Colorectal Surgeon Participation in Cytoreductive Surgery for Advanced Epithelial Ovarian Cancer: Improved Optimal Resection Without Increased Perioperative Morbidity—A Single-Center Retrospective Study

Colorectal Surgeon Participation in Cytoreductive Surgery for Advanced Epithelial Ovarian Cancer: Improved Optimal Resection Without Increased Perioperative Morbidity—A Single-Center Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Colorectal Surgeon Participation in Cytoreductive Surgery for Advanced Epithelial Ovarian Cancer: Improved Optimal Resection Without Increased Perioperative Morbidity—A Single-Center Retrospective Study Zhongyi Gu, Shenglian Lu, Shengyun Cai, Mingjuan Xu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8729121/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Advanced epithelial ovarian cancer frequently involves bowel structures, requiring multidisciplinary surgical expertise. This study evaluates the impact of colorectal surgeon participation on surgical outcomes in cytoreductive surgery (CRS) for FIGO stage III/IV disease. Methods We retrospectively analyzed 254 patients who underwent cytoreductive surgery at a single institution between January 2020 and December 2025. Patients were stratified into two groups based on colorectal surgeon participation: the participation group (n = 97) and the non-participation group (n = 157). The primary outcome measures included operative time, intraoperative blood loss, time to first postoperative flatus, length of postoperative hospital stay, R0 resection rate, and postoperative complications. Multivariable logistic regression was used to adjust for key confounding factors, including bowel involvement, FIGO stage, age, and neoadjuvant chemotherapy status. Results Bowel involvement was significantly higher in the colorectal surgeon participation group (94.8% vs. 17.8%, P < 0.001), which is consistent with clinical practice whereby colorectal surgeons were primarily involved in cases with overt bowel invasion requiring bowel resection. Despite this, perioperative outcomes were comparable between groups, including operative time (P = 0.18), intraoperative blood loss (P = 0.12), time to first flatus (P = 0.45), length of hospital stay (P = 0.62), and major postoperative complications (all P > 0.05; no anastomotic leaks or perioperative deaths). The R0 resection rate was markedly higher with colorectal surgeon participation (44.3% vs. 18.5%, P < 0.001).Multivariable analysis confirmed colorectal surgeon participation as an independent predictor of R0 resection (adjusted OR 2.32, 95% CI 1.35–3.98, P = 0.003), with no independent effect on the occurrence of complications (adjusted OR 0.92, 95% CI 0.55–1.54, P = 0.74). Conclusions Colorectal surgeon participation in cytoreductive surgery for advanced epithelial ovarian cancer enables significantly higher rates of complete (R0) resection in cases with substantial bowel involvement, without increasing perioperative morbidity or complications. These findings support the integration of multidisciplinary surgical teams to optimize oncologic outcomes in complex disease while maintaining safety, particularly in settings where specialized bowel surgery expertise may be limited among gynecologic oncologists. Ovarian cancer Cytoreductive surgery Colorectal surgeon R0 resection Bowel involvement Introduction Ovarian cancer remains one of the most lethal malignancies of the female reproductive system. Globally, approximately 290,000 women are diagnosed with ovarian cancer each year, and about 180,000 women die from the disease[ 1 ].Epithelial ovarian cancer is the most common histologic subtype, accounting for approximately 90% of cases. More than 70% of patients with epithelial ovarian cancer present with advanced-stage disease at diagnosis, with a 5-year overall survival rate of around 48%[ 2 ].Surgical treatment constitutes the cornerstone of management for advanced ovarian cancer. The primary goal of cytoreductive surgery (CRS) is to achieve either no visible residual disease (R0 resection) or, at minimum, residual disease ≤ 1 cm (R1), as this has been consistently shown to significantly improve progression-free survival (PFS) and overall survival (OS)[ 3 – 4 ].Ovarian cancer frequently involves the intestines and other intraperitoneal organs; therefore, achieving complete cytoreduction often necessitates extensive bowel surgery, including colorectal resection[ 5 ].In China, only a very small proportion of gynecologic oncologists are able to independently perform colorectal resection, largely due to the lack of systematic training in bowel surgery and restrictive medico-legal regulations[ 6 ].Consequently, during cytoreductive surgery for ovarian cancer, gynecologic oncologists commonly collaborate with colleagues from other surgical specialties, most frequently colorectal surgeons[ 7 ]. Our center established a multidisciplinary team (MDT) for ovarian tumors in 2020. Since then, the number of patients with advanced epithelial ovarian cancer admitted to our institution has increased year by year. During the process of collecting and analyzing data on patients with epithelial ovarian cancer who underwent surgical treatment at our center over the past 5 years, we observed that colorectal surgeons directly participated in the operations in as high as 38.2% of cases. To objectively evaluate the role of colorectal surgeons in the diagnosis and treatment of advanced epithelial ovarian cancer, we conducted a statistical analysis of the relevant case data from our center over the past 5 years. Materials and Methods This study was a single-center retrospective cohort study. We retrospectively analyzed the electronic medical records of 254 patients with advanced epithelial ovarian malignancy (FIGO stage III or IV) who underwent cytoreductive surgery at our institution between January 2020 and December 2025. Inclusion criteria (1) histologically confirmed epithelial ovarian malignancy, (2) advanced-stage disease (FIGO stage III or IV), (3) complete surgical records. Exclusion criteria: (1) early-stage disease (FIGO stage I–II), (2) incomplete medical records or performance of only palliative surgery, (3) secondary cytoreductive surgery for recurrent disease. Patients were divided into two groups according to whether a colorectal surgeon directly participated in the procedure: Colorectal surgeon participation group (n = 97): colorectal surgeons directly performed bowel-related procedures; Non-colorectal surgeon participation group (n = 157): the entire operation was completed solely by gynecologic oncologists. Data collection The following variables were extracted from the electronic medical record system: patient age, tumor stage (FIGO staging), bowel involvement by tumor (yes/no, confirmed by intraoperative exploration), receipt of neoadjuvant chemotherapy and number of cycles, preoperative CA125 level (U/mL), operative time (minutes, from skin incision to abdominal closure), intraoperative blood loss (mL, estimated from suction volume and weighed gauzes), time to first postoperative flatus (days, counted from the day of surgery), length of postoperative hospital stay (days, counted from the day of surgery), residual disease status (R0: no visible residual tumor; R1: residual tumor ≤ 1 cm; R2: residual tumor > 1 cm), and postoperative complications (including lower extremity deep vein thrombosis, pulmonary embolism, pneumonia, ileus, urinary tract infection, anastomotic leak/enterocutaneous fistula, and others).Due to limited follow-up duration, recurrence and survival data were not yet mature and were therefore not included in the primary outcome analysis. All data were anonymized to protect patient privacy. This study was approved by the Ethics Committee of the First Affiliated Hospital of Naval Medical University. Statistical Analysis Statistical analyses were performed using SPSS software version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) or median (interquartile range, IQR) and compared between groups using the independent samples t-test or Mann-Whitney U test, as appropriate. Categorical variables were presented as frequencies (percentages) and compared using the χ² test or Fisher’s exact test. Multivariable logistic regression analysis was used to evaluate the independent effect of colorectal surgeon participation on achievement of R0 resection and occurrence of postoperative complications. Variables with P < 0.10 in univariable analysis or those considered clinically important potential confounders (including bowel involvement, FIGO stage, age, and neoadjuvant chemotherapy status) were included in the models. A two-sided P value < 0.05 was considered statistically significant.Sample size calculation indicated that the study had 80% power to detect a 15% difference in R0 resection rate between the two groups (assuming the specified effect size). Results Baseline Characteristics of Patients The entire cohort consisted of 254 patients with a mean age of 59.9 ± 9.1 years (range 28–82 years). There were no significant differences between the colorectal surgeon participation group and the non-participation group in terms of age, FIGO stage distribution, proportion of patients who received neoadjuvant chemotherapy, or preoperative CA125 levels (all P > 0.05). A total of 59 patients received neoadjuvant chemotherapy (22 in the colorectal surgeon participation group and 37 in the non-participation group), with the majority receiving 3 cycles (median 3, IQR 2–4). The median preoperative CA125 level was 800 U/mL (IQR 320–1850). The rate of bowel involvement was significantly higher in the colorectal surgeon participation group compared with the non-participation group (94.8% vs. 17.8%, P < 0.001). This finding reflects clinical practice, whereby colorectal surgeons were primarily involved in cases with overt cancerous bowel invasion, whereas patients in the non-participation group had either no bowel involvement or only superficial disease amenable to stripping by gynecologic oncologists alone (Table 1 ). Table 1 Baseline Characteristics of the two patient groups Variable Colorectal surgeon participation group (n = 97) Non-participation Group (n = 157) P value Age (years, mean ± SD) 59.2 ± 9.8 60.4 ± 8.7 0.32 FIGO stage [n (%)] 0.42 Stage III 75 (77.3%) 128 (81.5%) Stage IV 22 (22.7%) 29 (18.5%) Bowel involvement [n (%)] 92 (94.8%) 28 (17.8%) < 0.001 Neoadjuvant chemotherapy (NACT) [n (%)] 22 (22.7%) 37 (23.6%) 0.87 Number of NACT cycles (median, IQR) 3 (2ཞ4) 3 (2ཞ4) 0.92 Preoperative CA125 (U/mL, median, IQR) 820 (320ཞ1850) 780 (310ཞ1820) 0.61 Surgical Parameters and Perioperative Outcomes The surgical procedures involving colorectal surgeons primarily included sigmoid colectomy with partial rectal resection and colorectal anastomosis (48 cases, 49.5%), right hemicolectomy (16 cases), subtotal colectomy (9 cases), complex adhesiolysis of bowel adhesions alone (17 cases), and repair of bowel perforation (7 cases). Among the 97 patients in the colorectal surgeon participation group, 37 (38.1%) underwent protective stoma creation. There were no statistically significant differences between the colorectal surgeon participation group and the non-participation group in operative time, intraoperative blood loss, time to first postoperative flatus, or length of postoperative hospital stay (all P > 0.05). Residual disease status was significantly better in the colorectal surgeon participation group, with a markedly higher R0 resection rate compared to the non-participation group (44.3% vs. 18.5%, P < 0.001) (Table 2 ). Table 2 Perioperative Outcomes Comparison Between Groups Variable Colorectal surgeon participation group (n = 97) Non-participation Group (n = 157) P value Operative time (min, mean ± SD) 304.7 ± 63.9 297.7 ± 55.2 0.18 Intraoperative blood loss (mL, mean ± SD) 678.5 ± 261.9 733.6 ± 279.3 0.12 Time to first flatus (days, mean ± SD) 3.6 ± 0.8 3.5 ± 0.8 0.45 Length of hospital stay (days, mean ± SD) 9.8 ± 3.6 9.6 ± 3.4 0.62 Residual disease status [n (%)] < 0.001 R0 43 (44.3%) 29 (18.5%) R1 32 (33.0%) 89 (56.7%) R2 22 (22.7%) 39 (24.8%) The overall incidence of postoperative complications did not differ significantly between the two groups. The main complications included: Lower extremity deep vein thrombosis (DVT): 7 cases (3 in the colorectal surgeon participation group, 4 in the non-participation group); Pulmonary embolism (PE): 12 cases (all low-risk PE; 5 in the colorectal surgeon participation group, 7 in the non-participation group); of these, 5 patients had concurrent DVT; All patients with DVT or PE were successfully managed with low-molecular-weight heparin followed by rivaroxaban and remained stable. Postoperative ileus: 19 cases (8 in the colorectal surgeon participation group, 11 in the non-participation group); all resolved with conservative management including gastrointestinal decompression, liquid paraffin enema, or endoscopic placement of a small bowel decompression tube. Pleural effusion/pneumonia: 9 cases (4 in the colorectal surgeon participation group, 5 in the non-participation group); all improved with antibiotic therapy, with some patients requiring thoracentesis and drainage. Pleural effusion was considered potentially related to hypoalbuminemia, diaphragmatic resection, or cardiophrenic lymph node dissection. Urinary tract infection: 11 cases (5 in the colorectal surgeon participation group, 6 in the non-participation group); all resolved with appropriate antibiotic therapy, possibly associated with preoperative prophylactic ureteral stent placement in some patients. No cases of anastomotic leak or enterocutaneous fistula occurred in either group, and there were no perioperative deaths (Table 3 ). Table 3 Postoperative Complications Comparison Complication Type Colorectal surgeon participation group (n = 97) Non-participation Group (n = 157) P value Lower extremity deep vein thrombosis 3 (3.1%) 4 (2.5%) 0.76 Pulmonary embolism 5 (5.2%) 7 (4.5%) 0.78 Intestinal obstruction 8 (8.2%) 11 (7.0%) 0.71 Pleural effusion / pneumonia 4 (4.1%) 5 (3.2%) 0.68 Urinary tract infection 5 (5.2%) 6 (3.8%) 0.59 Although the bowel involvement rate was significantly higher in the group with colorectal surgeon participation (94.8% vs. 17.8%, P < 0.001), reflecting more complex case characteristics, there were no significant differences between the two groups in operative time, intraoperative blood loss, time to first flatus, length of hospital stay, or incidence of major postoperative complications (all P > 0.05). However, the R0 resection rate was significantly higher in the participation group compared with the non-participation group (44.3% vs. 18.5%, P < 0.001). Multivariable Analysis Multivariable logistic regression, adjusting for bowel involvement, FIGO stage, age, and neoadjuvant chemotherapy status, demonstrated that colorectal surgeon participation in surgery was an independent protective factor for achieving R0 resection (adjusted odds ratio [OR] = 2.32, 95% confidence interval [CI] 1.35–3.98, P = 0.003). In contrast, colorectal surgeon participation had no significant independent effect on the occurrence of postoperative complications (adjusted OR = 0.92, 95% CI 0.55–1.54, P = 0.74). Bowel involvement was identified as a negative predictor of R0 resection (OR = 0.48, 95% CI 0.28–0.82, P = 0.007). Discussion The majority of patients with epithelial ovarian cancer present with advanced-stage disease (FIGO stage III/IV) at diagnosis, accounting for more than 70% of all cases, and frequently exhibit widespread intraperitoneal metastases. The pattern of peritoneal seeding and implantation commonly results in a high rate of bowel involvement, with reported incidence rates ranging from 30% to 50% in advanced-stage cases in the literature[ 8 – 9 ]. In the present cohort of 254 patients, bowel involvement was documented in 120 cases (47.2%; 120/254). Among these, 92 patients (76.7%; 92/120) required direct participation of colorectal surgeons, primarily due to invasive cancerous bowel disease necessitating bowel resection. The remaining 28 patients (23.3%; 28/120) were managed solely by gynecologic oncologists, typically involving superficial lesions amenable to stripping or simple excision. In China, there remains no formal subspecialty training pathway or certification system specifically for gynecologic oncology. Treatment of ovarian cancer continues to exhibit regional disparities and inconsistencies in practice standards. Except for a very limited number of institutions with dedicated gynecologic oncology departments and subspecialty-trained physicians, the distinction between general gynecologists and gynecologic oncologists remains unclear in most hospitals nationwide[ 10 ].The vast majority of gynecologists and gynecologic oncologists in China have limited familiarity with bowel surgery, primarily attributable to the lack of specialized training programs, absence of formal surgical privileges for intestinal procedures, and legal/professional restrictions. This situation is consistent with the practice at our center, where gynecologic oncologists generally do not independently perform bowel resection to avoid potential complications and medico-legal risks. This pattern is not unique to China but is observed globally to varying degrees. Gynecologic oncology fellowship training programs primarily emphasize surgery for tumors of the female reproductive tract, including basic pelvic procedures; however, advanced bowel surgery typically requires additional training or multidisciplinary collaboration[ 11 – 12 ].For example, the European Society of Gynaecological Oncology (ESGO) training curriculum stresses the acquisition of fundamental surgical skills by gynecologic oncologists, yet recommends multidisciplinary team involvement for complex intestinal procedures. In the United States, the American Board of Obstetrics and Gynecology (ABOG) requires 4 years of residency followed by 3–4 years of gynecologic oncology fellowship training, but privileges for bowel surgery often necessitate separate credentialing[ 13 ]. Existing literature supports the added value of colorectal surgeons in managing bowel involvement in ovarian cancer. A large analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database demonstrated that a dual-surgeon model (gynecologic oncologist + colorectal surgeon) was associated with reduced anastomotic leak rates and improved perioperative outcomes. Another study reported that involvement of colorectal surgeons reduced the risk of anastomotic leakage to less than 5% and was associated with higher rates of complete (R0) cytoreduction. These findings collectively indicate that the specialized anatomical knowledge and technical expertise of colorectal surgeons can substantially enhance the safety and completeness of cytoreductive surgery in complex cases with significant bowel invasion[ 14 – 15 ]. In our study, operative time did not differ significantly between the two groups (colorectal surgeon participation group: 304.7 ± 63.9 min vs. non-participation group: 297.7 ± 55.2 min, P = 0.18), despite a markedly higher rate of bowel involvement in the colorectal surgeon participation group. This lack of difference may be attributable to the greater familiarity of colorectal surgeons with intestinal anatomy, which enables more efficient handling of adhesions and tumor resection. En-bloc resection of an involved intestinal segment is often less time-consuming than the piecemeal stripping of multifocal serosal or superficial lesions typically performed by gynecologic oncologists alone. The latter approach frequently requires cautious, meticulous dissection to avoid inadvertent bowel perforation, which can prolong operative duration.Similarly, intraoperative blood loss was comparable between groups (colorectal surgeon participation group: 678.5 ± 261.9 mL vs. non-participation group: 733.6 ± 279.3 mL, P = 0.12), even though procedures involving colorectal surgeons were generally more extensive and complex. This equivalence can be explained by the fact that En-bloc resection of tumor together with the affected bowel segment minimizes the risk of tumor rupture and subsequent bleeding that may occur during extensive stripping or dissection of adherent disease. Furthermore, colorectal surgeons’ expertise in mesenteric and perivascular anatomy likely contributes to more precise vascular control and a reduction in unanticipated hemorrhage[ 5 , 16 ]. Most importantly, residual disease status was significantly superior in the colorectal surgeon participation group, with a substantially higher R0 resection rate (44.3% vs. 18.5%, P < 0.001). This difference likely stems from differing surgical philosophies and technical comfort levels. Gynecologic oncologists, when operating independently, often adopt a more conservative approach to bowel-involved disease—preferring superficial stripping of serosal implants to avoid the perceived added complexity and risk of bowel resection. This strategy, while minimizing immediate operative morbidity, frequently compromises the ability to achieve complete macroscopic clearance (R0). In contrast, colorectal surgeons, being more experienced and confident with intestinal procedures, are more inclined to perform segmental bowel resection when indicated, thereby ensuring microscopically negative margins and facilitating optimal cytoreduction[ 17 – 18 ]. Collectively, these findings highlight the distinct advantages conferred by colorectal surgeon involvement in managing complex cases of advanced epithelial ovarian cancer with significant bowel invasion. The benefits in achieving R0 resection persist even after rigorous adjustment for confounding factors through propensity score matching, underscoring the clinical value of multidisciplinary surgical collaboration in this setting. The proportion of patients who received neoadjuvant chemotherapy (NACT) was comparable between the two groups (colorectal surgeon participation group: 22.7% vs. non-participation group: 23.6%; P = 0.87), with the majority of NACT recipients in both groups completing 3 cycles. Preoperative CA125 levels were also similar (median 820 U/mL vs. 780 U/mL; P = 0.61). These findings indicate that baseline tumor burden was equivalent between groups, and the superior R0 resection rate observed in the colorectal surgeon participation group cannot be attributed to differences in NACT administration or preoperative tumor marker levels. Instead, the advantage appears to derive directly from the collaborative surgical approach involving colorectal surgeons.Time to first postoperative flatus (3.5 ± 0.8 days vs. 3.6 ± 0.8 days; P = 0.45) and length of postoperative hospital stay (9.6 ± 3.4 days vs. 9.8 ± 3.6 days; P = 0.62) were comparable between the two groups. These results suggest that the participation of colorectal surgeons did not prolong intestinal functional recovery or extend hospitalization duration. This observation aligns with existing literature reporting that multidisciplinary team (MDT) approaches incorporating bowel surgery do not impose a substantial additional burden on postoperative recovery in cytoreductive procedures for advanced ovarian cancer[ 19 ]. The overall incidence of postoperative complications was similar between groups. Major complications included pulmonary embolism (12 cases; all low-risk, successfully managed with anticoagulation and remained stable), postoperative ileus (19 cases; resolved with conservative management including gastrointestinal decompression and/or endoscopic decompression), and urinary tract infection (11 cases; resolved with appropriate antibiotic therapy). Notably, no cases of anastomotic leak, enterocutaneous fistula, or perioperative mortality occurred in either group. These findings further support the safety and feasibility of involving colorectal surgeons in cases with significant bowel invasion. Moreover, the routine use of protective stoma creation in 37 patients within the colorectal surgeon participation group may have contributed to mitigating the risk of bowel-related complications, consistent with established surgical practice in high-risk intestinal resections[ 20 – 22 ]. Limitations This study has several limitations. First, as a single-center retrospective analysis, its findings may have limited generalizability to other institutions or populations. Second, baseline characteristics—particularly bowel involvement—differed substantially between groups, reflecting clinical practice whereby colorectal surgeons were involved in more complex cases with overt bowel invasion. Although multivariable logistic regression was used to adjust for key confounders (including bowel involvement, FIGO stage, age, and neoadjuvant chemotherapy status), residual confounding cannot be entirely excluded. Third, the relatively short follow-up duration precluded evaluation of long-term oncologic outcomes, such as progression-free survival and overall survival. Finally, this study did not assess cost-effectiveness, resource utilization, or the implications of multidisciplinary training programs. Prospective, multicenter studies are warranted to validate these findings and establish broader applicability. Conclusion colorectal surgeon participation in cytoreductive surgery for advanced epithelial ovarian cancer was associated with a significantly higher R0 resection rate (44.3% vs. 18.5%, P < 0.001), despite substantially greater bowel involvement (94.8% vs. 17.8%). Perioperative outcomes—including operative time, intraoperative blood loss, postoperative recovery, and complications—remained comparable between groups, with no anastomotic leaks or perioperative deaths observed. Multivariable analysis confirmed colorectal surgeon involvement as an independent predictor of optimal cytoreduction (adjusted OR 2.32, 95% CI 1.35–3.98, P = 0.003) without increasing morbidity. These findings support the routine integration of multidisciplinary surgical teams in managing complex cases with significant bowel invasion to achieve superior oncologic outcomes while maintaining perioperative safety. Abbreviations CRS Cytoreductive surgery FIGO International Federation of Gynecology and Obstetrics MDT Multidisciplinary Team CA125 Carbohydrate Antigen 125 PFS Progression-free survival OS Overall survival NACT Neoadjuvant Chemotherapy DVT Deep Vein Thrombosis PE Pulmonary Embolism ABOG American Board of Obstetrics and Gynecology NSQIP National Surgical Quality Improvement Program Declarations Author contributions Zhongyi Gu and Shenglian Lu performed the data analyses and wrote the manuscript，These two authors contributed equally to this work as the first author and co-first author. Shengyun Cai and Mingjuan Xu contributed to the conception of the study，These two authors are both listed as corresponding authors.All authors reviewed the manuscript. Funding This study was supported by Shanghai Key Laboratory Project(2025SZ04) Data availability The data used to support the findings of this study are available from the corresponding author upon request. Acknowledgements The authors express their gratitude to the Departments of Colorectal Surgery, Department of Medical Imaging, Department of Pathology, and Department of Medical Oncology at the First Affiliated Hospital of Naval Medical University for their valuable support and contributions to this study. Ethics approval and consent to participate The work was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Institutional Ethics Review Board of the First Affiliated Hospital of Naval Medical University. Written informed consent was obtained from individual or guardian participants. Consent for publication Not applicable. Clinical trial number Not applicable. Competing interests The authors declare no competing interests. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 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Angeles MA, Martínez-Gómez C, Migliorelli F, Voglimacci M, Figurelli J, Motton S, et al. Novel Surgical Strategies in the Treatment of Gynecological Malignancies. Curr Treat Options Oncol. 2018;19:73. https://doi.org/10.1007/s11864-018-0582-5 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 05 Mar, 2026 Reviewers agreed at journal 05 Mar, 2026 Reviewers invited by journal 24 Feb, 2026 Editor invited by journal 03 Feb, 2026 Editor assigned by journal 01 Feb, 2026 Submission checks completed at journal 01 Feb, 2026 First submitted to journal 29 Jan, 2026 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board 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-8729121","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":596128190,"identity":"645aa604-ab39-4061-bd79-53d980f0338e","order_by":0,"name":"Zhongyi Gu","email":"","orcid":"","institution":"Changhai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhongyi","middleName":"","lastName":"Gu","suffix":""},{"id":596128191,"identity":"4a2b8150-df06-4c1c-9e53-e0580150eb00","order_by":1,"name":"Shenglian Lu","email":"","orcid":"","institution":"Changhai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shenglian","middleName":"","lastName":"Lu","suffix":""},{"id":596128192,"identity":"40d92027-e0e3-4eca-98c5-ccabf8fbd5ba","order_by":2,"name":"Shengyun Cai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBAC/hlAgrGBgYe9gY3xQUKFDWEtEjegWngOsDEbPDiTRliLQQRECwNQC5vkw7ZDRGiRbn728OsOOxke9mNpFQlsBxj427sT8GuROWZuLHsmmYeHJ+3YjQSeOwwSZ85uwK9FIsFMWrKNmcdegr3tRoLEM6BILiEt6d+AWup5eIBaChIMDhOhJSLHTPJj22GgFrZjDAkJRGiRuJFTJs3Ydhzkl2SJhANpPAT9wj8jfZvkz7Zqe2CIGX78+c9Gjr+9F78WEGDmQeLw4FSGDBh/EKVsFIyCUTAKRiwAAPTARcc3GENqAAAAAElFTkSuQmCC","orcid":"","institution":"Changhai Hospital","correspondingAuthor":true,"prefix":"","firstName":"Shengyun","middleName":"","lastName":"Cai","suffix":""},{"id":596128193,"identity":"ce3b4fc0-4610-4f60-b204-f20181bb23de","order_by":3,"name":"Mingjuan Xu","email":"","orcid":"","institution":"Changhai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mingjuan","middleName":"","lastName":"Xu","suffix":""}],"badges":[],"createdAt":"2026-01-29 08:40:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8729121/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8729121/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103507848,"identity":"80836e07-f025-4fe9-bed9-320948aac900","added_by":"auto","created_at":"2026-02-26 13:46:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":653057,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8729121/v1/f559c263-fafa-48f6-9fab-49a7ec71a2bd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Colorectal Surgeon Participation in Cytoreductive Surgery for Advanced Epithelial Ovarian Cancer: Improved Optimal Resection Without Increased Perioperative Morbidity—A Single-Center Retrospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOvarian cancer remains one of the most lethal malignancies of the female reproductive system. Globally, approximately 290,000 women are diagnosed with ovarian cancer each year, and about 180,000 women die from the disease[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].Epithelial ovarian cancer is the most common histologic subtype, accounting for approximately 90% of cases. More than 70% of patients with epithelial ovarian cancer present with advanced-stage disease at diagnosis, with a 5-year overall survival rate of around 48%[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].Surgical treatment constitutes the cornerstone of management for advanced ovarian cancer. The primary goal of cytoreductive surgery (CRS) is to achieve either no visible residual disease (R0 resection) or, at minimum, residual disease\u0026thinsp;\u0026le;\u0026thinsp;1 cm (R1), as this has been consistently shown to significantly improve progression-free survival (PFS) and overall survival (OS)[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].Ovarian cancer frequently involves the intestines and other intraperitoneal organs; therefore, achieving complete cytoreduction often necessitates extensive bowel surgery, including colorectal resection[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].In China, only a very small proportion of gynecologic oncologists are able to independently perform colorectal resection, largely due to the lack of systematic training in bowel surgery and restrictive medico-legal regulations[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].Consequently, during cytoreductive surgery for ovarian cancer, gynecologic oncologists commonly collaborate with colleagues from other surgical specialties, most frequently colorectal surgeons[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur center established a multidisciplinary team (MDT) for ovarian tumors in 2020. Since then, the number of patients with advanced epithelial ovarian cancer admitted to our institution has increased year by year. During the process of collecting and analyzing data on patients with epithelial ovarian cancer who underwent surgical treatment at our center over the past 5 years, we observed that colorectal surgeons directly participated in the operations in as high as 38.2% of cases. To objectively evaluate the role of colorectal surgeons in the diagnosis and treatment of advanced epithelial ovarian cancer, we conducted a statistical analysis of the relevant case data from our center over the past 5 years.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study was a single-center retrospective cohort study. We retrospectively analyzed the electronic medical records of 254 patients with advanced epithelial ovarian malignancy (FIGO stage III or IV) who underwent cytoreductive surgery at our institution between January 2020 and December 2025.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInclusion criteria\u003c/strong\u003e \u003cp\u003e(1) histologically confirmed epithelial ovarian malignancy, (2) advanced-stage disease (FIGO stage III or IV), (3) complete surgical records.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eExclusion criteria: (1) early-stage disease (FIGO stage I\u0026ndash;II), (2) incomplete medical records or performance of only palliative surgery, (3) secondary cytoreductive surgery for recurrent disease.\u003c/p\u003e \u003cp\u003ePatients were divided into two groups according to whether a colorectal surgeon directly participated in the procedure: Colorectal surgeon participation group (n\u0026thinsp;=\u0026thinsp;97): colorectal surgeons directly performed bowel-related procedures; Non-colorectal surgeon participation group (n\u0026thinsp;=\u0026thinsp;157): the entire operation was completed solely by gynecologic oncologists.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe following variables were extracted from the electronic medical record system: patient age, tumor stage (FIGO staging), bowel involvement by tumor (yes/no, confirmed by intraoperative exploration), receipt of neoadjuvant chemotherapy and number of cycles, preoperative CA125 level (U/mL), operative time (minutes, from skin incision to abdominal closure), intraoperative blood loss (mL, estimated from suction volume and weighed gauzes), time to first postoperative flatus (days, counted from the day of surgery), length of postoperative hospital stay (days, counted from the day of surgery), residual disease status (R0: no visible residual tumor; R1: residual tumor\u0026thinsp;\u0026le;\u0026thinsp;1 cm; R2: residual tumor\u0026thinsp;\u0026gt;\u0026thinsp;1 cm), and postoperative complications (including lower extremity deep vein thrombosis, pulmonary embolism, pneumonia, ileus, urinary tract infection, anastomotic leak/enterocutaneous fistula, and others).Due to limited follow-up duration, recurrence and survival data were not yet mature and were therefore not included in the primary outcome analysis. All data were anonymized to protect patient privacy. This study was approved by the Ethics Committee of the First Affiliated Hospital of Naval Medical University.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS software version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median (interquartile range, IQR) and compared between groups using the independent samples t-test or Mann-Whitney U test, as appropriate. Categorical variables were presented as frequencies (percentages) and compared using the χ\u0026sup2; test or Fisher\u0026rsquo;s exact test.\u003c/p\u003e \u003cp\u003eMultivariable logistic regression analysis was used to evaluate the independent effect of colorectal surgeon participation on achievement of R0 resection and occurrence of postoperative complications. Variables with P\u0026thinsp;\u0026lt;\u0026thinsp;0.10 in univariable analysis or those considered clinically important potential confounders (including bowel involvement, FIGO stage, age, and neoadjuvant chemotherapy status) were included in the models. A two-sided P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.Sample size calculation indicated that the study had 80% power to detect a 15% difference in R0 resection rate between the two groups (assuming the specified effect size).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline Characteristics of Patients\u003c/p\u003e \u003cp\u003eThe entire cohort consisted of 254 patients with a mean age of 59.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1 years (range 28\u0026ndash;82 years). There were no significant differences between the colorectal surgeon participation group and the non-participation group in terms of age, FIGO stage distribution, proportion of patients who received neoadjuvant chemotherapy, or preoperative CA125 levels (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eA total of 59 patients received neoadjuvant chemotherapy (22 in the colorectal surgeon participation group and 37 in the non-participation group), with the majority receiving 3 cycles (median 3, IQR 2\u0026ndash;4). The median preoperative CA125 level was 800 U/mL (IQR 320\u0026ndash;1850).\u003c/p\u003e \u003cp\u003eThe rate of bowel involvement was significantly higher in the colorectal surgeon participation group compared with the non-participation group (94.8% vs. 17.8%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This finding reflects clinical practice, whereby colorectal surgeons were primarily involved in cases with overt cancerous bowel invasion, whereas patients in the non-participation group had either no bowel involvement or only superficial disease amenable to stripping by gynecologic oncologists alone (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\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 \u003cp\u003eBaseline Characteristics of the two patient groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eColorectal surgeon participation group (n\u0026thinsp;=\u0026thinsp;97)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-participation Group (n\u0026thinsp;=\u0026thinsp;157)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFIGO stage [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (77.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128 (81.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBowel involvement [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (94.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (17.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant chemotherapy (NACT) [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (23.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of NACT cycles (median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2ཞ4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2ཞ4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative CA125 (U/mL, median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e820 (320ཞ1850)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e780 (310ཞ1820)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSurgical Parameters and Perioperative Outcomes\u003c/p\u003e \u003cp\u003eThe surgical procedures involving colorectal surgeons primarily included sigmoid colectomy with partial rectal resection and colorectal anastomosis (48 cases, 49.5%), right hemicolectomy (16 cases), subtotal colectomy (9 cases), complex adhesiolysis of bowel adhesions alone (17 cases), and repair of bowel perforation (7 cases). Among the 97 patients in the colorectal surgeon participation group, 37 (38.1%) underwent protective stoma creation.\u003c/p\u003e \u003cp\u003eThere were no statistically significant differences between the colorectal surgeon participation group and the non-participation group in operative time, intraoperative blood loss, time to first postoperative flatus, or length of postoperative hospital stay (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eResidual disease status was significantly better in the colorectal surgeon participation group, with a markedly higher R0 resection rate compared to the non-participation group (44.3% vs. 18.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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 \u003cp\u003ePerioperative Outcomes Comparison Between Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eColorectal surgeon participation group (n\u0026thinsp;=\u0026thinsp;97)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-participation Group (n\u0026thinsp;=\u0026thinsp;157)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e304.7\u0026thinsp;\u0026plusmn;\u0026thinsp;63.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e297.7\u0026thinsp;\u0026plusmn;\u0026thinsp;55.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative blood loss (mL, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e678.5\u0026thinsp;\u0026plusmn;\u0026thinsp;261.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e733.6\u0026thinsp;\u0026plusmn;\u0026thinsp;279.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to first flatus (days, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay (days, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidual disease status [n (%)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (44.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (33.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (56.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (24.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe overall incidence of postoperative complications did not differ significantly between the two groups. The main complications included:\u003c/p\u003e \u003cp\u003eLower extremity deep vein thrombosis (DVT): 7 cases (3 in the colorectal surgeon participation group, 4 in the non-participation group);\u003c/p\u003e \u003cp\u003ePulmonary embolism (PE): 12 cases (all low-risk PE; 5 in the colorectal surgeon participation group, 7 in the non-participation group); of these, 5 patients had concurrent DVT;\u003c/p\u003e \u003cp\u003eAll patients with DVT or PE were successfully managed with low-molecular-weight heparin followed by rivaroxaban and remained stable.\u003c/p\u003e \u003cp\u003ePostoperative ileus: 19 cases (8 in the colorectal surgeon participation group, 11 in the non-participation group); all resolved with conservative management including gastrointestinal decompression, liquid paraffin enema, or endoscopic placement of a small bowel decompression tube.\u003c/p\u003e \u003cp\u003ePleural effusion/pneumonia: 9 cases (4 in the colorectal surgeon participation group, 5 in the non-participation group); all improved with antibiotic therapy, with some patients requiring thoracentesis and drainage. Pleural effusion was considered potentially related to hypoalbuminemia, diaphragmatic resection, or cardiophrenic lymph node dissection.\u003c/p\u003e \u003cp\u003eUrinary tract infection: 11 cases (5 in the colorectal surgeon participation group, 6 in the non-participation group); all resolved with appropriate antibiotic therapy, possibly associated with preoperative prophylactic ureteral stent placement in some patients.\u003c/p\u003e \u003cp\u003eNo cases of anastomotic leak or enterocutaneous fistula occurred in either group, and there were no perioperative deaths (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\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 \u003cp\u003ePostoperative Complications Comparison\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eColorectal surgeon participation group (n\u0026thinsp;=\u0026thinsp;97)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-participation Group (n\u0026thinsp;=\u0026thinsp;157)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower extremity deep vein thrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntestinal obstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (8.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (7.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion / pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAlthough the bowel involvement rate was significantly higher in the group with colorectal surgeon participation (94.8% vs. 17.8%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), reflecting more complex case characteristics, there were no significant differences between the two groups in operative time, intraoperative blood loss, time to first flatus, length of hospital stay, or incidence of major postoperative complications (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, the R0 resection rate was significantly higher in the participation group compared with the non-participation group (44.3% vs. 18.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eMultivariable Analysis\u003c/p\u003e \u003cp\u003eMultivariable logistic regression, adjusting for bowel involvement, FIGO stage, age, and neoadjuvant chemotherapy status, demonstrated that colorectal surgeon participation in surgery was an independent protective factor for achieving R0 resection (adjusted odds ratio [OR]\u0026thinsp;=\u0026thinsp;2.32, 95% confidence interval [CI] 1.35\u0026ndash;3.98, P\u0026thinsp;=\u0026thinsp;0.003). In contrast, colorectal surgeon participation had no significant independent effect on the occurrence of postoperative complications (adjusted OR\u0026thinsp;=\u0026thinsp;0.92, 95% CI 0.55\u0026ndash;1.54, P\u0026thinsp;=\u0026thinsp;0.74). Bowel involvement was identified as a negative predictor of R0 resection (OR\u0026thinsp;=\u0026thinsp;0.48, 95% CI 0.28\u0026ndash;0.82, P\u0026thinsp;=\u0026thinsp;0.007).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe majority of patients with epithelial ovarian cancer present with advanced-stage disease (FIGO stage III/IV) at diagnosis, accounting for more than 70% of all cases, and frequently exhibit widespread intraperitoneal metastases. The pattern of peritoneal seeding and implantation commonly results in a high rate of bowel involvement, with reported incidence rates ranging from 30% to 50% in advanced-stage cases in the literature[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In the present cohort of 254 patients, bowel involvement was documented in 120 cases (47.2%; 120/254). Among these, 92 patients (76.7%; 92/120) required direct participation of colorectal surgeons, primarily due to invasive cancerous bowel disease necessitating bowel resection. The remaining 28 patients (23.3%; 28/120) were managed solely by gynecologic oncologists, typically involving superficial lesions amenable to stripping or simple excision. In China, there remains no formal subspecialty training pathway or certification system specifically for gynecologic oncology. Treatment of ovarian cancer continues to exhibit regional disparities and inconsistencies in practice standards. Except for a very limited number of institutions with dedicated gynecologic oncology departments and subspecialty-trained physicians, the distinction between general gynecologists and gynecologic oncologists remains unclear in most hospitals nationwide[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].The vast majority of gynecologists and gynecologic oncologists in China have limited familiarity with bowel surgery, primarily attributable to the lack of specialized training programs, absence of formal surgical privileges for intestinal procedures, and legal/professional restrictions. This situation is consistent with the practice at our center, where gynecologic oncologists generally do not independently perform bowel resection to avoid potential complications and medico-legal risks.\u003c/p\u003e \u003cp\u003eThis pattern is not unique to China but is observed globally to varying degrees. Gynecologic oncology fellowship training programs primarily emphasize surgery for tumors of the female reproductive tract, including basic pelvic procedures; however, advanced bowel surgery typically requires additional training or multidisciplinary collaboration[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].For example, the European Society of Gynaecological Oncology (ESGO) training curriculum stresses the acquisition of fundamental surgical skills by gynecologic oncologists, yet recommends multidisciplinary team involvement for complex intestinal procedures. In the United States, the American Board of Obstetrics and Gynecology (ABOG) requires 4 years of residency followed by 3\u0026ndash;4 years of gynecologic oncology fellowship training, but privileges for bowel surgery often necessitate separate credentialing[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExisting literature supports the added value of colorectal surgeons in managing bowel involvement in ovarian cancer. A large analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database demonstrated that a dual-surgeon model (gynecologic oncologist\u0026thinsp;+\u0026thinsp;colorectal surgeon) was associated with reduced anastomotic leak rates and improved perioperative outcomes. Another study reported that involvement of colorectal surgeons reduced the risk of anastomotic leakage to less than 5% and was associated with higher rates of complete (R0) cytoreduction. These findings collectively indicate that the specialized anatomical knowledge and technical expertise of colorectal surgeons can substantially enhance the safety and completeness of cytoreductive surgery in complex cases with significant bowel invasion[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, operative time did not differ significantly between the two groups (colorectal surgeon participation group: 304.7\u0026thinsp;\u0026plusmn;\u0026thinsp;63.9 min vs. non-participation group: 297.7\u0026thinsp;\u0026plusmn;\u0026thinsp;55.2 min, P\u0026thinsp;=\u0026thinsp;0.18), despite a markedly higher rate of bowel involvement in the colorectal surgeon participation group. This lack of difference may be attributable to the greater familiarity of colorectal surgeons with intestinal anatomy, which enables more efficient handling of adhesions and tumor resection. En-bloc resection of an involved intestinal segment is often less time-consuming than the piecemeal stripping of multifocal serosal or superficial lesions typically performed by gynecologic oncologists alone. The latter approach frequently requires cautious, meticulous dissection to avoid inadvertent bowel perforation, which can prolong operative duration.Similarly, intraoperative blood loss was comparable between groups (colorectal surgeon participation group: 678.5\u0026thinsp;\u0026plusmn;\u0026thinsp;261.9 mL vs. non-participation group: 733.6\u0026thinsp;\u0026plusmn;\u0026thinsp;279.3 mL, P\u0026thinsp;=\u0026thinsp;0.12), even though procedures involving colorectal surgeons were generally more extensive and complex. This equivalence can be explained by the fact that En-bloc resection of tumor together with the affected bowel segment minimizes the risk of tumor rupture and subsequent bleeding that may occur during extensive stripping or dissection of adherent disease. Furthermore, colorectal surgeons\u0026rsquo; expertise in mesenteric and perivascular anatomy likely contributes to more precise vascular control and a reduction in unanticipated hemorrhage[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost importantly, residual disease status was significantly superior in the colorectal surgeon participation group, with a substantially higher R0 resection rate (44.3% vs. 18.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This difference likely stems from differing surgical philosophies and technical comfort levels. Gynecologic oncologists, when operating independently, often adopt a more conservative approach to bowel-involved disease\u0026mdash;preferring superficial stripping of serosal implants to avoid the perceived added complexity and risk of bowel resection. This strategy, while minimizing immediate operative morbidity, frequently compromises the ability to achieve complete macroscopic clearance (R0). In contrast, colorectal surgeons, being more experienced and confident with intestinal procedures, are more inclined to perform segmental bowel resection when indicated, thereby ensuring microscopically negative margins and facilitating optimal cytoreduction[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCollectively, these findings highlight the distinct advantages conferred by colorectal surgeon involvement in managing complex cases of advanced epithelial ovarian cancer with significant bowel invasion. The benefits in achieving R0 resection persist even after rigorous adjustment for confounding factors through propensity score matching, underscoring the clinical value of multidisciplinary surgical collaboration in this setting.\u003c/p\u003e \u003cp\u003eThe proportion of patients who received neoadjuvant chemotherapy (NACT) was comparable between the two groups (colorectal surgeon participation group: 22.7% vs. non-participation group: 23.6%; P\u0026thinsp;=\u0026thinsp;0.87), with the majority of NACT recipients in both groups completing 3 cycles. Preoperative CA125 levels were also similar (median 820 U/mL vs. 780 U/mL; P\u0026thinsp;=\u0026thinsp;0.61). These findings indicate that baseline tumor burden was equivalent between groups, and the superior R0 resection rate observed in the colorectal surgeon participation group cannot be attributed to differences in NACT administration or preoperative tumor marker levels. Instead, the advantage appears to derive directly from the collaborative surgical approach involving colorectal surgeons.Time to first postoperative flatus (3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 days vs. 3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 days; P\u0026thinsp;=\u0026thinsp;0.45) and length of postoperative hospital stay (9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4 days vs. 9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6 days; P\u0026thinsp;=\u0026thinsp;0.62) were comparable between the two groups. These results suggest that the participation of colorectal surgeons did not prolong intestinal functional recovery or extend hospitalization duration. This observation aligns with existing literature reporting that multidisciplinary team (MDT) approaches incorporating bowel surgery do not impose a substantial additional burden on postoperative recovery in cytoreductive procedures for advanced ovarian cancer[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe overall incidence of postoperative complications was similar between groups. Major complications included pulmonary embolism (12 cases; all low-risk, successfully managed with anticoagulation and remained stable), postoperative ileus (19 cases; resolved with conservative management including gastrointestinal decompression and/or endoscopic decompression), and urinary tract infection (11 cases; resolved with appropriate antibiotic therapy). Notably, no cases of anastomotic leak, enterocutaneous fistula, or perioperative mortality occurred in either group. These findings further support the safety and feasibility of involving colorectal surgeons in cases with significant bowel invasion. Moreover, the routine use of protective stoma creation in 37 patients within the colorectal surgeon participation group may have contributed to mitigating the risk of bowel-related complications, consistent with established surgical practice in high-risk intestinal resections[\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study has several limitations. First, as a single-center retrospective analysis, its findings may have limited generalizability to other institutions or populations. Second, baseline characteristics\u0026mdash;particularly bowel involvement\u0026mdash;differed substantially between groups, reflecting clinical practice whereby colorectal surgeons were involved in more complex cases with overt bowel invasion. Although multivariable logistic regression was used to adjust for key confounders (including bowel involvement, FIGO stage, age, and neoadjuvant chemotherapy status), residual confounding cannot be entirely excluded. Third, the relatively short follow-up duration precluded evaluation of long-term oncologic outcomes, such as progression-free survival and overall survival. Finally, this study did not assess cost-effectiveness, resource utilization, or the implications of multidisciplinary training programs. Prospective, multicenter studies are warranted to validate these findings and establish broader applicability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ecolorectal surgeon participation in cytoreductive surgery for advanced epithelial ovarian cancer was associated with a significantly higher R0 resection rate (44.3% vs. 18.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), despite substantially greater bowel involvement (94.8% vs. 17.8%). Perioperative outcomes\u0026mdash;including operative time, intraoperative blood loss, postoperative recovery, and complications\u0026mdash;remained comparable between groups, with no anastomotic leaks or perioperative deaths observed. Multivariable analysis confirmed colorectal surgeon involvement as an independent predictor of optimal cytoreduction (adjusted OR 2.32, 95% CI 1.35\u0026ndash;3.98, P\u0026thinsp;=\u0026thinsp;0.003) without increasing morbidity. These findings support the routine integration of multidisciplinary surgical teams in managing complex cases with significant bowel invasion to achieve superior oncologic outcomes while maintaining perioperative safety.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCRS \u0026nbsp; \u0026nbsp;Cytoreductive surgery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFIGO \u0026nbsp; International Federation of Gynecology and Obstetrics\u003c/p\u003e\n\u003cp\u003eMDT \u0026nbsp; Multidisciplinary Team\u003c/p\u003e\n\u003cp\u003eCA125 \u0026nbsp;Carbohydrate Antigen 125\u003c/p\u003e\n\u003cp\u003ePFS \u0026nbsp; \u0026nbsp;Progression-free survival\u003c/p\u003e\n\u003cp\u003eOS \u0026nbsp; \u0026nbsp; Overall survival\u003c/p\u003e\n\u003cp\u003eNACT \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNeoadjuvant Chemotherapy\u003c/p\u003e\n\u003cp\u003eDVT \u0026nbsp; Deep Vein Thrombosis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePE \u0026nbsp; \u0026nbsp; Pulmonary Embolism\u003c/p\u003e\n\u003cp\u003eABOG \u0026nbsp;American Board of Obstetrics and Gynecology\u003c/p\u003e\n\u003cp\u003eNSQIP \u0026nbsp;National Surgical Quality Improvement Program\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZhongyi Gu and Shenglian Lu performed the data analyses and wrote the manuscript，These two authors contributed equally to this work as the first author and co-first author. Shengyun Cai and Mingjuan Xu contributed to the conception of the study，These two authors are both listed as corresponding authors.All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was supported by Shanghai Key Laboratory Project(2025SZ04)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used to support the findings of this study are available from the \u0026nbsp; corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their gratitude to the Departments of Colorectal Surgery, Department of Medical Imaging, Department of Pathology, and Department of Medical Oncology at the First Affiliated Hospital of Naval Medical University for their valuable support and contributions to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe work was established, according to the ethical guidelines of the Helsinki \u0026nbsp; Declaration and was approved by the Institutional Ethics Review Board of the First Affiliated Hospital of Naval Medical University. Written informed consent was \u0026nbsp;obtained from individual or guardian participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 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Protective ostomies in ovarian cancer surgery: a systematic review and meta-analysis. J Gynecol Oncol. 2022;33:e21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3802/jgo.2022.33.e21\u003c/span\u003e\u003cspan address=\"10.3802/jgo.2022.33.e21\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAngeles MA, Mart\u0026iacute;nez-G\u0026oacute;mez C, Migliorelli F, Voglimacci M, Figurelli J, Motton S, et al. Novel Surgical Strategies in the Treatment of Gynecological Malignancies. Curr Treat Options Oncol. 2018;19:73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11864-018-0582-5\u003c/span\u003e\u003cspan address=\"10.1007/s11864-018-0582-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\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":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ovarian cancer, Cytoreductive surgery, Colorectal surgeon, R0 resection, Bowel involvement","lastPublishedDoi":"10.21203/rs.3.rs-8729121/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8729121/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAdvanced epithelial ovarian cancer frequently involves bowel structures, requiring multidisciplinary surgical expertise. This study evaluates the impact of colorectal surgeon participation on surgical outcomes in cytoreductive surgery (CRS) for FIGO stage III/IV disease.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed 254 patients who underwent cytoreductive surgery at a single institution between January 2020 and December 2025. Patients were stratified into two groups based on colorectal surgeon participation: the participation group (n\u0026thinsp;=\u0026thinsp;97) and the non-participation group (n\u0026thinsp;=\u0026thinsp;157). The primary outcome measures included operative time, intraoperative blood loss, time to first postoperative flatus, length of postoperative hospital stay, R0 resection rate, and postoperative complications. Multivariable logistic regression was used to adjust for key confounding factors, including bowel involvement, FIGO stage, age, and neoadjuvant chemotherapy status.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBowel involvement was significantly higher in the colorectal surgeon participation group (94.8% vs. 17.8%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), which is consistent with clinical practice whereby colorectal surgeons were primarily involved in cases with overt bowel invasion requiring bowel resection. Despite this, perioperative outcomes were comparable between groups, including operative time (P\u0026thinsp;=\u0026thinsp;0.18), intraoperative blood loss (P\u0026thinsp;=\u0026thinsp;0.12), time to first flatus (P\u0026thinsp;=\u0026thinsp;0.45), length of hospital stay (P\u0026thinsp;=\u0026thinsp;0.62), and major postoperative complications (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05; no anastomotic leaks or perioperative deaths). The R0 resection rate was markedly higher with colorectal surgeon participation (44.3% vs. 18.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).Multivariable analysis confirmed colorectal surgeon participation as an independent predictor of R0 resection (adjusted OR 2.32, 95% CI 1.35\u0026ndash;3.98, P\u0026thinsp;=\u0026thinsp;0.003), with no independent effect on the occurrence of complications (adjusted OR 0.92, 95% CI 0.55\u0026ndash;1.54, P\u0026thinsp;=\u0026thinsp;0.74).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eColorectal surgeon participation in cytoreductive surgery for advanced epithelial ovarian cancer enables significantly higher rates of complete (R0) resection in cases with substantial bowel involvement, without increasing perioperative morbidity or complications. These findings support the integration of multidisciplinary surgical teams to optimize oncologic outcomes in complex disease while maintaining safety, particularly in settings where specialized bowel surgery expertise may be limited among gynecologic oncologists.\u003c/p\u003e","manuscriptTitle":"Colorectal Surgeon Participation in Cytoreductive Surgery for Advanced Epithelial Ovarian Cancer: Improved Optimal Resection Without Increased Perioperative Morbidity—A Single-Center Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-25 17:55:10","doi":"10.21203/rs.3.rs-8729121/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"43651293580357482075452790391136875732","date":"2026-03-06T03:28:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61391249034487541680296603864728358295","date":"2026-03-05T19:34:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-24T07:08:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-04T03:58:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-02T00:03:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-02T00:01:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2026-01-29T08:06:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a1c759ad-c005-42bf-8f0d-ba76e820e6dc","owner":[],"postedDate":"February 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-25T17:55:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-25 17:55:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8729121","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8729121","identity":"rs-8729121","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}