Anastomotic Leakage is Associated with Poor Long-Term Outcome in Patients After Curative Colorectal Resection for Malignancy
First Online: 26 January 2007 DOI:
10.1007/s11605-006-0049-z Cite this article as: Law, W.L., Choi, H.K., Lee, Y.M. et al. J Gastrointest Surg (2007) 11: 8. doi:10.1007/s11605-006-0049-z Abstract
The impact of anastomotic leakage on long-term outcomes after curative surgery for colorectal cancer has not been well documented. This study aimed to investigate the effect of anastomotic leakage on survival and tumor recurrence in patients who underwent curative resection for colorectal cancer. Prospectively collected data of the 1,580 patients (904 men) of a median age of 70 years (range: 24–94), who underwent potentially curative resection for colorectal cancer between 1996 and 2004, were reviewed. Cancer-specific survival and disease recurrence were analyzed using Kaplan Meier method, and variables were compared with log rank test. Cox regression model was used in multivariate analysis. The cancer was situated in the colon and the rectum in 933 and 647 patients, respectively. Anastomotic leakage occurred in 60 patients (clinical leakage:
n = 48; radiological leak: n = 12). The leakage rate was significantly higher in patients with surgery for rectal cancer (6.3 vs 2.0%, p < 0.001). The 5-year cancer-specific survivals were 56.9% in those with leakage and 75.9% in those without leakage ( p = 0.012). The 5-year systemic recurrence rates were 48.4 and 22.6% in patients with and without anastomotic leak, respectively ( p = 0.001), whereas the 5-year local recurrence rates were 12.9 and 5.7%, respectively ( p = 0.009). Anastomotic leakage remained an independent factor associated with a worse cancer-specific survival ( p = 0.043, hazard ratio: 1.63, 95% CI: 1.02–2.60) and a higher systemic recurrence rate (hazard ratio: 1.94, 95% CI: 1.23–3.06, p = 0.004) on multivariate analysis. In rectal cancer, anastomotic leakage was an independent factor for a higher local recurrence rate (hazard ratio: 2.55, 95% CI: 1.07–6.06, p = 0.034). In conclusion, anastomotic leakage is associated with a poor survival and a higher tumor recurrence rate after curative resection of colorectal cancer. Efforts should be undertaken to avoid this complication to improve the long-term outcome. Keywords Anastomotic leakage Colorectal cancer Curative colorectal resection Cancer-specific survival Malignancy
This work was presented in the plenary session of the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract at the Digestive Disease Week in Los Angeles on 22 May 2006.
Hong Kong Cancer Registry Hong Kong Hospital Authority. Hong Kong Cancer Registry. Cancer Incidence and Mortality in Hong Kong.
[Accessed May 2006].
Walker KG, Bell SW, Rickard MJ, Mehanna D, Dent OF, Chapuis PH, et al. Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer. Ann Surg 2004;240:255–259.
Petersen S, Freitag M, Hellmich G, Ludwig K. Anastomotic leakage: Impact on local recurrence and survival in surgery of colorectal cancer. Int J Colorectal Dis 1998;13:160–163.
McArdle CS, McMillan DC, Hole DJ. Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer. Br J Surg 2005;92:1150–1154.
Fujita S, Teramoto T, Watanabe M, Kodaira S, Kitajima M. Anastomotic leakage after colorectal cancer surgery: A risk factor for recurrence and poor prognosis. Jpn J Clin Oncol 1993;23:299–302.
Branagan G, Finnis D. Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum 2005;48:1021–1026.
Vignali A, Fazio VW, Lavery IC, Milsom JW, Church JM, Hull TL, et al. Factors associated with the occurrence of leaks in stapled rectal anastomoses: A review of 1,014 patients [see comments]. J Am Coll Surg 1997;185:105–113.
Stewart BT, Woods RJ, Collopy BT, Fink RJ, Mackay JR, Keck JO. Early feeding after elective open colorectal resections: A prospective randomized trial. Aust NZ J Surg 1998;68:125–128.
Pakkastie TE, Ovaska JT, Pekkala ES, Luukkonen PE, Jarvinen HJ. A randomised study of colostomies in low colorectal anastomoses. Eur J Surg 1997;163:929–933.
Karanjia ND, Corder AP, Bearn P, Heald RJ. Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum. Br J Surg 1994;81:1224–1226.
Isbister WH. Anastomotic leak in colorectal surgery: A single surgeon’s experience. ANZ J Surg 2001;71:516–520.
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;85:355–358.
Law WL, Chu KW. Anterior resection for rectal cancer with mesorectal excision: A prospective evaluation of 622 patients. Ann Surg 2004;240:260–268.
Bokey EL, Chapuis PH, Fung C, Hughes WJ, Koorey SG, Brewer D, et al. Postoperative morbidity and mortality following resection of the colon and rectum for cancer. Dis Colon Rectum 1995;38:480–486.
Alves A, Panis Y, Trancart D, Regimbeau JM, Pocard M, Valleur P. Factors associated with clinically significant anastomotic leakage after large bowel resection: Multivariate analysis of 707 patients. World J Surg 2002;26:499–502.
Fazio VW, Tekkis PP, Remzi F, Lavery IC. Assessment of operative risk in colorectal cancer surgery: The Cleveland Clinic Foundation colorectal cancer model. Dis Colon Rectum 2004;47:2015–2024.
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;179:92–96.
Peeters KC, Tollenaar RA, Marijnen CA, Klein KE, Steup WH, Wiggers T, et al. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 2005;92:211–216.
Schmidt O, Merkel S, Hohenberger W. Anastomotic leakage after low rectal stapler anastomosis: Significance of intraoperative anastomotic testing. Eur J Surg Oncol 2003;29:239–243.
Eriksen MT, Wibe A, Norstein J, Haffner J, Wiig JN. Anastomotic leakage following routine mesorectal excision for rectal cancer in a national cohort of patients. Colorectal Dis 2005;7:51–57.
Yeh CY, Changchien CR, Wang JY, Chen JS, Chen HH, Chiang JM, Tang R. Pelvic drainage and other risk factors for leakage after elective anterior resection in rectal cancer patients: A prospective study of 978 patients. Ann Surg 2005;241:9–13.
Phillips RK, Hittinger R, Blesovsky L, Fry JS, Fielding LP. Local recurrence following ‘curative’ surgery for large bowel cancer: I. The overall picture. Br J Surg 1984;71:12–16.
Sauven P, Playforth MJ, Evans M, Pollock AV. Early infective complications and late recurrent cancer in stapled colonic anastomoses. Dis Colon Rectum 1989;32:33–35.
Akyol AM, McGregor JR, Galloway DJ, Murray GD, George WD. Anastomotic leaks in colorectal cancer surgery: A risk factor for recurrence? Int J Colorectal Dis 1991;16:179–183.
Bell SW, Walker KG, Rickard MJ, Sinclair G, Dent OF, Chapuis PH, Bokey EL. Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence. Br J Surg 2003;90:1261–1266.
Merkel S, Wang WY, Schmidt O, Dworak O, Wittekind C, Hohenberger W, Hermanek P. Locoregional recurrence in patients with anastomotic leakage after anterior resection for rectal carcinoma. Colorectal Dis 2001;3:154–160.
Fermor B, Umpleby HC, Lever JV, Symes MO, Williamson RC. Proliferative and metastatic potential of exfoliated colorectal cancer cells. J Natl Cancer Inst 1986;76, 347–349.
van den Tol PM, van Rossen EE, van Eijck CH, Bonthuis F, Marquet RL, Jeekel H. Reduction of peritoneal trauma by using nonsurgical gauze leads to less implantation metastasis of spilled tumor cells. Ann Surg 1998;227:242–248.
Umpleby HC, Fermor B, Symes MO, Williamson RC. Viability of exfoliated colorectal carcinoma cells. Br J Surg 1984;71:659–663.
Slanetz CA Jr. The effect of inadvertent intraoperative perforation on survival and recurrence in colorectal cancer. Dis Colon Rectum 1984;27:792–797.
Finlay IG, McArdle CS. Occult hepatic metastases in colorectal carcinoma. Br J Surg 1986;73:732–735.
Denis MG, Lipart C, Leborgne J, LeHur PA, Galmiche JP, Denis M, Ruud E, Truchaud A, Lustenberger P. Detection of disseminated tumor cells in peripheral blood of colorectal cancer patients. Int J Cancer 1997;74:540–544.
Molnar B, Ladanyi A, Tanko L, Sreter L, Tulassay Z. Circulating tumor cell clusters in the peripheral blood of colorectal cancer patients. Clin Cancer Res 2001;7:4080–4085.
Nielsen HJ, Christensen IJ, Sorensen S, Moesgaard F, Brunner N. Preoperative plasma plasminogen activator inhibitor type-1 and serum C-reactive protein levels in patients with colorectal cancer. The RANX05 Colorectal Cancer Study Group. Ann Surg Oncol 2000;7:617–623.
McMillan DC, Canna K, McArdle CS. Systemic inflammatory response predicts survival following curative resection of colorectal cancer. Br J Surg 2003;90:215–219.
Balkwill F, Mantovani A. Inflammation and cancer: Back to Virchow? Lancet 2001;357:539–545.