International Journal of Colorectal Disease

, Volume 30, Issue 12, pp 1667–1675 | Cite as

Anastomotic leakage after curative rectal cancer resection has no impact on long-term survival: a propensity score analysis

  • Sabrina M. Ebinger
  • René Warschkow
  • Ignazio Tarantino
  • Bruno M. Schmied
  • Lukas MartiEmail author
Original Article



Anastomotic leakage (AL) is a severe and frequent complication of rectal cancer resection, with an incidence rate of approximately 9 %. Although the impact of AL on morbidity and short-term mortality has been established, the literature is contradictory regarding its influence on long-term, cancer-specific survival. The present investigation assessed the long-term survival of 584 patients with stage I–III rectal cancer.


The 10-year overall survival and cancer-specific survival were analyzed in 584 patients from a single tertiary center. All patients had undergone curative rectal cancer resection between 1991 and 2010. Patients with and without AL were compared using both a multivariate Cox hazards model and propensity score analysis.


A total of 64 patients developed AL (11.0 %, 95 % confidence interval (CI) = 8.7 to 13.8 %). The median follow-up was 5.2 years for all patients; and 7.4 years for patients still alive at the end of the investigated period. AL did persistently not impair cancer-specific survival based on unadjusted Cox regression (hazard ratio of death (HR) = 1.27, 95 % CI = 0.65 to 2.48, P = 0.489); risk-adjusted Cox regression (HR = 1.10, 95 % CI = 0.54 to 2.20, P = 0.799); and propensity score matching (HR = 1.18, 95 % CI = 0.57 to 2.43, P = 0.660).


Based on the present propensity score analysis, the oncologic outcomes in patients undergoing curative rectal cancer resections were not impaired by the development of anastomotic leakage.


Rectal cancer resection Anastomotic leackage Overall survival Cancer-specific survival Propensity score matching 


Conflict of interest

The authors declare that they have no competing interests.

Compliance with ethical standards

For this type of study formal consent is not required. However all patients agreed that their data may be used for scientific analyses on a general consenting form, when they entered the hospital. These proceedings were generally approved by the local ethic board.


  1. 1.
    Kim SH, Bae KB, Kim JM, Shin JH, An MS, Ha TG, Ryu SM, Kim KH, Kim TH, Choi CS, Shin JY, Oh M, Baek SH, Hong KH (2012) Oncologic outcomes and risk factors for recurrence after tumor-specific mesorectal excision of rectal cancer: 782 cases. J Korean Soc Coloproctol 28(2):100–107. doi: 10.3393/jksc.2012.28.2.100 PubMedCentralCrossRefPubMedGoogle Scholar
  2. 2.
    Chen ZH, Song XM, Chen SC, Li MZ, Li XX, Zhan WH, He YL (2012) Risk factors for adverse outcome in low rectal cancer. World J Gastroenterol 18(1):64–69. doi: 10.3748/wjg.v18.i1.64 PubMedCentralCrossRefPubMedGoogle Scholar
  3. 3.
    Reshef A, Lavery I, Kiran RP (2012) Factors associated with oncologic outcomes after abdominoperineal resection compared with restorative resection for low rectal cancer: patient- and tumor-related or technical factors only? Dis Colon Rectum 55(1):51–58. doi: 10.1097/DCR.0b013e3182351c1f CrossRefPubMedGoogle Scholar
  4. 4.
    Karanjia ND, Corder AP, Bearn P, Heald RJ (1994) Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum. Br J Surg 81(8):1224–1226CrossRefPubMedGoogle Scholar
  5. 5.
    Snijders HS, Wouters MW, van Leersum NJ, Kolfschoten NE, Henneman D, de Vries AC, Tollenaar RA, Bonsing BA (2012) Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol 38(11):1013–1019. doi: 10.1016/j.ejso.2012.07.111 CrossRefPubMedGoogle Scholar
  6. 6.
    den Dulk M, Marijnen CA, Collette L, Putter H, Pahlman L, Folkesson J, Bosset JF, Rodel C, Bujko K, van de Velde CJ (2009) Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg 96(9):1066–1075. doi: 10.1002/bjs.6694 CrossRefGoogle Scholar
  7. 7.
    Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P (2011) Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 253(5):890–899. doi: 10.1097/SLA.0b013e3182128929 CrossRefPubMedGoogle Scholar
  8. 8.
    Warschkow R, Steffen T, Thierbach J, Bruckner T, Lange J, Tarantino I (2011) Risk factors for anastomotic leakage after rectal cancer resection and reconstruction with colorectostomy. A retrospective study with bootstrap analysis. Ann Surg Oncol 18(10):2772–2782. doi: 10.1245/s10434-011-1696-1 CrossRefPubMedGoogle Scholar
  9. 9.
    Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351(17):1731–1740. doi: 10.1056/NEJMoa040694 CrossRefPubMedGoogle Scholar
  10. 10.
    Locker GY, Hamilton S, Harris J, Jessup JM, Kemeny N, Macdonald JS, Somerfield MR, Hayes DF, Bast RC Jr (2006) ASCO 2006 update of recommendations for the use of tumor markers in gastrointestinal cancer. J Clin Oncol 24(33):5313–5327. doi: 10.1200/jco.2006.08.2644 CrossRefPubMedGoogle Scholar
  11. 11.
    Ishwaran H, Kogalur UB, Blackstone EH, Lauer MS (2008) Random survival forests. Ann Appl Stat 841–860. doi: 10.1214/08-AOAS169
  12. 12.
    Joffe MM, Rosenbaum PR (1999) Invited commentary: propensity scores. Am J Epidemiol 150(4):327–333CrossRefPubMedGoogle Scholar
  13. 13.
    Rubin DB (1997) Estimating causal effects from large data sets using propensity scores. Ann Intern Med 127(8 Pt 2):757–763CrossRefPubMedGoogle Scholar
  14. 14.
    Rosenbaum PR (1987) Model-based direct adjustment. J Am Stat Assoc 82(398):387–394. doi: 10.1080/01621459.1987.10478441 CrossRefGoogle Scholar
  15. 15.
    Hansen BB, Klopfer SO (2006) Optimal full matching and related designs via network flows. J Comput Graph Stat 15:609–627CrossRefGoogle Scholar
  16. 16.
    Sekhon JS (2011) Multivariate and propensity score matching software with automated balance optimization: the matching package for R. J Stat Softw 42:1–52CrossRefGoogle Scholar
  17. 17.
    Warschkow R, Guller U, Koberle D, Muller SA, Steffen T, Thurnheer M, Schmied BM, Tarantino I (2014) Perioperative blood transfusions do not impact overall and disease-free survival after curative rectal cancer resection: a propensity score analysis. Ann Surg 259(1):131–138. doi: 10.1097/SLA.0b013e318287ab4d CrossRefPubMedGoogle Scholar
  18. 18.
    Smith JD, Butte JM, Weiser MR, D’Angelica MI, Paty PB, Temple LK, Guillem JG, Jarnagin WR, Nash GM (2013) Anastomotic leak following low anterior resection in stage IV rectal cancer is associated with poor survival. Ann Surg Oncol 20(8):2641–2646. doi: 10.1245/s10434-012-2854-9 CrossRefPubMedGoogle Scholar
  19. 19.
    Bertelsen CA, Andreasen AH, Jorgensen T, Harling H (2010) Anastomotic leakage after curative anterior resection for rectal cancer: short and long-term outcome. Colorectal Dis 12(7 Online):e76–81. doi: 10.1111/j.1463-1318.2009.01935.x PubMedGoogle Scholar
  20. 20.
    Kim HJ, Huh JW, Kim HR, Kim YJ (2014) Oncologic impact of anastomotic leakage in rectal cancer surgery according to the use of fibrin glue: case–control study using propensity score matching method. Am J Surg 207(6):840–846. doi: 10.1016/j.amjsurg.2013.07.047 CrossRefPubMedGoogle Scholar
  21. 21.
    Eberhardt JM, Kiran RP, Lavery IC (2009) The impact of anastomotic leak and intra-abdominal abscess on cancer-related outcomes after resection for colorectal cancer: a case control study. Dis Colon Rectum 52(3):380–386. doi: 10.1007/DCR.0b013e31819ad488 CrossRefPubMedGoogle Scholar
  22. 22.
    Gong JP, Yang L, Huang XE, Sun BC, Zhou JN, Yu DS, Zhou X, Li DZ, Guan X, Wang DF (2014) Outcomes based on risk assessment of anastomotic leakage after rectal cancer surgery. Asian Pac J Cancer Prev 15(2):707–712CrossRefPubMedGoogle Scholar
  23. 23.
    Kulu Y, Tarantio I, Warschkow R, Kny S, Schneider M, Schmied BM, Buchler MW, Ulrich A (2015) Anastomotic leakage is associated with impaired overall and disease-free survival after curative rectal cancer resection: a propensity score analysis. Ann Surg Oncol 22(6):2059–2067. doi: 10.1245/s10434-014-4187-3 CrossRefPubMedGoogle Scholar
  24. 24.
    Quirke P, Steele R, Monson J, Grieve R, Khanna S, Couture J, O’Callaghan C, Myint AS, Bessell E, Thompson LC, Parmar M, Stephens RJ, Sebag-Montefiore D (2009) Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 373(9666):821–828. doi: 10.1016/s0140-6736(09)60485-2 PubMedCentralCrossRefPubMedGoogle Scholar
  25. 25.
    Dik VK, Aarts MJ, Van Grevenstein WM, Koopman M, Van Oijen MG, Lemmens VE, Siersema PD (2014) Association between socioeconomic status, surgical treatment and mortality in patients with colorectal cancer. Br J Surg 101(9):1173–1182. doi: 10.1002/bjs.9555 CrossRefPubMedGoogle Scholar
  26. 26.
    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(6):902–908. doi: 10.1007/s10350-008-9272-x CrossRefPubMedGoogle Scholar
  27. 27.
    Sturmer T, Joshi M, Glynn RJ, Avorn J, Rothman KJ, Schneeweiss S (2006) A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods. J Clin Epidemiol 59(5):437–447. doi: 10.1016/j.jclinepi.2005.07.004 PubMedCentralCrossRefPubMedGoogle Scholar
  28. 28.
    Singh PP, Zeng IS, Srinivasa S, Lemanu DP, Connolly AB, Hill AG (2014) Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg 101(4):339–346. doi: 10.1002/bjs.9354 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Sabrina M. Ebinger
    • 1
  • René Warschkow
    • 1
    • 2
  • Ignazio Tarantino
    • 3
  • Bruno M. Schmied
    • 1
  • Lukas Marti
    • 1
    • 4
    Email author
  1. 1.Department of SurgeryCantonal Hospital of St. GallenSt. GallenSwitzerland
  2. 2.Institute of Medical Biometry and InformaticsUniversity of HeidelbergHeidelbergGermany
  3. 3.Department of SurgeryUniversity of HeidelbergHeidelbergGermany
  4. 4.Department of Surgery, University-Hospital Mannheim, Medical Faculty MannheimUniversity of HeidelbergMannheimGermany

Personalised recommendations