Abstract
Purpose
The aim of the present study was to investigate the characteristics of patients who developed delayed anastomotic leakage (DAL) following sphincter-preserving surgery for rectal cancer. We evaluated the following factors: (1) the incidence of DAL, (2) the clinical features of patients who developed DAL, (3) the risk factors for DAL, and (4) treatment outcomes.
Methods
We reviewed the case histories of 1,838 rectal cancer patients who had undergone curative resection with sphincter preservation and without protective stoma formation between January 2000 and December 2006. DAL was defined as the development of a pelvic abscess or fistula around the anastomosis more than 3 weeks post-surgery in patients without tumor recurrence who had resumed a normal diet and defecation.
Results
In 1.3% (24/1,838) of the patients, DAL developed on median postoperative day 99 (range 22–2,069). Pelvic abscess (50%) and anastomotic–vaginal fistula (41.7%) were the most common causes of DAL. Independent risk factors for the development of DAL were: (1) female gender (hazard ratio 3.03; 95% CI 1.06–8.8), (2) low-level anastomosis (≤4 cm from the anal verge) (hazard ratio 5.76; 95% CI 1.37–22.39), and (3) preoperative chemoradiation therapy (hazard ratio 4.56; 95% CI 1.4–14.92). Stoma formation was performed in all of the 24 patients. The 3-year stoma-retention rate in patients with DAL was significantly higher than in patients with early anastomotic leakage (72.2% vs 17.5%, P < 0.001).
Conclusions
DAL following sphincter-preserving surgery for rectal cancer occurred relatively frequently in our sample and was associated with female gender, a low level of anastomosis, and preoperative radiotherapy. DAL patients required long-term or permanent stomas.
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References
Cohen Z, Myers E, Langer B, Taylor B, Railton RH, Jamieson C (1983) Double stapling technique for low anterior resection. Dis Colon Rectum 26:231–235
Choi PW, Jung SH, Kim JR, Yu CS, Kim HS, Kim JC (2006) Trend of clinicopathologic characteristics of colorectal cancer in Asan Medical Center: a 15-year experience. J Korean Soc Coloproctol 22:387–395
Enker WE, Merchant N, Cohen AM, Lanouette NM, Swallow C, Guillem J, Paty P, Minsky B, Weyrauch K, Quan SH (1999) Safety and efficacy of low anterior resection for rectal cancer: 681 consecutive cases from a specialty service. Ann Surg 230:544–552, Discussion 552-544
Law WI, Chu KW, Ho JW, Chan CW (2000) Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision. Am J Surg 179:92–96
Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246:207–214
Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M (1998) Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg 85:355–358
Vignali A, Fazio VW, Lavery IC, Milsom JW, Church JM, Hull TL, Strong SA, Oakley JR (1997) Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients. J Am Coll Surg 185:105–113
Matthiessen P, Hallbook O, Andersson M, Rutegard J, Sjodahl R (2004) Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis 6:462–469
Eriksen MT, Wibe A, Norstein J, Haffner J, Wiig JN (2005) Anastomotic leakage following routine mesorectal excision for rectal cancer in a national cohort of patients. Colorectal Dis 7:51–57
Jung SH, Yu CS, Choi PW, Kim DD, Park IJ, Kim HC, Kim JC (2008) Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum 51:902–908
Hallbook O, Sjodahl R (1996) Anastomotic leakage and functional outcome after anterior resection of the rectum. Br J Surg 83:60–62
Nesbakken A, Nygaard K, Lunde OC (2001) Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg 88:400–404
Bell SW, Walker KG, Rickard MJ, Sinclair G, Dent OF, Chapuis PH, Bokey EL (2003) Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence. Br J Surg 90:1261–1266
Walker KG, Bell SW, Rickard MJ, Mehanna D, Dent OF, Chapuis PH, Bokey EL (2004) Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer. Ann Surg 240:255–259
Kasperk R, Philipps B, Vahrmeyer M, Willis S, Schumpelick V (2000) Risk factors for anastomosis dehiscence after very deep colorectal and coloanal anastomosis. Chirurg 71:1365–1369
Gastinger I, Marusch F, Steinert R, Wolff S, Koeckerling F, Lippert H (2005) Protective defunctioning stoma in low anterior resection for rectal carcinoma. Br J Surg 92:1137–1142
Marusch F, Koch A, Schmidt U, Wenisch H, Ernst M, Manger T, Wolff S, Pross M, Tautenhahn J, Gastinger I, Lippert H (2002) Early postoperative results of surgery for rectal carcinoma as a function of the distance of the tumor from the anal verge: results of a multicenter prospective evaluation. Langenbecks Arch Surg 387:94–100
Moran BJ, Heald RJ (2001) Risk factors for, and management of anastomotic leakage in rectal surgery. Colorectal Dis 3:135–137
Heald RJ, Leicester RJ (1981) The low stapled anastomosis. Dis Colon Rectum 24:437–444
Smith LE (1981) Anastomosis with EEA stapler after anterior colonic resection. Dis Colon Rectum 24:236–242
Fleshner PR, Schoetz DJ Jr, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC (1992) Anastomotic–vaginal fistula after colorectal surgery. Dis Colon Rectum 35:938–943
Lee RC, Rotmensch J (2004) Rectovaginal radiation fistula repair using an obturator fasciocutaneous thigh flap. Gynecol Oncol 94:277–282
Kosugi C, Saito N, Kimata Y, Ono M, Sugito M, Ito M, Sato K, Koda K, Miyazaki M (2005) Rectovaginal fistulas after rectal cancer surgery: Incidence and operative repair by gluteal-fold flap repair. Surgery 137:329–336
Kuzu MA, Koksoy C, Akyol FH, Uzal D, Kale IT (1999) Colonic anastomotic healing after preoperative chemo-radiotherapy in rat. Radiat Med 17:181–187
Terzi C, Sevinc AI, Kocdor H, Oktay G, Alanyali H, Kupelioglu A, Ergor G, Fuzun M (2004) Improvement of colonic healing by preoperative rectal irrigation with short-chain fatty acids in rats given radiotherapy. Dis Colon Rectum 47:2184–2194
Acknowledgments
This study was supported by a grant from the Korean Health 21 R&D project of the Ministry of Health & Welfare, Republic of Korea (A062254).
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This study was supported by a grant from the Korean Health 21 R&D project of the Ministry of Health & Welfare, Republic of Korea (A062254).
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Shin, U.S., Kim, C.W., Yu, C.S. et al. Delayed anastomotic leakage following sphincter-preserving surgery for rectal cancer. Int J Colorectal Dis 25, 843–849 (2010). https://doi.org/10.1007/s00384-010-0938-1
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DOI: https://doi.org/10.1007/s00384-010-0938-1