Oncological Outcomes After Anastomotic Leakage After Surgery for Colon or Rectal Cancer

Abstract

on behalf of the COLOR COLOR II study group jj Objective: The aim of this study was to evaluate oncological outcome for patients with and without anastomotic leakage after colon or rectal cancer surgery. Summary of Background Data: The role of anastomotic leakage in oncological outcome after colorectal cancer surgery is still topic of debate and impact on follow-up and consideration for further treatment remains unclear. Methods: Patients included in the international, multicenter, non-inferior, open label, randomized, controlled trials COLOR and COLOR II, comparing laparoscopic surgery for curable colon (COLOR) and rectal (COLOR II) cancer with open surgery, were analyzed. Patients operated by abdominoperineal excision were excluded. Both univariate and multivariate analyses were performed to investigate the impact of leakage on overall survival, diseasefree survival, local and distant recurrences, adjusted for possible confounders. Primary endpoints in the COLOR and COLOR II trial were disease-free survival and local recurrence at 3-year follow-up, respectively, and secondary endpoints included anastomotic leakage rate. Results: For colon cancer, anastomotic leakage was not associated with increased percentage of local recurrence or decreased disease-free-survival. For rectal cancer, an increase of local recurrences (13.3% vs 4.6%; hazard ratio 2.96; 95% confidence interval 1.38-6.34; P ¼ 0.005) and a decrease of disease-free survival (53.6% vs 70.9%; hazard ratio 1.67; 95% confidence interval 1.16-2.41; P ¼ 0.006) at 5-year follow-up were found in patients with anastomotic leakage.Conclusion: Short-term morbidity, mortality, and long-term oncological outcomes are negatively influenced by the occurrence of anastomotic leakage after rectal cancer surgery. For colon cancer, no significant effect was observed; however, due to low power, no conclusions on the influence of anastomotic leakage on outcomes after colon surgery could be reached. Clinical awareness of increased risk of local recurrence after anastomotic leakage throughout the follow-up is mandatory. Trial Registration: Registered with ClinicalTrials.gov, number NCT00387842 and NCT00297791.

Redefining the collateral system between the superior mesenteric artery and inferior mesenteric artery: a novel classification

“…Inadvertent mass ligation of these vessels without delineating the precise vascular anatomy can cause ischaemia of the descending colon, which may lead to necrosis, leak, stricture and, ultimately, the need for a permanent stoma. Moreover, anastomotic leaks obviously have a detrimental influence on oncological outcomes [19,20]. Although numerous clinical studies have been performed demonstrating hypoperfusion following the ligation of the IMA, none focused specifically on the importance of perfusion after the occlusion of the central mesocolic anastomosis [21].…”

Defunctioning stoma and short- and long-term outcomes after low anterior resection for rectal cancer—a nationwide register–based cohort study

“…The aforementioned study had a sample size of one-fourth of our study, but its results are consistent with ours showing no association with long-term outcome. The evidence base regarding the association of anastomotic leakage with long-term oncological outcome is larger but conflicting, with studies showing either no difference in risk or an increased risk of specific oncological outcomes, mostly local recurrence and to a smaller extent cancer-specific mortality [22][23][24][25]35]. These discrepant results have been attributed to various factors, including the variability in diagnosis and management of leakages as well as heterogeneity in patient populations analyzed with the presence of residual disease being the strongest determinant of local recurrence risk [23,36].…”

“…To date, few studies have examined whether or not a defunctioning stoma influences long-term oncological outcomes. Current evidence regarding the potential long-term impact of symptomatic anastomotic leakage in patients undergoing LAR is also conflicting [22][23][24][25].…”

The “reverse air leak test”: a new technique for the assessment of low colorectal anastomosis

“…From a functional point of view, anastomotic fistula is associated with deterioration in the quality of life with an increased risk of fecal incontinence and reduced sexual activity [4]. Furthermore, oncological outcomes in patients with anastomotic leakage after rectal surgery are far worse, with an increase of local recurrences and a decrease of disease-free survival at 5-year [5]. Despite a more accurate classification, the progress in recognizing and preventing pre-operative risk factors and the use of new anastomotic techniques, leakage…”