A total of 282 ovarian cancer patients with advanced tumor received bowel resection as part of debulking surgery. Among them, 182 and 100 patients underwent anastomosis and ostomy formation, resepectively. Figure 1 illustrates the number of bowel resection at our institution over the past 13 years. Table 1 presents the patient information and the surgery-related variables. For the entire cohort, the median age was 57 years (range, 23–92 years). The majority of the patients had high-grade serous histology (88.7%). Neoadjuvant chemotherapy was administered in 49 (17.3%) patients. Ascites was present in 78.7% of the patients, and the median volume was 800 mL (range, 50-8000 mL). Extensive bowel resection and upper abdominal operation was performed in 29 (10.2%) and 69 (24.4%) patients, respectively. Three patients had protective stoma. The debulking results were 121 (42.9%) patients with no gross residual disease, 248 (87.9%) with residual disease ≤ 1 cm. The median operation time was 197 minutes (range, 60–371 minutes), while the median blood loss was 1000 mL (range, 100–3500 mL). During operation, 87.9% of the patients received a transfusion, and the median volume transfused was three units (range, 1-11units). For the whole population, the median time from surgery to discharge and chemotherapy was 13 days (range, 5–53 days) and 19 days (range, 7–50), respectively.
Table 1
Patient information and surgery-related outcomes.
Variables | Total (n = 282) | Anastomosis (n = 182) | Ostomy (n = 100) | P |
Age (years) | 57(23–83) | 55 (25–77) | 58.5 (26–83) | 0.003 |
Body mass index (kg/m2) | 22.2 (14.2–37.3) | 22.0 (14.2–34.2) | 23.2 (16.0-37.3) | 0.101 |
Neo-adjuvant chemotherapy (%) | 49 (17.4%) | 29 (15.9%) | 20 (20.0%) | 0.389 |
Preoperative laboratory values |
CA-125 (U/mL) | 1006.5 (3.5-31803.7) | 1114.5 (3.5-31803.7) | 907.3 (7.4-23156.0) | 0.551 |
Albumin (g/L) | 40.0 (24.4–55.3) | 40.7 (26.9–55.3) | 39.6 (27.6–48.5) | 0.638 |
Hemoglobin (g/L) | 119 (62–151) | 119 (76–151) | 120 (62–147) | 0.873 |
Postoperative day 1 laboratory values |
Albumin (g/L) | 31.0 (19.3–48.9) | 31.2 (19.9–48.9) | 30.2 (19.3–43.5) | 0.279 |
Hemoglobin (g/L) | 111 (69–159) | 111 (72–159) | 111 (69–142) | 0.157 |
High-grade serous carcinoma (%) | 250 (88.7%) | 157 (86.3%) | 93 (93.0%) | 0.088 |
Presence of ascites at surgery (%) | 222 (78.7%) | 147 (80.8%) | 75 (75.0%) | 0.257 |
Ascites volume (mL) | 800 (50-8000) | 800 (50-8000) | 1000 (50-7500) | 0.721 |
Extensive bowel resection (%) | 29 (10.2%) | 20 (11.0%) | 9 (9.0%) | 0.599 |
Upper abdominal surgery (%) | 69 (24.4%) | 57 (31.3%) | 12 (12.0%) | < 0.001 |
Extent of debulking |
Residual disease = 0 cm (%) | 121 (42.9%) | 88 (48.4%) | 33 (33.0%) | 0.013 |
Residual disease ≤ 1 cm (%) | 248 (87.9%) | 166 (91.2%) | 82 (82.0%) | 0.023 |
Operation time (minutes) | 197 (60–371) | 203 (97–371) | 172 (60–324) | 0.002 |
Estimated blood loss (ml) | 1000 (100–3500) | 950 (100–3500) | 1000 (200–2500) | 0.983 |
Transfusion (%) | 248 (87.9%) | 156 (85.7%) | 92 (92.0%) | 0.121 |
Red blood cell transfusion (unit) | 3 (0–11) | 3 (0–11) | 3 (0–9) | 0.931 |
Postoperative hospital stay (days) | 13 (5–53) | 13 (5–53) | 10 (5–40) | < 0.001 |
Time to chemotherapy (days) | 19 (7–50) | 20 (7–50) | 18 (7–41) | 0.139 |
Abbreviations: CA-125 = Cancer Antigen 125 |
We further compared the patient information and perioperative outcomes between anastomosis and ostomy group. Patients who received ostomy formation were significantly older than the anastomosis counterparts. The percentage of upper abdominal surgery was higher in the anastomosis group compared to the ostomy group (31.3% Vs. 12.0%, P < 0.001). More patients in the anastomosis group achieved complete (R0) or R1 resection. Not surprisingly, patients with anastomosis had both longer operation time (203 Vs. 172 minutes, P = 0.002) and postoperative hospital stay (10 Vs. 13 days, P < 0.001). However, there was no difference between two groups concerning the time interval from surgery to chemotherapy.
Totally, 29 patients received more than one-segment bowel resection and the specific details are listed in Table 2. Rectosigmoid colon was the most commonly resected (268/320, 83.8%), followed by right hemicolectomy (19/320, 5.9%) and small bowel resection (9/320, 2.8%).
Table 2
One-segment bowel resection (n = 253) |
Rectosigmoid resection | 238 |
Right hemicolectomy | 7 |
Ileocecal resection | 2 |
Transverse colon resection | 2 |
Left colon segmental resection | 2 |
Left colon resection | 2 |
Extensive bowel resection (n = 29) |
Rectosigmoid resection + small bowel resection | 5 |
Rectosigmoid resection + ileocecal resection | 3 |
Rectosigmoid resection + right hemicolectomy | 10 |
Rectosigmoid resection + transverse colon resection | 1 |
Rectosigmoid resection + left colon resection | 4 |
Rectosigmoid resection + right colon segmental resection + small bowel resection | 1 |
Rectosigmoid resection + right hemicolectomy + small bowel resection | 1 |
Rectosigmoid resection + right hemicolectomy + left colon resection | 1 |
Rectosigmoid resection + transverse colon segmental resection + left colon segmental resection | 2 |
Rectosigmoid resection + left colon resection + small bowel resection | 1 |
Rectosigmoid resection + right colon segmental resection + small bowel resection | 1 |
Type of bowel surgery in descending order (n = 320) |
Rectosigmoid resection | 268 |
Right hemicolectomy | 19 |
Small bowel resection | 9 |
Left colon resection | 8 |
Ileocecal resection | 5 |
Left colon segmental resection | 4 |
Transverse colon resection | 3 |
Right colon segmental resection | 2 |
Transverse colon segmental resection | 2 |
Table 3 shows the details on surgical complications. For the entire cohort, 19.9% (56/282) experienced complications (not include AL) to different extent. Of them, severe complications (CDC 3–5) accounted for 7.8%, mostly pleural effusion requiring drainage (3.5%), and followed by wound dehiscence requiring delayed repair in operation room (1.8%).
Table 3
Mild complications in entire population (CDC 0–2) | 34 | 12.1% |
Bowel obstruction | 15 | 5.3% |
Infection (abdominal/pelvic/bloodstream) | 8 | 2.8% |
Wound infection/dehiscence | 4 | 1.4% |
Pleural effusion | 4 | 1.4% |
Heart arrhythmia | 1 | 0.4% |
Pancreatic leak | 1 | 0.4% |
Deep venous thrombosis | 1 | 0.4% |
Severe complications in entire population (CDC 3–5) | 22 | 7.8% |
Pleural effusion requiring drainage | 10 | 3.5% |
Wound dehiscence requiring delayed repair in operation room | 5 | 1.8% |
Bowel obstruction | 2 | 0.7% |
Bleeding requiring return to operating room | 2 | 0.7% |
Septic shock | 1 | 0.4% |
Acute kidney failure | 1 | 0.4% |
Ureterostenosis requiring stent implantation in operation room | 1 | 0.4% |
Anastomotic leak | | |
Anastomotic leak in the entire population with anastomosis | 9 | 4.2% a |
Anastomotic leak in the anastomosis group | 8 | 4.0% a |
4.4% b |
Anastomotic leak in patients with one-segment bowel resection and anastomosis | 7 | 4.3% ab |
Anastomotic leak in patients with extensive bowel resection and anastomosis | 2 | 4.0% a |
8.0% b |
Anastomotic leak in patients with rectosigmoid resection only and anastomosis | 6 | 5.0% ab |
Abbreviations: CDC = Clavien-Dindo Classification a Anastomotic leak rate per anastomosis. b Anastomotic leak rate per patient. |
When it comes to anastomotic leak, nine events were reported in total: one in the ostomy group (rectosigmoid resection + right hemicolectomy + left colon resection + ileostomy), and eight in the anastomosis group. The total number of bowel anastomosis in the entire population was 212 and it translated in an overall AL rate of 4.2% (9/212) per anastomosis. In the anastomosis group, the AL per patient was 4.4% (8/182) while the AL per anastomosis 4.0% (8/202). Five patients with AL (four in anastomosis group and one in ostomy group) were successfully managed with conservative treatment. Overall, 187 patients had anastomosis after bowel resection: 162 with one-segment (162 anastomosis) and 25 with multiple bowel resections (50 anastomosis). The AL per patient was higher in patients with extensive bowel resection (8%, 2/25) compared to those with one-segment resection (4.3%, 7/162). However, the AL per anastomosis was quite comparable between two groups (4.3% Vs. 4.0%). We further focused on the patients with isolated rectosigmoid resection and anastomosis (n = 146). Among them, 119 had end-to-end anastomosis while 27 had end-to-side anastomosis. Six patients (5.0%) in the end-to-end anastomosis group experienced AL while no case was reported in the end-to-side group.