Multiple large bowel resections: Potential risk factor for anastomotic leak

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 and 05/20/2011 were identified and matched 1:2 with controls for age (± 5 years), sub-stage (IIIA/IIIB; IIIC; IV), and date of surgery (± 4 years). 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 < 1 cm 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 patients 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).