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

doi:10.1016/j.surg.2016.12.033

Surgery

Volume 161, Issue 6, June 2017, Pages 1619-1627

Presented at the annual meeting of the American Society of Colon and Rectal Surgeons in Los Angeles, CA, April 30, 2016–May 4, 2016.

https://doi.org/10.1016/j.surg.2016.12.033 Get rights and content

Background

Anastomotic leak is a major source of morbidity in colorectal operations and has become an area of interest in performance metrics. It is unclear whether anastomotic leak is associated primarily with surgeons’ technical performance or explained better by patient characteristics and institutional factors. We sought to establish if anastomotic leak could serve as a valid quality metric in colorectal operations 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 anastomotic leak. Hierarchical logistic regression was used to derive risk-adjusted rates of anastomotic leak.

Results

Of 9,192 colorectal resections, 244 (2.7%) had a documented anastomotic leak. The incidence of anastomotic leak 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/emergency operations were independently associated with anastomotic leak (C-statistic = 0.75). After accounting for patient and procedural risk factors, 5 hospitals had a significantly greater incidence of postoperative anastomotic leak.

Conclusion

This population-based study shows that risk factors for anastomotic leak include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergency operation; models including these factors predict most of the variation in anastomotic leak rates. This study suggests that anastomotic leak can serve as a valid metric that can identify opportunities for quality improvement.

Section snippets

Study population and setting

This study analyzes data from the Michigan Surgical Quality Collaborative (MSQC), a statewide organization of community and academic hospitals with a validated surgical registry focused on quality assessment and improvement in general and vascular surgery.19, 20 The MSQC is a provider-led, quality improvement organization funded by Blue Cross and Blue Shield of Michigan. Participating hospitals vary in size and teaching status, with a predominance of community hospitals. At every hospital,

Study population

We studied 9,192 patients who underwent colorectal resection with anastomosis at 64 Michigan hospitals. The mean number of cases per hospital was 144 ± 94. There were 244 (2.7%) ALs identified. Among the 82 minor leaks (34%), 42 (17%) were managed with antibiotics alone and 40 (16%) underwent percutaneous drainage. The 162 (66%) major leaks managed with reoperation included 46 exploration and reanastomosis (18.9%), 33 exploration with creation of a defunctioning stoma (13.5%), and 83

Discussion

In this population-based study, we found a significant variation in hospital risk-adjusted rates of AL after colorectal resection. In addition, we identified independent risk factors for AL that will be important in performing valid, risk-adjusted comparisons of hospital AL rates. Following a modified Delphi methodology, the American Society of Colon and Rectal Surgeons generated recently a consensus of outcome measures, which identified AL as the “most important” quality indicator after

References (40)

S.Y. Jeong et al.
Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial
Lancet Oncol
(2014)
J. Leahy et al.
What is the risk of clinical anastomotic leak in the diverted colorectal anastomosis?
J Gastrointest Surg
(2014)
L.S. Kao et al.
Reliability of superficial surgical site infections as a hospital quality measure
J Am Coll Surg
(2011)
D.W. Dietz
Multidisciplinary management of rectal cancer: the OSTRICH
J Gastrointest Surg
(2013)
J.F. Waljee et al.
Collaborative quality improvement in surgery
Hand Clin
(2014)
N.N. Rahbari et al.
Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer
Surgery
(2010)
J. Hammond et al.
The burden of gastrointestinal anastomotic leaks: an evaluation of clinical and economic outcomes
J Gastrointest Surg
(2014)
N.H. Hyman et al.
Anastomotic leaks after bowel resection: what does peer review teach us about the relationship to postoperative mortality?
J Am Coll Surg
(2009)
Z. Estrov et al.
Elevated plasma thrombopoietic activity in patients with metastatic cancer-related thrombocytosis
Am J Med
(1995)
M.D. Jafari et al.
Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study
J Am Coll Surg
(2015)

C.A. Bertelsen et al.

Anastomotic leakage after curative anterior resection for rectal cancer: short and long-term outcome

Colorectal Dis

(2010)

N. Damen et al.

Anastomotic leaks in colorectal surgery

ANZ J Surg

(2014)

J. Fleshman et al.

Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial

JAMA

(2015)

A.R. Stevenson et al.

Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial

JAMA

(2015)

H.J. Bonjer et al.

A randomized trial of laparoscopic versus open surgery for rectal cancer

N Engl J Med

(2015)

G. Branagan et al.

Prognosis after anastomotic leakage in colorectal surgery

Dis Colon Rectum

(2005)

E.F. Midura et al.

Risk factors and consequences of anastomotic leak after colectomy: a national analysis

Dis Colon Rectum

(2015)

M.L. Manwaring et al.

Identification of consensus-based quality end points for colorectal surgery

Dis Colon Rectum

(2012)

W.P. Tan et al.

Anastomotic leaks after colorectal anastomosis occurring more than 30 days postoperatively: a single-institution evaluation

Am Surg

(2014)

A. Alves et al.

Factors associated with clinically significant anastomotic leakage after large bowel resection: multivariate analysis of 707 patients

World J Surg

(2002)

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Although non-steroidal anti-inflammatory drugs (NSAIDs) are useful options for multimodal opioid-sparing analgesia, their effect on anastomotic leakage (AL) after colorectal surgery remains unclear. We aimed to investigate the association between early postoperative NSAID use and AL occurrence in patients who underwent colorectal cancer surgery at a high-volume tertiary care center.
This retrospective observational study included all adult patients who underwent elective colorectal cancer resection surgery during 2011–2021 at a tertiary teaching hospital. Based on NSAID use within five postoperative days, patients were classified into either NSAID or no NSAID groups. We performed multivariable logistic regression analysis for the primary outcome, AL, within the first 30 postoperative days, before and after propensity score analysis using stabilized inverse probability of treatment weighting (sIPTW).
Among the 7928 patients analyzed, 0.6% experienced AL after surgery. The occurrence rates of AL were 1.7% (12/714) and 0.5% (37/7214) in the NSAID and no NSAID groups, respectively. Multivariable logistic regression analysis revealed that early postoperative NSAID use was significantly associated with AL [odds ratio (OR), 3.41; 95% confidence interval (CI), 1.76–6.60; P < 0.001]. Significance was maintained after sIPTW (OR, 3.65; 95% CI, 1.86–6.72; P < 0.001).
Early postoperative NSAID use was significantly associated with AL in patients undergoing colorectal cancer surgery at a high-volume tertiary care center. Further prospective studies are required to investigate NSAIDs' clinically meaningful unfavorable effects following colorectal cancer surgery.
Anastomotic leakage after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer
2022, European Journal of Surgical Oncology
Anastomotic leakage (AL) after colorectal surgery is well-researched, yet the effect of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) after Cytoreductive Surgery (CRS) is unclear. Assessment of risk factors in these patients may assist surgeons during perioperative decision making.
This was a single-center, retrospective study of patients who underwent CRS-HIPEC for colorectal peritoneal metastases. Main outcome measures were anastomotic leakage and associated morbidity.
AL was observed in 17 of the 234 (7.3%) anastomoses in 17 of the total of 165 (10.3%) of patients. No association was observed between the number and location of anastomoses and AL, although only one in 87 small bowel anastomoses showed leakage. The only factor associated with AL was administration of bevacizumab within 60 days prior to surgery with an odds ratio (OR) of 6.13 (1.32–28.39), P = 0.03. Deviating stomata were not statistically protective of increased morbidity, although more AL occurred in the patients with colocolic and colorectal anastomoses when no concomitant deviating stoma was created. Deviation stomata were reversed in 52.6%, and no AL was observed after stoma reversal.
The overall AL rate of CRS-HIPEC is comparable to colorectal surgery, and there is no cumulative risk of multiple anastomoses – especially in the case of small bowel anastomoses. Deviating stomata should be considered in patients with colocolic or colorectal anastomosis, although there is a significant chance that the stoma will not be reversed in these patients. Due to increased AL-risk surgeons should be aware of previous bevacizumab treatment, and plan the CRS-HIPEC at least 60 days after the treatment-day.
A preoperative prediction model for anastomotic leakage after rectal cancer resection based on 13.175 patients
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This study aims to develop a robust preoperative prediction model for anastomotic leakage (AL) after surgical resection for rectal cancer, based on established risk factors and with the power of a large prospective nation-wide population-based study cohort.
A development cohort was formed by using the DCRA (Dutch ColoRectal Audit), a mandatory population-based repository of all patients who undergo colorectal cancer resection in the Netherlands. Patients aged 18 years or older were included who underwent surgical resection for rectal cancer with primary anastomosis (with or without deviating ileostomy) between 2011 and 2019. Anastomotic leakage was defined as clinically relevant leakage requiring reintervention. Multivariable logistic regression was used to build a prediction model and cross-validation was used to validate the model.
A total of 13.175 patients were included for analysis. AL was diagnosed in 1319 patients (10%). A deviating stoma was constructed in 6853 patients (52%). The following variables were identified as significant risk factors and included in the prediction model: gender, age, BMI, ASA classification, neo-adjuvant (chemo)radiotherapy, cT stage, distance of the tumor from anal verge, and deviating ileostomy. The model had a concordance-index of 0.664, which remained 0.658 after cross-validation. In addition, a nomogram was developed.
The present study generated a discriminative prediction model based on preoperatively available variables. The proposed score can be used for patient counselling and risk-stratification before undergoing rectal resection for cancer.
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Reducing anastomotic leak (AL) continues to be a main focus in colorectal research. Several new technologies have been developed with an aim to reduce this fluorescence angiography (FA) with indocyanine green (ICG) in colorectal surgery is now a well-established technique. By using FA we are able to have a visual representation of perfusion which aids intraoperative decision making. The main impact is change in the level of bowel transection at the proximal side of an anastomosis. Previous studies have shown that routine FA use is safe and reproducible. Recent results from randomized control trials and meta-analyses show that FA use reduces the rate of anastomotic leak. The main limitation of FA is its lack of ability to quantify perfusion. Novel technologies are being developed that will quantify tissue perfusion and oxygenation. Overall, FA is a safe technique and we would advocate its routine use.
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Citation Excerpt :
In some studies, any leakage detected both clinically or radiologically is defined as AL; in others, AL is only a leakage needing and early re-do surgery. Evidence have demonstrated the risk factors for AL (Table 3) [8,14,41–51], [52–86]. Preoperative risk factors are generally divided into two types: modifiable, meaning that the patient or the physician can take measures to change them; or non-modifiable, meaning that they cannot be changed [87].
The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2–3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non‐operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum‐assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.
Prophylactic defunctioning stomas improve clinical outcomes of anastomotic leak following rectal cancer resections: An analysis of the US Rectal Cancer Consortium
2024, International Journal of Colorectal Disease

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: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

: The elements of the study would not be possible without significant contributions from all authors. Conception of design: S.H., V.C.N., N.S.K. Acquisition of data: N.S.K., V.C.N., S.H. Analysis and interpretation of data: V.C.N., N.S.K., S.H., A.M.M., S.E.R., J.C.B., P.A.S., D.A.C. Drafting article: V.C.N., N.S.K., S.H. Critical revisions: all authors. Final approval of the version to be submitted: all authors.

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

Background

Methods

Results

Conclusion

Section snippets

Study population and setting

Study population

Discussion

Lancet Oncol

J Gastrointest Surg

J Am Coll Surg

J Gastrointest Surg

Hand Clin

Surgery

J Gastrointest Surg

J Am Coll Surg

Am J Med

J Am Coll Surg

Anastomotic leakage after curative anterior resection for rectal cancer: short and long-term outcome

Colorectal Dis

Anastomotic leaks in colorectal surgery

ANZ J Surg

Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial

JAMA

Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial

JAMA

A randomized trial of laparoscopic versus open surgery for rectal cancer

N Engl J Med

Prognosis after anastomotic leakage in colorectal surgery

Dis Colon Rectum

Risk factors and consequences of anastomotic leak after colectomy: a national analysis

Dis Colon Rectum

Identification of consensus-based quality end points for colorectal surgery

Dis Colon Rectum

Anastomotic leaks after colorectal anastomosis occurring more than 30 days postoperatively: a single-institution evaluation

Am Surg

Factors associated with clinically significant anastomotic leakage after large bowel resection: multivariate analysis of 707 patients

World J Surg

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