Diagnosis, treatment, and consequences of anastomotic leakage in colorectal surgery
Diagnosis, treatment, and consequences of anastomotic leakage in colorectal surgery
Bodil Gessler 0
Olle Eriksson 0
Eva Angenete 0
0 Department of Surgery, Scandinavian Surgical Outcomes Research Group (SSORG), Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital/Östra , SE-416 85 Gothenburg , Sweden
Purpose The aim of this study was to explore the choice of modality for diagnosis, treatments, and consequences of anastomotic leakage. Methods This is a retrospective study of consecutive patients who underwent surgery that included a colorectal anastomosis due to colorectal cancer, diverticulitis, inflammatory bowel disease (IBD), or benign polyps. Results A total of 600 patients were included during 20102012, and 60 (10%) had an anastomotic leakage. It took in mean 8.8 days (range 2-42) until the anastomotic leakage was diagnosed. A total of 44/60 of the patients with a leakage had a CT scan of the abdomen; 11 (25%) were initially negative for anastomotic leakage. Among all leakages, the anastomosis was taken down in 45 patients (76.3%). All patients with a grade B leakage (n = 6) were treated with antibiotics, and two also received transanal drainage. The overall complication rate was also significantly higher in those with leakage (93.3 vs. 28.5%, p < 0.001), and it was more common with more than three complications (70 vs. 1.5%, p < 0.001). There was a higher mortality in the leakage group. Conclusion This study demonstrated that one fourth of the CT scans that were executed were initially negative for leakage. Most patients with a grade C leakage will not have an intact anastomosis. An anastomotic leakage leads to significantly more severe postoperative complications, higher rate of reoperations, and higher mortality. An earlier relaparotomy instead of a CT scan and improved postoperative surveillance could possibly reduce the consequences of the anastomotic leakage.
Colrectal surgery; Anastomotic leakage; Postoperative complications
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Anastomotic leakage remains a severe complication after
abdominal surgery with considerable morbidity and mortality
[1–11]. The frequency ranges from 1.8 to 19.2% and depends
partly on different risk factors [4, 12–20]. Risk factors for
leakage have been extensively studied, and the most frequent
factors mentioned are male sex, high age, a low anastomosis,
malignant disease, high American Society of Anesthesiologists
(ASA) score, long operation time, emergency operation,
preoperative radiotherapy, and perioperative blood loss or transfusion
[4, 13, 18, 21–26]. There is no universal grading of the
leakages, but the definition proposed by Rahbari et al. is often used
for rectal cancer and consists of a three-grade scale. Grade A
requires no therapeutic intervention; grade B includes active
intervention without laparotomy, and if laparotomy is required,
the leakage is classified as grade C [27]. The diagnostic
methods commonly used when a leakage is suspected are CT
scan, contrast enema, endoscopic examination, and reoperation
[28]. The leakage may be diagnosed at different time points
postoperatively, and there are theories that early and late
leakages are different entities. One suggestion is that a later
diagnosed leakage only has more subtle symptoms, and thus, more
is accurately described as discrete than late [29–33]. Treatment
of an anastomotic leakage differs with the severity and the
location of the anastomosis. Often, there is a high frequency
of permanent stoma after a reoperation and anastomotic take
down. Salvage of the anastomosis is more common in grade A
and B leakages with the treatment consisting of drainage and/or
antibiotics [3, 34–36]. Despite the increased knowledge of an
anastomotic leakage, there is still a need for studies in an
unselected cohort of patients receiving surgery for both benign and
malignant diseases, to try to improve results after the
anastomotic leakage has occurred.
The aim of this study was to explore the choice of modality
for diagnosis, treatments, and consequences of anastomotic
leakage in colorectal surgery in an unselected population.
This is a retrospective study of a consecutive series of patients,
over 16 years old, between the first of January 2010 to the 30
June 2012, who underwent colorectal surgery that included an
anastomosis due to colorectal cancer, diverticulitis,
inflammatory bowel disease (IBD), or benign polyps. All patients were
treated at the Sahlgrenska University Hospital/Östra in
Sweden, that serves approximately 700,000 inhabitants. The
Nordic Medico-Statistical Committee (NOMESCO)
Classification of Surgical Procedures version 1.9 was used
to identify all patients. End follow-up was set to 6
May 2014 or the date of death. The median time of
followup was 32 months (interquartile range (IQR) = 16).
Included variables
The medical records were studied, and data was collected
including patient-related information such as demography
(date of birth, (...truncated)