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      Risk Factors for Anastomotic Leakage in Advanced Ovarian Cancer Surgery: A Large Single-Center Experience

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          Abstract

          Background

          Cytoreductive surgery is currently the main treatment for advanced epithelial ovarian cancer (OC), and several surgical maneuvers, including colorectal resection, are often needed to achieve no residual disease. High surgical complexity carries an inherent risk of postoperative complications, including anastomosis leakage (AL). Albeit rare, AL is a life-threatening condition. The aim of this single-center retrospective study is to assess the AL rate in patients undergoing colorectal resection and anastomosis during primary surgery for advanced epithelial OC through a standardized surgical technique and to evaluate possible pre/intra- and postoperative risk factors to identify the population at greatest risk.

          Methods

          A retrospective analysis of clinical and surgical characteristics of 515 patients undergoing colorectal resection and anastomosis during primary or interval debulking surgery between December 2011 and October 2019 was performed. Several pre/intra- and postoperative variables were evaluated by multivariate analysis as potential risk factors for AL.

          Results

          The overall anastomotic leakage rate was 2.9% (15/515) with a significant negative impact on postoperative course. Body mass index < 18 kg/m 2, preoperative albumin value lower than 30 mg/dL, section of the inferior mesenteric artery at its origin, and medium–low colorectal anastomosis (< 10 cm from the anal verge) were identified as independent risk factors for AL on multivariate analysis.

          Conclusions

          AL is confirmed to be an extremely rare but severe postoperative complication of OC surgery, being responsible for increased early postoperative mortality. Preoperative nutritional status and surgical characteristics, such as blood supply and anastomosis level, appear to be the most significant risk factors.

          Supplementary Information

          The online version contains supplementary material available at 10.1245/s10434-022-11686-y.

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          Most cited references56

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          Cancer statistics, 2020

          Rebecca Siegel, Kimberly D Miller, Ahmedin Jemal (2020)
          Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on population-based cancer occurrence. Incidence data (through 2016) were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2017) were collected by the National Center for Health Statistics. In 2020, 1,806,590 new cancer cases and 606,520 cancer deaths are projected to occur in the United States. The cancer death rate rose until 1991, then fell continuously through 2017, resulting in an overall decline of 29% that translates into an estimated 2.9 million fewer cancer deaths than would have occurred if peak rates had persisted. This progress is driven by long-term declines in death rates for the 4 leading cancers (lung, colorectal, breast, prostate); however, over the past decade (2008-2017), reductions slowed for female breast and colorectal cancers, and halted for prostate cancer. In contrast, declines accelerated for lung cancer, from 3% annually during 2008 through 2013 to 5% during 2013 through 2017 in men and from 2% to almost 4% in women, spurring the largest ever single-year drop in overall cancer mortality of 2.2% from 2016 to 2017. Yet lung cancer still caused more deaths in 2017 than breast, prostate, colorectal, and brain cancers combined. Recent mortality declines were also dramatic for melanoma of the skin in the wake of US Food and Drug Administration approval of new therapies for metastatic disease, escalating to 7% annually during 2013 through 2017 from 1% during 2006 through 2010 in men and women aged 50 to 64 years and from 2% to 3% in those aged 20 to 49 years; annual declines of 5% to 6% in individuals aged 65 years and older are particularly striking because rates in this age group were increasing prior to 2013. It is also notable that long-term rapid increases in liver cancer mortality have attenuated in women and stabilized in men. In summary, slowing momentum for some cancers amenable to early detection is juxtaposed with notable gains for other common cancers.
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            Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer.

            Nuh N. Rahbari, Jürgen Weitz, Werner Hohenberger … (2010)
            Anastomotic leakage represents a major complication after anterior resection of the rectum. The incidence of anastomotic leakage varies considerably among clinical studies in part owing to the lack of a standardized definition of this complication. The aim of the present article was to propose a definition and severity grading of anastomotic leakage after anterior rectal resection. After a literature review a consensus definition and severity grading of anastomotic leakage was developed within the International Study Group of Rectal Cancer. Anastomotic leakage should be defined as a defect of the intestinal wall at the anastomotic site (including suture and staple lines of neorectal reservoirs) leading to a communication between the intra- and extraluminal compartments. Severity of anastomotic leakage should be graded according to the impact on clinical management. Grade A anastomotic leakage results in no change in patients' management, whereas grade B leakage requires active therapeutic intervention but is manageable without re-laparotomy. Grade C anastomotic leakage requires re-laparotomy. The proposed definition and clinical grading is applicable easily in the setting of clinical studies. It should be applied in future reports to facilitate valid comparison of the results of different studies. Copyright 2010 Mosby, Inc. All rights reserved.
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              Determinants of long-term survival after major surgery and the adverse effect of postoperative complications.

              Shukri F Khuri, William G Henderson, Ralph DePalma … (2005)
              The objective of this study was to identify the determinants of 30-day postoperative mortality and long-term survival after major surgery as exemplified by 8 common operations. The National Surgical Quality Improvement Program (NSQIP) database contains pre-, intra-, and 30-day postoperative data, prospectively collected in a standardized fashion by a dedicated nurse reviewer, on major surgery in the Veterans Administration (VA). The Beneficiary Identification and Records Locator Subsystem (BIRLS) is a VA file that depicts the vital status of U.S. veterans with 87% to 95% accuracy. NSQIP data were merged with BIRLS to determine the vital status of 105,951 patients who underwent 8 types of operations performed between 1991 and 1999, providing an average follow up of 8 years. Logistic and Cox regression analyses were performed to identify the predictors of 30-day mortality and long-term survival, respectively. The most important determinant of decreased postoperative survival was the occurrence, within 30 days postoperatively, of any one of 22 types of complications collected in the NSQIP. Independent of preoperative patient risk, the occurrence of a 30-day complication in the total patient group reduced median patient survival by 69%. The adverse effect of a complication on patient survival was also influenced by the operation type and was sustained even when patients who did not survive for 30 days were excluded from the analyses. The occurrence of a 30-day postoperative complication is more important than preoperative patient risk and intraoperative factors in determining the survival after major surgery in the VA. Quality and process improvement in surgery should be directed toward the prevention of postoperative complications.
              Article 0 comments Cited 287 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Giovanni Scambia: giovanni.scambia@policlinicogemelli.it
                Journal
                Journal ID (nlm-ta): Ann Surg Oncol
                Journal ID (iso-abbrev): Ann Surg Oncol
                Title: Annals of Surgical Oncology
                Publisher: Springer International Publishing (Cham )
                ISSN (Print): 1068-9265
                ISSN (Electronic): 1534-4681
                Publication date (Electronic): 18 April 2022
                Publication date PMC-release: 18 April 2022
                Publication date (Print): 2022
                Volume: 29
                Issue: 8
                Pages: 4791-4802
                Affiliations
                [1 ]GRID grid.8142.f, ISNI 0000 0001 0941 3192, Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, , Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, ; Rome, Italy
                [2 ]Department of Oncology, Gemelli Molise Spa, Campobasso, Italy
                [3 ]GRID grid.414603.4, Surgical Unit of Peritoneum and Retroperitoneum, , Fondazione Policlinico Universitario A. Gemelli IRCCS, ; Rome, Italy
                [4 ]GRID grid.414603.4, Fondazione Policlinico Universitario A. Gemelli IRCCS, ; Rome, Italy
                [5 ]GRID grid.8142.f, ISNI 0000 0001 0941 3192, Università Cattolica del Sacro Cuore, ; Rome, Italy
                Article
                Publisher ID: 11686
                DOI: 10.1245/s10434-022-11686-y
                PMC ID: 9246984
                PubMed ID: 35435561
                SO-VID: a06a57b0-b5f7-413a-a432-396717dac78f
                Copyright © © The Author(s) 2022
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 4 November 2021
                Date accepted : 8 February 2022
                Categories
                Subject: Gynecologic Oncology
                Custom metadata
                issue-copyright-statement © Society of Surgical Oncology 2022

                ScienceOpen disciplines: Oncology & Radiotherapy
                Data availability:
                ScienceOpen disciplines: Oncology & Radiotherapy

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