Dual-Surgeon Approach Lowers Anastomotic Leak Rates in Ovarian Cancer Surgery

The rate of anastomotic leaks significantly decreased among patients with epithelial ovarian cancer (EOC) when 2 surgeons were involved in their cytoreductive debulking and bowel surgery, according to a study published in JAMA Surgery.¹

In hopes of achieving complete cytoreduction, patients with EOC must undergo either primary or interval cytoreductive surgery, depending on disease distribution, and platinum-based chemotherapy. Also, extensive bowel surgery is often necessary for complete cytoreduction since the disease frequently involves the bowel and other intraperitoneal organs.²

Past research shows that patients with advanced EOC experience a significant survival benefit when operated on by a gynecologic oncologist vs another surgical subspecialist.¹ However, only 51% of gynecologic oncologists are independently performing large-bowel resections, likely because of hospital-wide surgical policies or variations in gastrointestinal procedure training.³

Therefore, gynecologic oncologists may seek assistance with bowel resections during cytoreductive surgeries from a colorectal surgeon, general surgeon, surgical oncologist, or another gynecologic oncologist. Regardless of who performs the surgery, bowel resection is a high-risk procedure, with an anastomotic leak being one of the most severe complications that can occur.⁴

Consequently, the researchers conducted a study to compare surgical outcomes between a general surgeon, gynecologic oncologist, and 2-surgeon team approach in patients with EOC who underwent bowel surgery during a cytoreductive debulking.¹ Although the primary surgical outcome was an anastomotic leak, they also evaluated other bowel-specific morbidities, namely enteric fistula and ileus at 1 week or longer.

The involvement of 2 surgeons during cytoreductive debulking and bowel surgery in patients with epithelial ovarian cancer (EOC) significantly reduces the rate of anastomotic leaks. | Image Credit: Gorodenkoff - stock.adobe.com

To create their study population, they used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) datasets from 2012 through 2020, which include data from more than 700 US hospitals.^5,6 Data collection is performed by trained data reviewers who extract preoperative and 30-day postoperative information from medical records.⁷

The study population consisted of patients 18 years or older who underwent both cytoreductive surgery and a bowel procedure for suspected advanced ovarian malignancy by a gynecologic oncologist, general surgeon, or a 2-surgeon team between 2012 and 2020. The researchers determined ovarian malignancies through the relevant International Classification of Diseases, Ninth Revision (ICD-9) and ICD, Tenth Revision (ICD-10) codes.¹ They also determined which patients underwent debulking surgery and a bowel resection or repair using related Current Procedural Terminology codes.

The researchers identified 1810 relevant patients. They stratified the study population by surgeon type: general surgeon, gynecologic oncologist, and a 2-surgeon team approach; the 2-surgeon team could consist of 2 gynecologic oncologists, 2 general surgeons, or a team of a gynecologic oncologist and a general surgeon, like a colorectal surgeon. The gynecologic oncologist group performed 1217 procedures (67.2%), a 2-surgeon team performed 496 (27.4%), and general surgeons performed 97 (5.4%).

The researchers found a significant difference between the racial makeup of the 3 groups. More specifically, there was a lower proportion of Black patients in the gynecologic oncologist group (3.7%; n = 82) compared with the general surgeon (10.3%; n = 10) and 2-surgeon team (8.3%; n = 41) groups. Similarly, there was a lower proportion of Hispanic patients in the gynecologic oncologist group (4.4%; n = 53) compared with the general surgeon (8.3%; n = 8) and 2-surgeon team (7.1%; n = 35) groups.

Also, the rate of anastomotic leaks was lowest in the 2-surgeon team group (0.4%), followed by the gynecologic oncologist (3.6%) and general surgeon (5.2%) groups (P < .001). However, there was no significant difference among the groups regarding ileus and enteric fistula rates.

When they repeated the same analysis with only patients who received an ostomy during their bowel resection, the researchers found no significant difference in bowel-specific morbidity among the groups. Additionally, they determined that the anastomotic leak rate was still lower for the 2-surgeon team group (0.6%) vs the gynecologic oncologist (2.0%) and general surgeon (6.7%) groups (P= .08).

Also, those in the gynecologic oncologist group had the highest return to the operating room rate (7.1%) compared with the general surgeon (6.2%) and 2-surgeon team (3.0%) groups (P = .003). Lastly, through their multivariate logistic regression, the researchers determined the adjusted odds ratio for the anastomotic leak to be 1.53 (95% CI, 0.59-3.96) for the general surgeon group vs 0.11 (95% CI, 0.03-0.47) for the 2-surgeon team group (P = .003); the gynecologic oncologist group was used as the referent group.

The researchers acknowledged their limitations, one being their use of NSQIP data. This was because they were retrospectively analyzed, and the data availability was confined to the parameters offered through the NSQIP database; these factors could lead to selection bias. Despite their limitations, the researchers expressed confidence in their findings and suggested areas for further research.

“These results support that both gynecologic oncologists and general surgeons provide similar care with regards to bowel-related procedures in patients with EOC and team-based care further improves outcomes,” the authors concluded. “Further research on the underlying drivers that lead to improved outcomes with a 2-surgeon team is warranted.”

References

1. Ebott J, Has P, Raker C, Robison K. Bowel resection outcomes in ovarian cancer cytoreductive surgery by surgeon specialty. JAMA Surg. Published online August 7, 2024. doi:10.1001/jamasurg.2024.2924

2. Chi DS, Eisenhauer EL, Lang J, et al. What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)? Gynecol Oncol. 2006;103(2):559-564. doi:10.1016/j.ygyno.2006.03.051

3. Park SJ, Kim J, Kim SN, et al. Practice patterns of surgery for advanced ovarian cancer: analysis from international surveys. Jpn J Clin Oncol. 2019;49(2):137-145. doi:10.1093/jjco/hyy175

4. Grimm C, Harter P, Alesina PF, et al. The impact of type and number of bowel resections on anastomotic leakage risk in advanced ovarian cancer surgery. Gynecol Oncol. 2017;146(3):498-503. doi:10.1016/j.ygyno.2017.06.007

5. Raval MV, Pawlik TM. Practical guide to surgical data sets: National Surgical Quality Improvement Program (NSQIP) and Pediatric NSQIP. JAMA Surg. 2018;153(8):764-765. doi:10.1001/jamasurg.2018.0486

6. Fink AS, Campbell DA Jr, Mentzer RM Jr, et al. The National Surgical Quality Improvement Program in non-veterans administration hospitals: initial demonstration of feasibility. Ann Surg. 2002;236(3):344-354. doi:10.1097/00000658-200209000-00011

7. American College of Surgeons National Surgical Quality Improvement Program. User guide for the 2021 ACS NSQIP participant use. Accessed July 3, 2024. https://www.facs.org/media/wd2hlqzv/nsqip_puf_userguide_2021.pdf