Risk Factors of Anastomotic Leakage and Long-Term Survival After Colorectal Surgery

Abstract

Anastomotic leakage (AL) is one of the most serious complications of colorectal surgery. It can affect long-term oncologic outcomes, but the impact on long-term survival remains uncertain. The aim of this study is to evaluate the operative characteristics of leakage and no leakage groups and to analyze long-term oncologic outcomes.We prospectively enrolled 10,477 patients from 2000 to 2011 and retrospectively reviewed the data.Male sex (odds ratio [OR], 3.90; P < 0.001), intraoperative transfusion (OR, 2.31; P = 0.042), and operative time (OR, 1.73; P = 0.032) were independent risk factors of AL in the colon. In the rectum, male sex (OR, 2.37; P < 0.001), neoadjuvant chemoradiotherapy (OR, 2.26; P < 0.001), and regional lymph node metastasis (OR, 1.43; P = 0.012) were independent risk factors of AL, and diverting stoma (OR, 0.24; P < 0.001) was associated with a deceased risk of AL. AL in the rectum without a diverting stoma was associated with disease-free survival (DFS, OR, 1.47; P = 0.037). Colonic leakage was not associated with 5-year DFS (leakage group vs nonleakage group, 72.4% vs 80.9%, P = 0.084); however, in patients undergoing rectal resection, there was a significant difference in 5-year DFS (67.0% vs 76.6%, P = 0.005, respectively).AL in the rectum is associated with worse long-term DFS and overall survival. A diverting stoma was shown to protect against this effect and was associated with long-term survival in rectal surgery. Therefore, creating a diverting stoma should be considered in high-risk patients undergoing rectal surgery.

Very Early Colorectal Anastomotic Leakage within 5 Post-operative Days: a More Severe Subtype Needs Relaparatomy

“…However, since majorities of AL occurred 5–10 days after surgery, cut-point of 30 post-operative days makes late AL rarity17 accounting for less than 4 percent of AL cases as indicated by a Korean team reporting 290 AL from 10477 colorectal carcinomas1. Therefore, redefinition of early anastomotic leakage with optimal cut-point time may be helpful to distinguish truly lethal cases needing urgent intervention.…”

“…The incidence is reported about 2.8~8.4% as all12, of which 75% occurs for rectal anastomosis resulting in a mortality rate of 1.7~16.4%13. Thus, understanding the nature and management of this disease is of great clinical importance.…”

“…Great bodies of evidence has demonstrated risk factors for AL including male sex, high American Society of Anesthesiologists (ASA) fitness grade, emergency surgery and tumor location, of which neo-adjuvant radiotherapy has been widely regarded as most important one for mid-low rectal carcinoma1345. However, one recent meta-analysis referring to literature from 1980 to 2015 has demonstrated no significant correlation between increased incidence of AL and neoadjuvant therapy6.…”

“…Definition of late AL is generally regarded as leakage occurred one month after surgery121315 or patient’s discharge16 from majorities of literature. This cut-point time makes late AL a rare event17 accounting for less than 4% as indicated by a Korean team reporting 290 AL from 10477 colorectal carcinomas1. In fact, median time of AL is about 5–6 post-operative days (range: 1–85 days) from several large sample reports12418 (22–290 AL from 455–10477 colorectal carcinomas).…”

“…This cut-point time makes late AL a rare event17 accounting for less than 4% as indicated by a Korean team reporting 290 AL from 10477 colorectal carcinomas1. In fact, median time of AL is about 5–6 post-operative days (range: 1–85 days) from several large sample reports12418 (22–290 AL from 455–10477 colorectal carcinomas). Therefore, redefinition of early AL with proper cut-point is important for precise discrimination and in-time intervention of lethal cases.…”