Anastomotic leakage

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Anastomotic leakage

• Risk Factors
• POW Journal Club 14 May 2007
• Sanjay Warrier

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Anastomotic leakage

• Patient factors nutrition, ischaemia,
  comorbidities, bowel preparation, obesity. age,
  sex.
• Operator factors stapled versus handsewn
  anastomosis. Surgical variability.

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Aim

• Review patient dependent factors.
• Surgical variability will be there. Identify
  patient risk factors in colorectal disease that
  may alter clinical management.
• Aim to chose an article which had a conclusion
  which would be of clinical significance
• Recent publication within the last 5 years.

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Paper choice

• No recent prospective studies designed review
  risk factors
• Choice Diseases of the colon and rectum 2003.
• Risk factors for anastomotic leakage after left
  sided colorectal resection with rectal
  anastomosis

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Methods

• Case control retrospective analysis
• 10 year period
• Identify all anastomotic leaks44
• Control group obtained from same registrary.

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Inclusion/exclusion criteria

• Inclusion All patients operated on for leakage.
• Control group same surgeons performed the
  operations in leakage and control group. Patients
  chosen with same age, sex, type of cancer and
  operation.
• Exclusion Patients not operated on for suspected
  leakage.

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Methods

• Data review on 88 patients
• Nutritional status on admission determined.
  Malnourished if albuminlt35g/l, weight loss gt5kg
  in few months.
• Obesity BMI gt 27kg/m2
• Anemia defined as HBlt 110 umol
• Creatinine lt110 umol/1 and serum bilirubin
  lt20umol/l

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Methods continued

• Medical illnesses diabetes, cardiovascular
  disease, lung disease, renal disease,
  cerebrovascular accident.
• Previous abdominal surgery, alcohol consumption,
  smoking, pre operative use of steroids, type of
  intestinal preparation and antibiotic
  prophylaxis.
• Surgical factors type of surgery, mobilisation
  of splenic flexure, type of anastomosis( stapled,
  sutured), technique of stapling (single/double),
  size of stapler, completeness of doughnuts,
  distance of anastomosis from the anal verge, use
  of drain, operation time and need for blood
  transfusion.

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Analysis

• Continuous variables - analysed students t test.
• Categorical variables pearson chi squared test
• Odds ratio used to calculate degree of
  association between risk factors and group (
  case/control).
• Logistic regression model used for multivariate
  analysis.

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Results

• Anastomotic leakage 44 patients, reoperation at
  8/- 5days
• 25 of 44 radiological evidence of leakage15 had
  signs of local and 10 diffuse peritonitis
• Remaining 19 were operated on for signs of
  diffuse generalized peritonitis.
• All 44 patients were treated surgically

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Results

• Patients in leakage group were more often
  malnourished (17/44) than in control group
  (2/44 p- 0.0001)
• mean albumin was 33.8 in leakage group, and 38
  in control group
• Other biochemical values did not differ
  significantly

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Results

• Use of alcohol 14/44 (leakage group) and
  6/44(control group) (OR 6.1, pvalue0.001).
• Low anastomosis was 12/44(leakage group) and
  5/44(control group)
• Blood transfusions (p0.0001) and intra operative
  contamination (p0.002) were more common in
  leakage group
• No statistical difference with drain usage, use
  of single or double stapling, emergency operation
  or mobilisation of splenic flexure.

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Results

• Number of risk factors were significantly higher
  in leakage group.
• 5 risk factors ( 100)
• 4 risk factors ( 87)
• 3 risk factors (76)

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Conclusion

• Malnutrition, weight loss, use of alcohol, blood
  transfusions, intraoperative contamination and
  distance from anal verge were statistically
  significant risk factors
• Multiple risk factors increase the chance of
  anastomotic leakage.
• Recommend use of protective stoma in low rectal
  anastomoses whenever patient has three or more
  risk factors

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Comment

• Small number study
• Aim to look at patient related risk factors.
• Definition of anastomotic leakage.
• Study design
• Definition of malnutrition definitive but not
  entirely accurate ( albuminlt35g/L). Weight loss
  related to a figure(gt5kg) rather than body mass
  index
• Alcohol consumption not quantified. Blood
  transfusions not obviously documented as
  preoperative analysis.

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Anastomotic leakage

• Rullier et al 1998 BJS 1980 to 1995 look at 272
  consecutive anterior resection. Statistical
  significant risk for distance from verge ( less
  than 5cm from rectum), also more likely in men(
  2.7 times more likely).
• Lipska et al ANZ Journal of Surgery July 2006,
  535 patients in single colorectal unit 1999
  2004. All colonic anastomosis. Anastomotic
  leakage rate of 6.5.
• Statistical significant results for male, history
  of abdominal surgery and low level of cancer.
  Increased rates of leak with hypoalbuminemic
  patients and those who Etoh or smoke but no
  statistical significance. Blood transfusion not
  shown to be a factor.

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Anastomotic leakage

• Yeh et al. Annals of surgery 2005. Risk factors
  after elective anterior resection. Statistical
  significant for level of anastomosis and
  leakage, and also male patients.
• Pre operative hypoalbuminemia lost statistical
  significance in final regression model. Higher
  rate of leakage in those with poor bowel
  preparation.