The surgical outcomes and perioperative complications of bowel resection as part of debulking surgery of advanced ovarian cancer patients.

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Shuang Ye, Yiyong Wang, Lei Chen, Xiaohua Wu, Huijuan Yang, Libing Xiang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-21911/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Mar, 2022 Read the published version in BMC Surgery → Version 1 posted You are reading this latest preprint version Abstract Background: To review the utilization and perioperative outcomes of bowel resection during cytoreduction of ovarian cancer patients in our institution. Methods: All the patients who received bowel resection including anastomosis and ostomy formation between 2006/01 and 2018/12 were identified. Clinicopathological information was abstracted from the medical records. Postoperative morbidities were assessed according to Clavien-Dindo classification (CDC). Results: There were 182 patients in the anastomosis group and 100 patients in the ostomy group, leading to a total of 282 patients. The median age was 57 years and most patients had high-grade serous histology (88.7%). 49 (17.3%) patients received neoadjuvant chemotherapy. During operation, 78.7% patients had ascites and the median volume was 800 mL. Extensive bowel resection (at least two-segment) and upper abdominal operation was performed in 29 (10.2%) and 69 (24.4%) patients, respectively. Rectosigmoid colon was the most commonly resected (83.8%), followed by right hemicolectomy (5.9%) and small bowel resection (2.8%). No macroscopic residual disease was observed in 42.9% of the patients, while 87.9% of had residual disease ≤1 cm. For the entire cohort, 19.9% (56/282) experienced different complications, not including anastomotic leak (AL). 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%). Nine patients experienced AL: one in the ostomy group with extensive bowel resection and eight in the anastomosis group. The overall AL rate was 4.2% (9/212) per anastomosis. The AL rate per anastomosis was quite comparable in different populations: 4.4% (patients in the anastomosis group), 4.3% (patients with one-segment bowel resection and anastomosis), 4.0% (patients with extensive bowel resection and anastomosis) and 5.0% (patients with isolated rectosigmoid resection and anastomosis). Conclusions: Execution of bowel resection as part of debulking surgery of patients with newly diagnosed ovarian cancer resulted in an acceptable morbidity rate. Surgery Oncology Ovarian carcinoma Bowel Resection Surgical outcomes Complications Figures Figure 2 Background Ovarian carcinoma is the most lethal gynecologic malignancy ( 1 ). Most patients present with advanced stage tumor, and optimal cytoreduction is well accepted to be the cornerstone of effective treatment ( 2 , 3 ). Debulking surgery for advanced ovarian cancer patients is complicated, which requires removal of several organs and extensive amounts of peritoneum ( 4 ). According to a recent publication from Japan, gynecologic oncologists rarely perform bowel resection and upper abdominal operation ( 4 ). It is quite the same situation in China. Only a few gynecologic oncologists are willing to perform extensive radical surgery, possibly due to either a lack of the relevant surgical skills or the intense patient-physician relationship ( 5 ). As one of the leading cancer centers with high-volume cases, the gynecologic oncologists in our department have adopted the concept of radical surgery including upper abdominal surgery ( 5 , 6 ) and modified posterior pelvic exenteration ( 7 , 8 ). Back in 2004, we first reported low colorectal staple anastomosis after rectosigmoid resection in primary surgery in eight ovarian cancer patients in a Chinese journal ( 7 ). Then a series of 50 cases between January 2006 and December 2010 was updated in 2018 ( 8 ). The two publications were both in Chinese and only focused patients undergoing rectosigmoid resection and anastomosis. Not only large bowels but also small bowels are involved in ovarian cancer patients with bulky tumor. Therefore, we conducted the current study to comprehensively review the utilization of bowel resection as part of debuking surgery in ovarian cancer patients. The specific details of bowel surgery and surgical-related outcomes were evaluated. A standardized scoring system was applied in assessing perioperative complications. Methods The study was approved by the institutional review board and the requirement for written informed consent was waived considering its retrospective design. We searched the electronic medical record database and included all the patients with advanced ovarian cancer who underwent bowel surgery in primary or interval cytoreduction between January 2006 and December 2018 in our department. Patient-, disease- and surgery-related information was abstracted from the medical records. The data collection included age at diagnosis, body mass index (BMI, calculated as weight (kg)/[height (m)] 2 ), histology, and administration of neoadjuvant chemotherapy. Preoperative laboratory values, including hemoglobin, albumin, and cancer antigen 125 (CA-125), were also recorded. The surgery-related variables were listed as follows: the presence and volume of ascites, upper abdominal surgery, type of bowel resection, estimated blood loss (EBL), intra-operative transfusion, extent of cytoreduction, postoperative complications, postoperative hospital stay and time interval from surgery to chemotherapy. A protective stoma was not routine and was performed at the surgeon’s discretion. The bowel resections were dichotomized into one-segment and extensive bowel resection (at least two-segment) ( 9 ). The postoperative complications were graded according to Clavien-Dindo classification (CDC) ( 10 ) and further categorized into mild (CDC 0–2) and severe (CDC 3–5) subgroup ( 11 ). All the complications and CDC scores were recorded in patients who experienced more than one complication. We specially focused on anastomotic leak (AL) after bowel resection and anastomosis which was defined as follows: 1) feculent fluid from drainage tube, wound or vagina; 2) extravasation/leakage from anastomotic site verified by imaging and/or intraoperative findings ( 12 ). The AL rate is calculated as both per patient and per anastomosis considering one patient might have at least two anastomoses after extensive bowel resection. Concerning extent of debulking, R0 resection is defined as no visible gross tumor after cytoreduction, while R1 resection refers to residual disease ≤ 1 cm. Statistical Package for Social Science (SPSS) (Version 17.0, SPSS, Inc., Chicago, IL, USA) was used for the analyses and GraphPad Prism (Version 5.0, GraphPad Software, Inc., La Jolla, CA, USA) was used for figure illustration. Continuous data were presented as median (range) and categorical data as proportions. Parametric Student’s t -tests were employed in evaluating continuous variables, while chi-square tests were used for the categorical variables. All of the P values reported were two-sided, and a value of P < 0.05 was considered statistically significant. Results 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/m 2 ) 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 Type of bowel resections 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 Surgical complications 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. Discussion In the current series, we analyzed the results of patients with advanced ovarian cancer receiving bowel resection in debulking surgery. Different from our previous two publications ( 7 , 8 ), the current study included all the patients with bowel operation, instead of isolated rectosigmoid resection. To the best of our knowledge, the present study is probably the first study from a Chinese academic center. All the surgical procedures were performed by the gynecologic oncologists in our institution. We demonstrated that the bowel resections as part of debulking were feasible and safe, which resulted in acceptable complication rate. Ovarian cancer often spreads along the peritoneal surface and invades the bowel serosa and mesentery ( 9 ). According to a previous study, 72% of the advanced ovarian cancer patients had visible tumor in the small and large bowels ( 13 ). The bowel resection rate during cytoreductive surgery ranged from 40–80% in institutions adopting radical surgery ( 12 , 14 – 16 ). Two recent publications evaluated multiple bowel resections in ovarian cancer, one from Germany ( 12 ) and one from Korea ( 9 ). In terms of perioperative adverse events especially anastomotic leak, we presented that the overall AL rate was 4.2% per anastomosis. In our previous work including 50 cases receiving isolated rectosigmoid resection and anastomosis, the AL rate was 4.0% per patient. The AL rate was higher in patients with multiple bowel resections if the rate was calculated by patient (8.0%). However there was no difference concerning AL rate per anastomosis. Our reported AL rate is quite in line with previous findings, as other series reported AL rates of 6.0% (Memorial Sloan-Kettering Cancer Center, USA) ( 14 ), 6.6% (eight hospitals in Spain) ( 17 ), 2.89% (Hopital Europeen Georges Pompidou, France) ( 18 ), and 6.9% (Comprehensive Cancer Center Vienna, Austria) ( 12 ). Given the small number of patients with anastomotic leak, we did not assess the underlying risk factors. A recent multi-center study from Spain, including 457 patients, investigated the risk factors for anastomotic leak after colorectal resection in ovarian cancer patients ( 17 ). They concluded that the following variables were independent risk factors for AL: age at surgery, preoperative serum albumin level, one or more additional small bowel resections, manual anastomosis and distance of the anastomosis form the anal verge ( 17 ). Another study from Mayo Clinic evaluated 42 AL cases in comparison to 84 controls with matched factors ( 19 ). They found that multiple large bowel resection (rectosigmoid resection coupled with additional large bowel resection) was related with AL and protective diverting stomas decreased the risk ( 19 ). In our study, only three patients had protective stomas while the AL rate was acceptable. Therefore, we do not routinely perform protective stomas in our center. We did pay attention to blood transfusion to ensure adequate blood supply and albumin supplementation as reflected by the pre- and post- laboratory parameters (Table 1 ). Out of curiosity, we compared the different kinds of anastomosis in patients with only rectosigmoid resection and anastomosis (n = 146). Interestingly, six patients (5.0%) in the end-to-end anastomosis group experienced AL while no case was reported in the end-to-side group. However, due to the small size, we could not arrive at a conclusion. The study has some limitations. Firstly, it has inherent bias pertaining to its retrospective design. Secondly, as mentioned before, we didn't evaluate the risk factors for AL given the small outcome events. Thirdly, we only assessed the perioperative outcomes and survival information was not available. Lastly, given that the study patients were collected from a tertiary referral center, the results might not be generalizable to all of the patients in China. Conclusions Performance of bowel surgery in cytoreduction by experienced gynecologic oncologists in a high-volume center were feasible and resulted in an acceptable morbidity rate. Referrals should be considered at institutions where the necessary treatments are unavailable. Abbreviations BMI: Body Mass Index; CA-125: Cancer Antigen 125; Estimated Blood Loss (EBL); CDC: Clavien-Dindo classification; AL: anastomotic leak. Declarations Ethics approval and consent to participate This study was approved by the institutional review board at Fudan University Shanghai Cancer Center. The written informed consent was waived due to retrospective design. Consent for publication Not applicable. Availability of data and material The dataset supporting the conclusions of this article is available upon request. Please contact Prof. Libing Xiang ( [email protected] ) and Prof. Huijuan Yang ( [email protected] ). Competing interests All the authors have nothing to declare. Funding No specific funding was received for this study. Author’s contributions All the authors contributed to the contraception and design of the study. SY, YW and LC collected and analyzed patients’ clinicopathological data. SY, LX and HY were responsible for statistic analysis. SY, YW and LC were major contributors in writing the manuscript. All authors read and approved the final manuscript. Acknowledgements None References Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011;61(2):69–90. Bristow RE, Tomacruz RS, Armstrong DK, Trimble EL, Montz FJ. 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Role of maximal primary cytoreductive surgery in patients with advanced epithelial ovarian and tubal cancer: Surgical and oncological outcomes. Single institution experience. Gynecol Oncol. 2010;119(2):259–64. Tozzi R, Giannice R, Cianci S, Tardino S, Campanile RG, Gubbala K, et al. Neo-adjuvant chemotherapy does not increase the rate of complete resection and does not significantly reduce the morbidity of Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer. Gynecol Oncol. 2015;138(2):252–8. Lago V, Fotopoulou C, Chiantera V, Minig L, Gil-Moreno A, Cascales-Campos PA, et al. Risk factors for anastomotic leakage after colorectal resection in ovarian cancer surgery: A multi-centre study. Gynecol Oncol. 2019;153(3):549–54. Fournier M, Huchon C, Ngo C, Bensaid C, Bats AS, Combe P, et al. Morbidity of rectosigmoid resection in cytoreductive surgery for ovarian cancer. Risk factor analysis. Eur J Surg Oncol. 2018;44(6):750–3. Kalogera E, Dowdy SC, Mariani A, Weaver AL, Aletti G, Bakkum-Gamez JN, et al. Multiple large bowel resections: potential risk factor for anastomotic leak. Gynecol Oncol. 2013;130(1):213–8. Cite Share Download PDF Status: Published Journal Publication published 04 Mar, 2022 Read the published version in BMC Surgery → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-21911","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":478974,"identity":"c7cfb404-dd99-47a2-bbe5-ddaba4ce4d2b","order_by":1,"name":"Shuang Ye","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shuang","middleName":"","lastName":"Ye","suffix":""},{"id":478975,"identity":"334ba438-b6c2-4ad6-b1e9-cd91aead4965","order_by":2,"name":"Yiyong Wang","email":"","orcid":"","institution":"Baoshan Luodian Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yiyong","middleName":"","lastName":"Wang","suffix":""},{"id":478976,"identity":"1317567a-c2d3-42fd-8a89-c185c04c1e13","order_by":3,"name":"Lei Chen","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center Minhang Branch Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Chen","suffix":""},{"id":478977,"identity":"24164e8d-2c17-407f-ad02-0b3870bb3021","order_by":4,"name":"Xiaohua Wu","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaohua","middleName":"","lastName":"Wu","suffix":""},{"id":478978,"identity":"ec9d5039-38fa-4440-88fb-d98d3e79215b","order_by":5,"name":"Huijuan Yang","email":"","orcid":"","institution":"Fudan university shanghai cancer center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Huijuan","middleName":"","lastName":"Yang","suffix":""},{"id":478979,"identity":"6e8761ae-20fb-4a33-8f11-429c151aceb2","order_by":6,"name":"Libing Xiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIiWNgGAWjYDACZhBRIJHABqITKmrkICIEtRhAtTw4c8yYsBYwMGBIAFGMD9uYExsIKj7O/OzhFwOLPD7p9gsMCWxs6fPbeQ9+YKixicalRbKZzdxYxkCimE3mTAFDAo9M7obDfMkSDMfScnFZx8/MYCYtYSCR2CaRk8CQIMGWu4GZx0CCseEwTi1szOzfkLQYMKfLN/MY/8CnhZ+Zx0zyA1hL+gGGhATmBIbDPGZ4bZFs5imTZgD5RSIHGC8HjhluAGqxSMDjF4Pzx7dJ/qioy5Ofkf6A8ee/Gnn5/jPGNz7U2ODUAgLMPGCKx/wHXCgBj3IQYIQoZX9AQN0oGAWjYBSMVAAA6MlOGmbSII4AAAAASUVORK5CYII=","orcid":"","institution":"","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Libing","middleName":"","lastName":"Xiang","suffix":""}],"badges":[],"createdAt":"2020-04-08 10:49:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-21911/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-21911/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-022-01531-0","type":"published","date":"2022-03-04T14:15:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":884608,"identity":"14162d4c-6f91-49ba-af55-731313918820","added_by":"auto","created_at":"2020-04-12 16:57:32","extension":"tiff","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":187216,"visible":true,"origin":"","legend":"The number of bowel resection during debulking surgery in ovarian cancer patients at the Fudan University Shanghai Cancer Center over the past 13 years.","description":"","filename":"3.Figure1.tiff","url":"https://assets-eu.researchsquare.com/files/rs-21911/v1/3.Figure 1.tiff"},{"id":18863578,"identity":"a5b2f09b-1a0e-43ba-809c-93e327856b66","added_by":"auto","created_at":"2022-03-04 14:15:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":470062,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-21911/v1/a4d40ce7-73a5-4583-b4b3-7216bbb4f685.pdf"}],"financialInterests":"","formattedTitle":"The surgical outcomes and perioperative complications of bowel resection as part of debulking surgery of advanced ovarian cancer patients.","fulltext":[{"header":"Background","content":" \u003cp\u003eOvarian carcinoma is the most lethal gynecologic malignancy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Most patients present with advanced stage tumor, and optimal cytoreduction is well accepted to be the cornerstone of effective treatment (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Debulking surgery for advanced ovarian cancer patients is complicated, which requires removal of several organs and extensive amounts of peritoneum (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). According to a recent publication from Japan, gynecologic oncologists rarely perform bowel resection and upper abdominal operation (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). It is quite the same situation in China. Only a few gynecologic oncologists are willing to perform extensive radical surgery, possibly due to either a lack of the relevant surgical skills or the intense patient-physician relationship (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs one of the leading cancer centers with high-volume cases, the gynecologic oncologists in our department have adopted the concept of radical surgery including upper abdominal surgery (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and modified posterior pelvic exenteration (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Back in 2004, we first reported low colorectal staple anastomosis after rectosigmoid resection in primary surgery in eight ovarian cancer patients in a Chinese journal (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Then a series of 50 cases between January 2006 and December 2010 was updated in 2018 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The two publications were both in Chinese and only focused patients undergoing rectosigmoid resection and anastomosis. Not only large bowels but also small bowels are involved in ovarian cancer patients with bulky tumor.\u003c/p\u003e \u003cp\u003eTherefore, we conducted the current study to comprehensively review the utilization of bowel resection as part of debuking surgery in ovarian cancer patients. The specific details of bowel surgery and surgical-related outcomes were evaluated. A standardized scoring system was applied in assessing perioperative complications.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eThe study was approved by the institutional review board and the requirement for written informed consent was waived considering its retrospective design. We searched the electronic medical record database and included all the patients with advanced ovarian cancer who underwent bowel surgery in primary or interval cytoreduction between January 2006 and December 2018 in our department.\u003c/p\u003e \u003cp\u003ePatient-, disease- and surgery-related information was abstracted from the medical records. The data collection included age at diagnosis, body mass index (BMI, calculated as weight (kg)/[height (m)]\u003csup\u003e2\u003c/sup\u003e), histology, and administration of neoadjuvant chemotherapy. Preoperative laboratory values, including hemoglobin, albumin, and cancer antigen 125 (CA-125), were also recorded. The surgery-related variables were listed as follows: the presence and volume of ascites, upper abdominal surgery, type of bowel resection, estimated blood loss (EBL), intra-operative transfusion, extent of cytoreduction, postoperative complications, postoperative hospital stay and time interval from surgery to chemotherapy. A protective stoma was not routine and was performed at the surgeon\u0026rsquo;s discretion.\u003c/p\u003e \u003cp\u003eThe bowel resections were dichotomized into one-segment and extensive bowel resection (at least two-segment) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The postoperative complications were graded according to Clavien-Dindo classification (CDC) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and further categorized into mild (CDC 0\u0026ndash;2) and severe (CDC 3\u0026ndash;5) subgroup (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). All the complications and CDC scores were recorded in patients who experienced more than one complication. We specially focused on anastomotic leak (AL) after bowel resection and anastomosis which was defined as follows: 1) feculent fluid from drainage tube, wound or vagina; 2) extravasation/leakage from anastomotic site verified by imaging and/or intraoperative findings (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The AL rate is calculated as both per patient and per anastomosis considering one patient might have at least two anastomoses after extensive bowel resection. Concerning extent of debulking, R0 resection is defined as no visible gross tumor after cytoreduction, while R1 resection refers to residual disease\u0026thinsp;\u0026le;\u0026thinsp;1\u0026nbsp;cm.\u003c/p\u003e \u003cp\u003eStatistical Package for Social Science (SPSS) (Version 17.0, SPSS, Inc., Chicago, IL, USA) was used for the analyses and GraphPad Prism (Version 5.0, GraphPad Software, Inc., La Jolla, CA, USA) was used for figure illustration. Continuous data were presented as median (range) and categorical data as proportions. Parametric Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-tests were employed in evaluating continuous variables, while chi-square tests were used for the categorical variables. All of the \u003cem\u003eP\u003c/em\u003e values reported were two-sided, and a value of \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e "},{"header":"Results","content":" \u003cp\u003eA 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\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the number of bowel resection at our institution over the past 13\u0026nbsp;years. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the patient information and the surgery-related variables. For the entire cohort, the median age was 57\u0026nbsp;years (range, 23\u0026ndash;92\u0026nbsp;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\u0026nbsp;mL (range, 50-8000\u0026nbsp;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\u0026thinsp;\u0026le;\u0026thinsp;1\u0026nbsp;cm. The median operation time was 197 minutes (range, 60\u0026ndash;371 minutes), while the median blood loss was 1000\u0026nbsp;mL (range, 100\u0026ndash;3500\u0026nbsp;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\u0026nbsp;days (range, 5\u0026ndash;53\u0026nbsp;days) and 19\u0026nbsp;days (range, 7\u0026ndash;50), respectively.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatient information and surgery-related outcomes.\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVariables\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eTotal\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e(n\u0026thinsp;=\u0026thinsp;282)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnastomosis\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e(n\u0026thinsp;=\u0026thinsp;182)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eOstomy\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e(n\u0026thinsp;=\u0026thinsp;100)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eP\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAge (years)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e57(23\u0026ndash;83)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e55 (25\u0026ndash;77)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e58.5 (26\u0026ndash;83)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e0.003\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e22.2 (14.2\u0026ndash;37.3)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e22.0 (14.2\u0026ndash;34.2)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e23.2 (16.0-37.3)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.101\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNeo-adjuvant chemotherapy (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e49 (17.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e29 (15.9%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e20 (20.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.389\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePreoperative laboratory values\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCA-125 (U/mL)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1006.5 (3.5-31803.7)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1114.5 (3.5-31803.7)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e907.3 (7.4-23156.0)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.551\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAlbumin (g/L)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e40.0 (24.4\u0026ndash;55.3)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e40.7 (26.9\u0026ndash;55.3)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e39.6 (27.6\u0026ndash;48.5)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.638\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHemoglobin (g/L)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e119 (62\u0026ndash;151)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e119 (76\u0026ndash;151)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e120 (62\u0026ndash;147)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.873\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePostoperative day 1 laboratory values\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAlbumin (g/L)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e31.0 (19.3\u0026ndash;48.9)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e31.2 (19.9\u0026ndash;48.9)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e30.2 (19.3\u0026ndash;43.5)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.279\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHemoglobin (g/L)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e111 (69\u0026ndash;159)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e111 (72\u0026ndash;159)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e111 (69\u0026ndash;142)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.157\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHigh-grade serous carcinoma (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e250 (88.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e157 (86.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e93 (93.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.088\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePresence of ascites at surgery (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e222 (78.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e147 (80.8%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e75 (75.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.257\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAscites volume (mL)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e800 (50-8000)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e800 (50-8000)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1000 (50-7500)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.721\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eExtensive bowel resection (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e29 (10.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e20 (11.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e9 (9.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.599\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eUpper abdominal surgery (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e69 (24.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e57 (31.3%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e12 (12.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eExtent of debulking\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eResidual disease\u0026thinsp;=\u0026thinsp;0\u0026nbsp;cm (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e121 (42.9%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e88 (48.4%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e33 (33.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e0.013\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eResidual disease\u0026thinsp;\u0026le;\u0026thinsp;1\u0026nbsp;cm (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e248 (87.9%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e166 (91.2%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e82 (82.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e0.023\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOperation time (minutes)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e197 (60\u0026ndash;371)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e203 (97\u0026ndash;371)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e172 (60\u0026ndash;324)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e0.002\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEstimated blood loss (ml)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1000 (100\u0026ndash;3500)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e950 (100\u0026ndash;3500)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1000 (200\u0026ndash;2500)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.983\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTransfusion (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e248 (87.9%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e156 (85.7%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e92 (92.0%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.121\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRed blood cell transfusion (unit)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (0\u0026ndash;11)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (0\u0026ndash;11)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (0\u0026ndash;9)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.931\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePostoperative hospital stay (days)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e13 (5\u0026ndash;53)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e13 (5\u0026ndash;53)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e10 (5\u0026ndash;40)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTime to chemotherapy (days)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e19 (7\u0026ndash;50)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e20 (7\u0026ndash;50)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e18 (7\u0026ndash;41)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.139\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAbbreviations: CA-125\u0026thinsp;=\u0026thinsp;Cancer Antigen 125\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe 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%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;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, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) and postoperative hospital stay (10 Vs. 13 days, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, there was no difference between two groups concerning the time interval from surgery to chemotherapy.\u003c/p\u003e \u003cp\u003eTotally, 29 patients received more than one-segment bowel resection and the specific details are listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. 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%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eType of bowel resections\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOne-segment bowel resection (n\u0026thinsp;=\u0026thinsp;253)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e238\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRight hemicolectomy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eIleocecal resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTransverse colon resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLeft colon segmental resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLeft colon resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eExtensive bowel resection (n\u0026thinsp;=\u0026thinsp;29)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;small bowel resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;ileocecal resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;right hemicolectomy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e10\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;transverse colon resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;left colon resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;right colon segmental resection\u0026thinsp;+\u0026thinsp;small bowel resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;right hemicolectomy\u0026thinsp;+\u0026thinsp;small bowel resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;right hemicolectomy\u0026thinsp;+\u0026thinsp;left colon resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;transverse colon segmental resection\u0026thinsp;+\u0026thinsp;left colon segmental resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;left colon resection\u0026thinsp;+\u0026thinsp;small bowel resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u0026thinsp;+\u0026thinsp;right colon segmental resection\u0026thinsp;+\u0026thinsp;small bowel resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType of bowel surgery in descending order (n\u0026thinsp;=\u0026thinsp;320)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRectosigmoid resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e268\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRight hemicolectomy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e19\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSmall bowel resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLeft colon resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eIleocecal resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLeft colon segmental resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTransverse colon resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRight colon segmental resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTransverse colon segmental resection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e 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\u0026ndash;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%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eSurgical complications\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMild complications in entire population (CDC 0\u0026ndash;2)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e34\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e12.1%\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBowel obstruction\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e15\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e5.3%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eInfection (abdominal/pelvic/bloodstream)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.8%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWound infection/dehiscence\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.4%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePleural effusion\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.4%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHeart arrhythmia\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.4%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePancreatic leak\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.4%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDeep venous thrombosis\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.4%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSevere complications in entire population (CDC 3\u0026ndash;5)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7.8%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePleural effusion requiring drainage\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e10\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.5%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWound dehiscence requiring delayed repair in operation room\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.8%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBowel obstruction\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.7%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBleeding requiring return to operating room\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.7%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSeptic shock\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.4%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAcute kidney failure\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.4%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eUreterostenosis requiring stent implantation in operation room\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.4%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnastomotic leak\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnastomotic leak in the entire population with anastomosis\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.2% \u003csup\u003ea\u003c/sup\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnastomotic leak in the anastomosis group\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.0% \u003csup\u003ea\u003c/sup\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.4% \u003csup\u003eb\u003c/sup\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnastomotic leak in patients with one-segment bowel resection and anastomosis\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.3% \u003csup\u003eab\u003c/sup\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnastomotic leak in patients with extensive bowel resection and anastomosis\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.0% \u003csup\u003ea\u003c/sup\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e8.0% \u003csup\u003eb\u003c/sup\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnastomotic leak in patients with rectosigmoid resection only and anastomosis\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e5.0% \u003csup\u003eab\u003c/sup\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAbbreviations: CDC\u0026thinsp;=\u0026thinsp;Clavien-Dindo Classification\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e\u003csup\u003ea\u003c/sup\u003e Anastomotic leak rate per anastomosis.\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e\u003csup\u003eb\u003c/sup\u003e Anastomotic leak rate per patient.\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen it comes to anastomotic leak, nine events were reported in total: one in the ostomy group (rectosigmoid resection\u0026thinsp;+\u0026thinsp;right hemicolectomy\u0026thinsp;+\u0026thinsp;left colon resection\u0026thinsp;+\u0026thinsp;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\u0026thinsp;=\u0026thinsp;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.\u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eIn the current series, we analyzed the results of patients with advanced ovarian cancer receiving bowel resection in debulking surgery. Different from our previous two publications (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), the current study included all the patients with bowel operation, instead of isolated rectosigmoid resection. To the best of our knowledge, the present study is probably the first study from a Chinese academic center. All the surgical procedures were performed by the gynecologic oncologists in our institution. We demonstrated that the bowel resections as part of debulking were feasible and safe, which resulted in acceptable complication rate.\u003c/p\u003e \u003cp\u003eOvarian cancer often spreads along the peritoneal surface and invades the bowel serosa and mesentery (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). According to a previous study, 72% of the advanced ovarian cancer patients had visible tumor in the small and large bowels (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The bowel resection rate during cytoreductive surgery ranged from 40\u0026ndash;80% in institutions adopting radical surgery (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Two recent publications evaluated multiple bowel resections in ovarian cancer, one from Germany (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and one from Korea (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn terms of perioperative adverse events especially anastomotic leak, we presented that the overall AL rate was 4.2% per anastomosis. In our previous work including 50 cases receiving isolated rectosigmoid resection and anastomosis, the AL rate was 4.0% per patient. The AL rate was higher in patients with multiple bowel resections if the rate was calculated by patient (8.0%). However there was no difference concerning AL rate per anastomosis. Our reported AL rate is quite in line with previous findings, as other series reported AL rates of 6.0% (Memorial Sloan-Kettering Cancer Center, USA) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), 6.6% (eight hospitals in Spain) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), 2.89% (Hopital Europeen Georges Pompidou, France) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), and 6.9% (Comprehensive Cancer Center Vienna, Austria) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the small number of patients with anastomotic leak, we did not assess the underlying risk factors. A recent multi-center study from Spain, including 457 patients, investigated the risk factors for anastomotic leak after colorectal resection in ovarian cancer patients (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). They concluded that the following variables were independent risk factors for AL: age at surgery, preoperative serum albumin level, one or more additional small bowel resections, manual anastomosis and distance of the anastomosis form the anal verge (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Another study from Mayo Clinic evaluated 42 AL cases in comparison to 84 controls with matched factors (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). They found that multiple large bowel resection (rectosigmoid resection coupled with additional large bowel resection) was related with AL and protective diverting stomas decreased the risk (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In our study, only three patients had protective stomas while the AL rate was acceptable. Therefore, we do not routinely perform protective stomas in our center. We did pay attention to blood transfusion to ensure adequate blood supply and albumin supplementation as reflected by the pre- and post- laboratory parameters (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Out of curiosity, we compared the different kinds of anastomosis in patients with only rectosigmoid resection and anastomosis (n\u0026thinsp;=\u0026thinsp;146). Interestingly, six patients (5.0%) in the end-to-end anastomosis group experienced AL while no case was reported in the end-to-side group. However, due to the small size, we could not arrive at a conclusion.\u003c/p\u003e \u003cp\u003eThe study has some limitations. Firstly, it has inherent bias pertaining to its retrospective design. Secondly, as mentioned before, we didn't evaluate the risk factors for AL given the small outcome events. Thirdly, we only assessed the perioperative outcomes and survival information was not available. Lastly, given that the study patients were collected from a tertiary referral center, the results might not be generalizable to all of the patients in China.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003ePerformance of bowel surgery in cytoreduction by experienced gynecologic oncologists in a high-volume center were feasible and resulted in an acceptable morbidity rate. Referrals should be considered at institutions where the necessary treatments are unavailable.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eBMI: Body Mass Index; CA-125: Cancer Antigen 125; Estimated Blood Loss (EBL); CDC: Clavien-Dindo classification; AL: anastomotic leak.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional review board at Fudan University Shanghai Cancer Center. The written informed consent was waived due to retrospective design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset supporting the conclusions of this article is available upon request. Please contact Prof. Libing Xiang (\u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e) and Prof. Huijuan Yang (\u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors have nothing to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo specific funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors contributed to the contraception and design of the study. SY, YW and LC collected and analyzed patients\u0026rsquo; clinicopathological data. SY, LX and HY were responsible for statistic analysis. SY, YW and LC were major contributors in writing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e \u003cspan\u003eJemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011;61(2):69\u0026ndash;90.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eBristow RE, Tomacruz RS, Armstrong DK, Trimble EL, Montz FJ. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. J Clin Oncol. 2002;20(5):1248\u0026ndash;59.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eChi DS, Eisenhauer EL, Lang J, Huh J, Haddad L, Abu-Rustum NR, 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\u0026ndash;64.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eNishikimi K, Tate S, Kato K, Matsuoka A, Shozu M. Well-trained gynecologic oncologists can perform bowel resection and upper abdominal surgery safely. J Gynecol Oncol. 2020;31(1):e3.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eRen Y, Jiang R, Yin S, You C, Liu D, Cheng X, et al. Radical surgery versus standard surgery for primary cytoreduction of bulky stage IIIC and IV ovarian cancer: an observational study. BMC Cancer. 2015;15:583.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eXiang L, Tu Y, He T, Shen X, Li Z, Wu X, et al. Distal pancreatectomy with splenectomy for the management of splenic hilum metastasis in cytoreductive surgery of epithelial ovarian cancer. J Gynecol Oncol. 2016;27(6):e62.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eXiaohua Wu ZL, Zhao G, Zhu H, Fang Y, Zhou Y, Huang X, Zhang Z. Low colorectal staple anastomosis after radical pelvic surgery for gynecologic malignancies. Shanghai Medical Journal. 2004;27(9):629\u0026ndash;32.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eJie Tang DL, Zang R, Li Z, Wu X. Modified posterior pelvic exenteration in primary cytoreductive surgery for epithelial ovarian cancer. China Oncology. 2012;22(6):430\u0026ndash;5.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eSon JH, Kong TW, Paek J, Chang SJ, Ryu HS. Perioperative outcomes of extensive bowel resection during cytoreductive surgery in patients with advanced ovarian cancer. J Surg Oncol. 2019;119(7):1011\u0026ndash;5.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eClavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187\u0026ndash;96.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eAtaseven B, du Bois A, Reinthaller A, Traut A, Heitz F, Aust S, et al. Pre-operative serum albumin is associated with post-operative complication rate and overall survival in patients with epithelial ovarian cancer undergoing cytoreductive surgery. Gynecol Oncol. 2015;138(3):560\u0026ndash;5.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eGrimm C, Harter P, Alesina PF, Prader S, Schneider S, Ataseven B, 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\u0026ndash;503.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eJaeger W, Ackermann S, Kessler H, Katalinic A, Lang N. The effect of bowel resection on survival in advanced epithelial ovarian cancer. Gynecol Oncol. 2001;83(2):286\u0026ndash;91.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eChi DS, Zivanovic O, Levinson KL, Kolev V, Huh J, Dottino J, et al. The incidence of major complications after the performance of extensive upper abdominal surgical procedures during primary cytoreduction of advanced ovarian, tubal, and peritoneal carcinomas. Gynecol Oncol. 2010;119(1):38\u0026ndash;42.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003ePeiretti M, Zanagnolo V, Aletti GD, Bocciolone L, Colombo N, Landoni F, et al. Role of maximal primary cytoreductive surgery in patients with advanced epithelial ovarian and tubal cancer: Surgical and oncological outcomes. Single institution experience. Gynecol Oncol. 2010;119(2):259\u0026ndash;64.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eTozzi R, Giannice R, Cianci S, Tardino S, Campanile RG, Gubbala K, et al. Neo-adjuvant chemotherapy does not increase the rate of complete resection and does not significantly reduce the morbidity of Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer. Gynecol Oncol. 2015;138(2):252\u0026ndash;8.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eLago V, Fotopoulou C, Chiantera V, Minig L, Gil-Moreno A, Cascales-Campos PA, et al. Risk factors for anastomotic leakage after colorectal resection in ovarian cancer surgery: A multi-centre study. Gynecol Oncol. 2019;153(3):549\u0026ndash;54.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eFournier M, Huchon C, Ngo C, Bensaid C, Bats AS, Combe P, et al. Morbidity of rectosigmoid resection in cytoreductive surgery for ovarian cancer. Risk factor analysis. Eur J Surg Oncol. 2018;44(6):750\u0026ndash;3.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eKalogera E, Dowdy SC, Mariani A, Weaver AL, Aletti G, Bakkum-Gamez JN, et al. Multiple large bowel resections: potential risk factor for anastomotic leak. Gynecol Oncol. 2013;130(1):213\u0026ndash;8.\u003c/span\u003e \u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ovarian carcinoma, Bowel Resection, Surgical outcomes, Complications","lastPublishedDoi":"10.21203/rs.3.rs-21911/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-21911/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: To review the utilization and perioperative outcomes of bowel resection during cytoreduction of ovarian cancer patients in our institution. \u003c/p\u003e\u003cp\u003eMethods: All the patients who received bowel resection including anastomosis and ostomy formation between 2006/01 and 2018/12 were identified. Clinicopathological information was abstracted from the medical records. Postoperative morbidities were assessed according to Clavien-Dindo classification (CDC).\u003c/p\u003e\u003cp\u003eResults: There were 182 patients in the anastomosis group and 100 patients in the ostomy group, leading to a total of 282 patients. The median age was 57 years and most patients had high-grade serous histology (88.7%). 49 (17.3%) patients received neoadjuvant chemotherapy. During operation, 78.7% patients had ascites and the median volume was 800 mL. Extensive bowel resection (at least two-segment) and upper abdominal operation was performed in 29 (10.2%) and 69 (24.4%) patients, respectively. Rectosigmoid colon was the most commonly resected (83.8%), followed by right hemicolectomy (5.9%) and small bowel resection (2.8%). No macroscopic residual disease was observed in 42.9% of the patients, while 87.9% of had residual disease ≤1 cm. For the entire cohort, 19.9% (56/282) experienced different complications, not including anastomotic leak (AL). 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%). Nine patients experienced AL: one in the ostomy group with extensive bowel resection and eight in the anastomosis group. The overall AL rate was 4.2% (9/212) per anastomosis. The AL rate per anastomosis was quite comparable in different populations: 4.4% (patients in the anastomosis group), 4.3% (patients with one-segment bowel resection and anastomosis), 4.0% (patients with extensive bowel resection and anastomosis) and 5.0% (patients with isolated rectosigmoid resection and anastomosis).\u003c/p\u003e\u003cp\u003eConclusions: Execution of bowel resection as part of debulking surgery of patients with newly diagnosed ovarian cancer resulted in an acceptable morbidity rate.\u003c/p\u003e","manuscriptTitle":"The surgical outcomes and perioperative complications of bowel resection as part of debulking surgery of advanced ovarian cancer patients.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-04-12 16:57:30","doi":"10.21203/rs.3.rs-21911/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9831d2cf-59a5-4e9c-a2a4-8d98dd9bd3f5","owner":[],"postedDate":"April 12th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":82294,"name":"Surgery"},{"id":82295,"name":"Oncology"}],"tags":[],"updatedAt":"2022-03-04T14:15:23+00:00","versionOfRecord":{"articleIdentity":"rs-21911","link":"https://doi.org/10.1186/s12893-022-01531-0","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2022-03-04 14:15:23","publishedOnDateReadable":"March 4th, 2022"},"versionCreatedAt":"2020-04-12 16:57:30","video":"","vorDoi":"10.1186/s12893-022-01531-0","vorDoiUrl":"https://doi.org/10.1186/s12893-022-01531-0","workflowStages":[]},"version":"v1","identity":"rs-21911","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-21911","identity":"rs-21911","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}