Invited Commentary
August 7, 2024
Surgeon Type and Anastomotic Leaks in Ovarian Cancer
Alexandra C. Istl, Nerlyne Desravines, Ugwuji N. Maduekwe
JAMA Surg. Published online August 7, 2024. doi:10.1001/jamasurg.2024.2929
For patients with advanced ovarian cancer, cytoreductive surgery (CRS) and platinum-based chemotherapy are pillars of treatment.1 Optimal completeness of cytoreduction, which may necessitate multivisceral resections, aims to achieve minimal residual disease and improve oncologic outcomes.2,3
Ebott et al4 used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to explore whether postoperative complication rates differ between gynecological oncologists and general surgeons after bowel resection during CRS for ovarian cancer. They also investigated whether multisurgeon teams were associated with fewer postoperative complications. They found no significant differences in surgical outcomes between surgeon specialties. However, multivariate analysis adjusting for race, ethnicity, and the presence of ascites revealed that 2-surgeon teams had lower odds of anastomotic leak (adjusted odds ratio, 0.11, 95% CI, 0.03-0.47). Although pairwise comparisons and predictive analyses were not conducted, it was presumed that 2-surgeon teams also had lower rates of return to the operating room. While clinically important confounders such as level of bowel resection and anastomosis (eg, small bowel vs colorectal), extent of disease, completeness of cytoreduction, and diversion were not accounted for, these findings raise important questions about safe approaches to complex cytoreductive procedures.
The authors suggest some reasons for reduced anastomotic leak in 2-surgeon cases, including enhanced communication and collaborative discussion around optimal surgical approach.5 Additional considerations include mitigation of fatigue. Debulking procedures for peritoneal surface malignancies can be lengthy and challenging cases. It is unclear from the NSQIP database whether 2 surgeons were present for the duration of the case or simply the reconstruction. However, it is possible surgeon fatigue could impact quality of reconstruction or decision-making in a prolonged case.
It is important to acknowledge other essential factors that may contribute to complication rates after CRS for ovarian cancer. Gynecologic oncology is increasingly centralized: patients with high-volume disease have better outcomes at high-volume centers with high-volume surgeons.1 Without understanding the surgeons’ CRS experience in this cohort, it is difficult to attribute meaning to the value of surgeon teams. The addition of hyperthermic intraperitoneal chemotherapy to cytoreduction for ovarian cancer has been supported by phase 3 data showing an overall survival benefit,5,6 but it may be associated with higher bowel-specific complications, and this association also depends on the level of anastomosis.
Studies within NSQIP controlling for level of anastomosis, extent of disease, steroid use, and other confounders may generate hypotheses about the benefit of multisurgeon teams in complex cytoreductive surgical procedures. Prospective studies across high-volume institutions accounting for factors that are unavailable in NSQIP (eg, institutional CRS/hyperthermic intraperitoneal chemotherapy volume for ovarian cancer and other peritoneal surface malignancies, surgeon experience, peritoneal carcinomatosis index, use of adjuncts to determine bowel/anastomosis health such as fluorescence imaging) may then provide the necessary data to shift clinical practice.
