Innovation through standardization: Reducing the ileostomy rates while targeting zero anastomotic leaks at...

Anastomotic leak (AL) following rectosigmoid resection (RSR) is a key driver of postoperative morbidity and early mortality in ovarian cancer (OC). We previously reported a prospective study reducing AL but resulting in a high rate of prophylactic diversion. We refined the protocol to reduce prophylactic diversion without increasing AL.

Retrospective analysis of two prospective cohorts with implementation of a revised protocol intended to reduce unnecessary prophylactic diversions began November 2016 with analysis through July 2024 for differences using descriptive statistics, Chi-square, Fisher's exact, and Wilcoxon two-sample tests. Protocol revisions included indocyanine green perfusion mapping, removal of multiple large bowel resections (LBR) as a diversion criterion and a change in the minimum albumin level.

One hundred and twenty-two patients with OC underwent cytoreduction with RSR from 2016 to 2024 utilizing the revised protocol. Outcomes were compared to a previously published cohort of 67 patients from 2012 to 2016. Median age and BMI were similar between the cohorts. Neoadjuvant chemotherapy was used for 33.6% in the revised protocol period versus 17.9% (p = 0.02). The proportion of multiple LBR was similar (17.9% versus 19.7%, respectively, p = 0.77). The rate of AL was similar (0.8% versus 3%). The diversion rates were 16.4% vs. 31.3% (p = 0.02). The most common reason for diversion in the revised cohort was anastomosis ≤6 cm in 10 cases.

Use of a modified protocol resulted in a lower prophylactic diversion rate without an increase in AL. The reduction in prophylactic diversion was primarily related to avoidance in carefully selected and assessed patients who underwent multiple LBR under the revised protocol.