Standardization of surgical procedures to reduce risk of anastomotic leakage, reoperation, and surgical site infection in colorectal cancer surgery: a retrospective cohort study of 1189 patients
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Anastomotic leakage (AL) and surgical site infection (SSI) are prevalent complications of colorectal surgery. To lower this risk, we standardized our surgical procedures in 2012, with a preferential use of laparoscopic approach (LS) for both colon and rectal surgery, combined with triangulating anastomosis (TA) for colon surgery and defunctioning ileostomy (DI) for low anterior resection. Our aim was to evaluate the outcomes of our standardized procedures.
The incidence rate of AL (primary outcome) and of reoperation and SSI (secondary outcome) was compared before (early period, n = 648) and after (late period, n = 541) standardization, through a retrospective analysis.
The incidence rate of AL (6.6 versus 1.8%; P = 0.001), reoperation (3.5 versus 0.7%; P = 0.0012), and SSI (7.7 versus 4.6%; P = 0.029) was lower in late than in the early period. For colon cancer, TA and LS reduced the risk of AL (2.1 versus 0.3%, P = 0.020, for TA, and 3.2 versus 0.4%, P = 0.0027, for LS) and reoperation (2.9 versus 0.3%, P = 0.003, for TA, and 2.5 versus 0.2%, P = 0.0040, for LS). For rectal cancer, the incidence of all adverse outcomes (AL, reoperation, and SSI) was lower in cases treated by LS. However, the incidence of AL was lower in the late than in early period (P = 0.002) and with LS (P = 0.002). On multivariate analysis, late period and LS were independent factors of a lower risk of adverse outcomes.
Our surgical standardization seems to be effective in lowering the risks of AL, reoperation, and SSI after colorectal cancer surgery.
KeywordsAnastomotic leakage Reoperation Surgical site infections Laparoscopic surgery
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 1.Alves A, Panis Y, Trancart D, Regimbeau JM, Pocard M, Valleur P (2002) Factors associated with clinically significant anastomotic leakage after large bowel resection: multivariate analysis of 707 patients. World J Surg 26:499–502. https://doi.org/10.1007/s00268-001-0256-4 CrossRefPubMedGoogle Scholar
- 2.Frasson M, Flor-Lorente B, Rodriguez JL, Granero-Castro P, Hervas D, Alvarez Rico MA, Brao MJ, Sanchez Gonzalez JM, Garcia-Granero E (2015) Risk factors for anastomotic leak after colon resection for cancer: multivariate analysis and nomogram from a multicentric, prospective, national study with 3193 patients. Ann Surg 262:321–330. https://doi.org/10.1097/sla.0000000000000973 CrossRefPubMedGoogle Scholar
- 4.Turrentine FE, Denlinger CE, Simpson VB, Garwood RA, Guerlain S, Agrawal A, Friel CM, LaPar DJ, Stukenborg GJ, Jones RS (2015) Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks. J Am Coll Surg 220:195–206. https://doi.org/10.1016/j.jamcollsurg.2014.11.002 CrossRefPubMedGoogle Scholar
- 5.Nachiappan S, Askari A, Malietzis G, Giacometti M, White I, Jenkins JT, Kennedy RH, Faiz O (2015) The impact of anastomotic leak and its treatment on cancer recurrence and survival following elective colorectal cancer resection. World J Surg 39:1052–1058. https://doi.org/10.1007/s00268-014-2887-2 CrossRefPubMedGoogle Scholar
- 7.Tanner J, Padley W, Assadian O, Leaper D, Kiernan M, Edmiston C (2015) Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery 158:66–77. https://doi.org/10.1016/j.surg.2015.03.009 CrossRefPubMedGoogle Scholar
- 8.Blumetti J, Luu M, Sarosi G, Hartless K, McFarlin J, Parker B, Dineen S, Huerta S, Asolati M, Varela E, Anthony T (2007) Surgical site infections after colorectal surgery: do risk factors vary depending on the type of infection considered? Surgery 142:704–711. https://doi.org/10.1016/j.surg.2007.05.012 CrossRefPubMedGoogle Scholar
- 9.Serra-Aracil X, Garcia-Domingo MI, Pares D, Espin-Basany E, Biondo S, Guirao X, Orrego C, Sitges-Serra A (2011) Surgical site infection in elective operations for colorectal cancer after the application of preventive measures. Arch Surg 146:606–612. https://doi.org/10.1001/archsurg.2011.90 CrossRefPubMedGoogle Scholar
- 14.Katsuno H, Shiomi A, Ito M, Koide Y, Maeda K, Yatsuoka T, Hase K, Komori K, Minami K, Sakamoto K, Saida Y, Saito N (2016) Comparison of symptomatic anastomotic leakage following laparoscopic and open low anterior resection for rectal cancer: a propensity score matching analysis of 1014 consecutive patients. Surg Endosc 30:2848–2856. https://doi.org/10.1007/s00464-015-4566-2 CrossRefPubMedGoogle Scholar
- 16.Kawada K, Hasegawa S, Hida K, Hirai K, Okoshi K, Nomura A, Kawamura J, Nagayama S, Sakai Y (2014) Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis. Surg Endosc 28:2988–2995. https://doi.org/10.1007/s00464-014-3564-0 CrossRefPubMedPubMedCentralGoogle Scholar
- 17.Park JS, Choi GS, Kim SH, Kim HR, Kim NK, Lee KY, Kang SB, Kim JY, Lee KY, Kim BC, Bae BN, Son GM, Lee SI, Kang H (2013) Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg 257:665–671. https://doi.org/10.1097/SLA.0b013e31827b8ed9 CrossRefPubMedGoogle Scholar
- 19.Frasson M, Granero-Castro P, Ramos Rodriguez JL, Flor-Lorente B, Braithwaite M, Marti Martinez E, Alvarez Perez JA, Codina Cazador A, Espi A, Garcia-Granero E (2016) Risk factors for anastomotic leak and postoperative morbidity and mortality after elective right colectomy for cancer: results from a prospective, multicentric study of 1102 patients. Int J Color Dis 31:105–114. https://doi.org/10.1007/s00384-015-2376-6 CrossRefGoogle Scholar
- 21.Mrak K, Uranitsch S, Pedross F, Heuberger A, Klingler A, Jagoditsch M, Weihs D, Eberl T, Tschmelitsch J (2016) Diverting ileostomy versus no diversion after low anterior resection for rectal cancer: a prospective, randomized, multicenter trial. Surgery 159:1129–1139. https://doi.org/10.1016/j.surg.2015.11.006 CrossRefPubMedGoogle Scholar
- 22.Kiran RP, El-Gazzaz GH, Vogel JD, Remzi FH (2010) Laparoscopic approach significantly reduces surgical site infections after colorectal surgery: data from national surgical quality improvement program. J Am Coll Surg 211:232–238. https://doi.org/10.1016/j.jamcollsurg.2010.03.028 CrossRefPubMedGoogle Scholar
- 25.Shiomi A, Ito M, Maeda K, Kinugasa Y, Ota M, Yamaue H, Shiozawa M, Horie H, Kuriu Y, Saito N (2015) Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1,014 consecutive patients. J Am Coll Surg 220:186–194. https://doi.org/10.1016/j.jamcollsurg.2014.10.017 CrossRefPubMedGoogle Scholar
- 26.Messaris E, Connelly TM, Kulaylat AN, Miller J, Gusani NJ, Ortenzi G, Wong J, Bhayani N (2015) Is a diverting ostomy needed in mid-high rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation? An NSQIP analysis. Surgery 158:686–691. https://doi.org/10.1016/j.surg.2015.02.026 CrossRefPubMedGoogle Scholar