The risk factors for gastrointestinal anastomotic leak after cytoreduction with hyperthermic intraperitoneal chemotherapy

BACKGROUND: Gastrointestinal anastomotic leak (GAL) is a major cause of morbidity and mortality after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study is to determine the risk factors associated with GAL in peritoneal metastases (PM) surgery. METHODS: Patients who underwent CRS and HIPEC with gastrointestinal anastomosis were included. Charlson Comorbidity Index (CCI) and Eastern Cooperative Oncology Group (ECOG) performance status were used to assess preoperative condition of the patients. GAL was recorded as gastrointestinal extralumination diagnosed clinically, radiologicaly, or during reoperation. RESULTS: Among 362 patients who were analyzed, the median age was 54 years, 72.6% were female, and the most common histopathologies were ovarian cancer (37.8%) and colorectal (36.2%) cancer. The median Peritoneal Cancer Index was 11 and 80.1% of the patients underwent complete cytoreduction. A single anastomosis was performed in 293 (80.9%) patients, two anastomoses in 51 (14.1%) and three anastomoses in 18 (5%) patients. Diverting stoma was performed in 43 (11.8%) patients. GAL was seen in 38 (10.5%) patients. Smoking (p<0.001), ECOG performance status (p=0.014), CCI score (p=0.009), pre-operative albumin level (p=0.010), and number of resected organs (p=0.006) were significantly associated factors with GAL. Independent risk factors for GAL were smoking (Odds Radio [OR]: 6.223, confidence interval [CI]: 2.814–13.760; p<0.001), CCI score ≥7 (OR: 4.252, CI: 1.590–11.366; p=0.004), and pre-operative albumin level ≤3.5 g/dl (OR: 3.942, CI: 1.534–10.130; p=0.004). CONCLUSION: Patient-related factors such as smoking, comorbidity, and pre-operative nutritional status had an impact on anastomotic complications. Proper patient selection and prediction of an index patient requiring a prehabilitation program with a high level of care are essential prerequisites to obtaining lower anastomotic leak rates and improving outcomes in PM surgery.