Anastomotic leak after colorectal resection: A population-based study of risk factors and hospital variation

Abstract

Background Anastomotic leak (AL) is a major source of morbidity in colorectal surgery and has become an area of interest in performance metrics. It is unclear whether AL is associated primarily with surgeons’ technical performance or explained better by patient characteristics and institutional factors. We sought to establish if AL could serve as a valid quality metric in colorectal surgery by evaluating provider variation after adjusting for patient factors. Methods We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with AL. Hierarchical logistic regression was used to derive risk-adjusted rates of AL. Results Of 9,192 colorectal resections, 244 (2.7%) had a documented AL. The incidence of AL was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index > 30 kg/m2, tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count > 400×109/L), and urgent/emergent surgery were independently associated with AL (C-statistic = 0.75). After accounting for patient and procedural risk factors, there were five hospitals with a significantly greater incidence of postoperative AL. Conclusions This population-based study shows that risk factors for AL include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergent surgery; models including these factors predict most of the variation in AL rates. This study suggests that AL can serve as a valid metric that can identify opportunities for quality improvement.

Safety of Anastomoses in Right Hemicolectomy for Colon Cancer

“…Operating time is well known in field literature to contribute to patients' evolution and prognosis (22), fact that requested a time analysis among the subjects included in the present study. There was observed that a shorter operating time was identified as a significant protective factor in the development of the anastomotic fistula, other published studies presenting prolonged duration of surgery as an independent risk factor in the occurrence of anastomotic leakage (23). Furthermore, the assessment of intraoperative blood loss showed no statistical differences in patients with anastomotic leakage, compared to those with anastomotic integrity.…”

Obesity as a surgical risk factor

“…Similar adverse influences have been recognized for surgical procedures such as right hemicolectomy, LAR, Hartmann surgery, Miles surgery, and robotic surgery . Moreover, obesity might reportedly be an independent risk factor for leakage …”

The effect of age on anastomotic leakage in colorectal cancer surgery: A population‐based study

“…Another large prospective multicenter study from Germany which included 17 867 patients found similar results . Recently, a study from the Michigan Surgical Quality Collaborative cohort found a younger mean age in patients with CAL . These findings were not explicitly evaluated in these studies but were one of the risk factors that were identified.…”

“…Most studies identified age as a risk factor but the results were contradictive. Some studies showed a decreased risk of CAL in older patients, [10][11][12][13][14] while others suggest advancing age is a risk factor for CAL. 9,11 In addition, it was previously demonstrated that mortality following CAL is increased in elderly patients.…”