Risk Factors for Anastomotic Leakage After Anterior Resection for Rectal Cancer | JAMA Surgery | JAMA Network
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National Cancer Institute.  Colon and rectal cancer age-adjusted incidence: surveillance epidemiology and end results. http://seer.cancer.gov/faststats. Accessed December 8, 2011
Paun BC, Cassie S, MacLean AR, Dixon E, Buie WD. Postoperative complications following surgery for rectal cancer.  Ann Surg. 2010;251(5):807-81820395841PubMedGoogle ScholarCrossref
Tjandra JJ, Kilkenny JW, Buie WD,  et al; Standards Practice Task Force; American Society of Colon and Rectal Surgeons.  Practice parameters for the management of rectal cancer (revised).  Dis Colon Rectum. 2005;48(3):411-42315875292PubMedGoogle ScholarCrossref
Swedish Rectal Cancer Trial.  Initial report from a Swedish multicentre study examining the role of preoperative irradiation in the treatment of patients with resectable rectal carcinoma.  Br J Surg. 1993;80(10):1333-13368242317PubMedGoogle ScholarCrossref
Fazio VW, Zutshi M, Remzi FH,  et al.  A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers.  Ann Surg. 2007;246(3):481-49017717452PubMedGoogle ScholarCrossref
Ptok H, Steinert R, Meyer F,  et al.  Long-term oncological results after laparoscopic, converted and primary open procedures for rectal carcinoma: results of a multicenter observational study.  Chirurg. 2006;77(8):709-71716799790PubMedGoogle ScholarCrossref
Veenhof AA, Kropman RH, Engel AF,  et al.  Preoperative radiation therapy for locally advanced rectal cancer: a comparison between two different time intervals to surgery.  Int J Colorectal Dis. 2007;22(5):507-51317009009PubMedGoogle ScholarCrossref
Zhou ZG, Hu M, Li Y,  et al.  Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer.  Surg Endosc. 2004;18(8):1211-121515457380PubMedGoogle ScholarCrossref
Lipska MA, Bissett IP, Parry BR, Merrie AE. Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk.  ANZ J Surg. 2006;76(7):579-58516813622PubMedGoogle ScholarCrossref
Hallböök O, Sjödahl R. Anastomotic leakage and functional outcome after anterior resection of the rectum.  Br J Surg. 1996;83(1):60-628653367PubMedGoogle ScholarCrossref
Riss S, Stremitzer S, Riss K, Mittlböck M, Bergmann M, Stift A. Pelvic organ function and quality of life after anastomotic leakage following rectal cancer surgery.  Wien Klin Wochenschr. 2011;123(1-2):53-5721191658PubMedGoogle ScholarCrossref
Law WL, Choi HK, Lee YM, Ho JW, Seto CL. Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy.  J Gastrointest Surg. 2007;11(1):8-1517390180PubMedGoogle ScholarCrossref
Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis.  Ann Surg. 2011;253(5):890-89921394013PubMedGoogle ScholarCrossref
 Nationwide Inpatient Sample. Healthcare Cost and Utilization Project website. http://www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed April 3, 2012
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data.  Med Care. 1998;36(1):8-279431328PubMedGoogle ScholarCrossref
 The R project for statistical computing. http://www.r-project.org/index.html. Accessed April 3, 2012
Tibshirani R. Regression shrinkage and selection via the lasso.  J R Stat Soc B (Methodological). 1996;58(1):267-288Google Scholar
Friedman J, Hastie T, Tibshirani R. Regularization paths for generalized linear models via coordinate descent.  J Stat Softw. 2010;33(1):1-2220808728PubMedGoogle Scholar
Rutegård M, Hemmingsson O, Matthiessen P, Rutegård J. High tie in anterior resection for rectal cancer confers no increased risk of anastomotic leakage.  Br J Surg. 2012;99(1):127-13222038493PubMedGoogle ScholarCrossref
Gatta G, Ciccolallo L, Capocaccia R,  et al; EUROCARE Working Group.  Differences in colorectal cancer survival between European and US populations: the importance of sub-site and morphology.  Eur J Cancer. 2003;39(15):2214-222214522381PubMedGoogle ScholarCrossref
Jörgren F, Johansson R, Damber L, Lindmark G. Anastomotic leakage after surgery for rectal cancer: a risk factor for local recurrence, distant metastasis and reduced cancer-specific survival?  Colorectal Dis. 2011;13(3):272-28319912285PubMedGoogle ScholarCrossref
Rabau M, Eyal A, Kluger Y, Dayan D. Bursting pressure in anastomotic healing in experimentally induced colitis in rats.  Dis Colon Rectum. 1998;41(4):468-4729559632PubMedGoogle ScholarCrossref
Rabau MY, Hirshberg A, Hiss Y, Dayan D. Intestinal anastomosis healing in rat: collagen concentration and histochemical characterization by Picrosirius red staining and polarizing microscopy.  Exp Mol Pathol. 1995;62(3):160-1658612719PubMedGoogle ScholarCrossref
Rea JD, Lu KC, Diggs BS, Cone MM, Hardiman KM, Herzig DO. Specialized practice reduces inpatient mortality, length of stay, and cost in the care of colorectal patients.  Dis Colon Rectum. 2011;54(7):780-78621654243PubMedGoogle ScholarCrossref
McPhee JT, Robinson WP III, Eslami MH, Arous EJ, Messina LM, Schanzer A. Surgeon case volume, not institution case volume, is the primary determinant of in-hospital mortality after elective open abdominal aortic aneurysm repair.  J Vasc Surg. 2011;53(3):591-59921144692PubMedGoogle ScholarCrossref
Eppsteiner RW, Csikesz NG, Simons JP, Tseng JF, Shah SA. High volume and outcome after liver resection: surgeon or center?  J Gastrointest Surg. 2008;12(10):1709-171618704600PubMedGoogle ScholarCrossref
Drolet S, MacLean AR, Myers RP, Shaheen AA, Dixon E, Buie WD. Elective resection of colon cancer by high-volume surgeons is associated with decreased morbidity and mortality.  J Gastrointest Surg. 2011;15(4):541-55021279550PubMedGoogle ScholarCrossref
Suding P, Jensen E, Abramson MA, Itani K, Wilson SE. Definitive risk factors for anastomotic leaks in elective open colorectal resection.  Arch Surg. 2008;143(9):907-91218794430PubMedGoogle ScholarCrossref
Zhu QL, Feng B, Lu AG,  et al.  Laparoscopic low anterior resection for rectal carcinoma: complications and management in 132 consecutive patients.  World J Gastroenterol. 2010;16(36):4605-461020857534PubMedGoogle ScholarCrossref
Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M. Risk factors for anastomotic leakage after resection of rectal cancer.  Br J Surg. 1998;85(3):355-3589529492PubMedGoogle ScholarCrossref
Law WL, Chu KW. Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients.  Ann Surg. 2004;240(2):260-26815273550PubMedGoogle ScholarCrossref
Dehni N, Schlegel RD, Cunningham C, Guiguet M, Tiret E, Parc R. Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch-anal anastomosis.  Br J Surg. 1998;85(8):1114-11179718009PubMedGoogle ScholarCrossref
Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial.  Ann Surg. 2007;246(2):207-21417667498PubMedGoogle ScholarCrossref
Hüser N, Michalski CW, Erkan M,  et al.  Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery.  Ann Surg. 2008;248(1):52-6018580207PubMedGoogle ScholarCrossref
Kong AP, Kim J, Holt A,  et al.  Selective treatment of rectal cancer with single-stage coloanal or ultralow colorectal anastomosis does not adversely affect morbidity and mortality.  Int J Colorectal Dis. 2007;22(8):897-90117361396PubMedGoogle ScholarCrossref
van de Pavoordt HD, Fazio VW, Jagelman DG, Lavery IC, Weakley FL. The outcome of loop ileostomy closure in 293 cases.  Int J Colorectal Dis. 1987;2(4):214-2173320231PubMedGoogle ScholarCrossref
Mala T, Nesbakken A. Morbidity related to the use of a protective stoma in anterior resection for rectal cancer.  Colorectal Dis. 2008;10(8):785-78818190612PubMedGoogle ScholarCrossref
Ordemann J, Jacobi CA, Schwenk W, Stösslein R, Müller JM. Cellular and humoral inflammatory response after laparoscopic and conventional colorectal resections.  Surg Endosc. 2001;15(6):600-60811591950PubMedGoogle ScholarCrossref
Whelan RL, Franklin M, Holubar SD,  et al.  Postoperative cell mediated immune response is better preserved after laparoscopic vs open colorectal resection in humans.  Surg Endosc. 2003;17(6):972-97812640542PubMedGoogle ScholarCrossref
Matthiessen P, Hallböök O, Andersson M, Rutegård J, Sjödahl R. Risk factors for anastomotic leakage after anterior resection of the rectum.  Colorectal Dis. 2004;6(6):462-46915521937PubMedGoogle ScholarCrossref
Law WI, Chu KW, Ho JW, Chan CW. Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision.  Am J Surg. 2000;179(2):92-9610773140PubMedGoogle ScholarCrossref
Rudinskaite G, Tamelis A, Saladzinskas Z, Pavalkis D. Risk factors for clinical anastomotic leakage following the resection of sigmoid and rectal cancer.  Medicina (Kaunas). 2005;41(9):741-74616227705PubMedGoogle Scholar
Vignali A, Fazio VW, Lavery IC,  et al.  Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients.  J Am Coll Surg. 1997;185(2):105-1139249076PubMedGoogle Scholar
Telem DA, Chin EH, Nguyen SQ, Divino CM. Risk factors for anastomotic leak following colorectal surgery: a case-control study.  Arch Surg. 2010;145(4):371-37620404288PubMedGoogle ScholarCrossref
Boccola MA, Buettner PG, Rozen WM,  et al.  Risk factors and outcomes for anastomotic leakage in colorectal surgery: a single-institution analysis of 1576 patients.  World J Surg. 2011;35(1):186-19520972678PubMedGoogle ScholarCrossref
Akasu T, Takawa M, Yamamoto S, Yamaguchi T, Fujita S, Moriya Y. Risk factors for anastomotic leakage following intersphincteric resection for very low rectal adenocarcinoma.  J Gastrointest Surg. 2010;14(1):104-11119841989PubMedGoogle ScholarCrossref
Kim MJ, Shin R, Oh HK, Park JW, Jeong SY, Park JG. The impact of heavy smoking on anastomotic leakage and stricture after low anterior resection in rectal cancer patients.  World J Surg. 2011;35(12):2806-281021959931PubMedGoogle ScholarCrossref
Poster Session
January 2013

Risk Factors for Anastomotic Leakage After Anterior Resection for Rectal Cancer

Author Affiliations

Author Affiliations: Department of Surgery, School of Medicine (Drs Kang, Halabi, Chaudhry, Pigazzi, Carmichael, Mills, and Stamos), and Department of Statistics (Dr Nguyen), University of California Irvine, Irvine.

JAMA Surg. 2013;148(1):65-71. doi:10.1001/2013.jamasurg.2

Background The risk factors for anastomotic leak (AL) after anterior resection have been evaluated in several studies and remain controversial as the findings are often inconsistent or inconclusive.

Objective To analyze the risk factors for AL after anterior resection in patients with rectal cancer.

Design Retrospective analysis.

Setting The Nationwide Inpatient Sample 2006 to 2009.

Patients A total of 72 055 patients with rectal cancer who underwent elective anterior resection.

Main Outcome Measures To build a predictive model for AL using demographic characteristics and preadmission comorbidities, the lasso algorithm for logistic regression was used to select variables most predictive of AL.

Results The AL rate was 13.68%. The AL group had higher mortality vs the non-AL group (1.78% vs 0.74%). Hospital length of stay and cost were significantly higher in the AL group. Laparoscopic and open resections with a diverting stoma had a higher incidence of AL than those without a stoma (15.97% vs 13.25%). Multivariate analysis revealed that weight loss and malnutrition, fluid and electrolyte disorders, male sex, and stoma placement were associated with a higher risk of AL. The use of laparoscopy was associated with a lower risk of AL. Postoperative ileus, wound infection, respiratory/renal failure, urinary tract infection, pneumonia, deep vein thrombosis, and myocardial infarction were independently associated with AL.

Conclusions Anastomotic leak after anterior resection increased mortality rates and health care costs. Weight loss and malnutrition, fluid and electrolyte disorders, male sex, and stoma placement independently increased the risk of leak. Laparoscopy independently decreased the risk of leak. Further studies are needed to delineate the significance of these findings.