow-up regime, as described above, with close post-operative surveillance.…”

“…In the literature, anastomotic leak rates range from 0.8% to 3.2% in surgery for gynecologic malignancy. The subsequent mortality rate after an anastomotic leakage after rectosigmoid resection is 7.3% to 16% [10,11]. This study found a 90-day mortality in less than 3% of patients with anastomosis, which is within the reported results by others.…”

“…The patients in this study had reoperation within 7-11 days after the primary surgery, whereas Bartl et al [10] had 2-17 days to revision. Unlike Bartl et al [10] there exists a standardized follow-up regime, as described above, with close post-operative surveillance. This to ensure diagnostics of leakage as soon as possible.…”