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Gefahr der Anastomoseninsuffizienz nach laparoskopischer und offener kolorektaler Resektion

Risk of anastomotic leak after laparoscopic versus open colectomy

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coloproctology Aims and scope

Zusammenfassung

Fragestellung und Hintergrund

Tritt nach kolorektalen Operationen eine Anastomoseninsuffizienz auf, so geht diese mit einer erheblichen Morbidität und Mortalität einher. Mit dem zunehmenden Einsatz laparoskopischer Verfahren liegen jetzt Daten erster klinischer Studien vor, in denen die Wirksamkeit der laparoskopischen und offenen Operationstechnik vergleichend untersucht wurden. Allerdings ist eine Generalisierung dieser Daten nicht uneingeschränkt möglich. Wir untersuchten das Risiko einer Anastomoseninsuffizienz nach laparoskopischer und offener kolorektaler Resektion unter Verwendung von Daten einer nationalen Datenbank in den USA, die standardisierte Definitionen verwendete.

Patienten und Methodik

In der NSQIP-Datenbank der ACS erfolgte eine Suche nach allen zwischen 2012 und 2013 erfassten elektiven kolorektalen Resektionen. Die Charakteristika der Patienten, die sich einer laparoskopischen Operation unterzogen, wurden mit denen von Patienten mit offener Operation verglichen. Der Einfluss des laparoskopischen Vorgehens auf die Entwicklung einer Anastomoseninsuffizienz wurde mithilfe univariabler und multivariabler Analysen und einer anschließenden Propensity-Score-Matching-Analyse beurteilt.

Ergebnisse

Von den insgesamt 23.568 Patienten entwickelten 3,4 % eine Anastomoseninsuffizienz. Die Anastomoseninsuffizienzrate betrug bei laparoskopischer Operationstechnik 2,8 % (n = 425) und beim offenen Vorgehen 4,5 % (n = 378; p < 0,0001). Patienten, die eine Leckage entwickelten, hatten ein höheres Risiko, innerhalb von 30 Tagen nach dem Eingriff zu versterben (5,7 vs. 0,6 %; p < 0,0001). Patienten, die laparoskopisch operiert wurden, waren im Vergleich zu Patienten mit offener Operation jünger und hatten weniger Komorbiditäten (61 vs. 63 Jahre; p = 0; p = 0,045). In der univariablen Analyse ging das laparoskopische Verfahren mit einer geringeren Wahrscheinlichkeit der Entwicklung einer Anastomoseninsuffizienz einher (OR 0,60; p < 0,0001). Diese Assoziation bleibt auch nach Adjustierung für alle relevanten präoperativen und krankheitsbezogenen Störgrößen erhalten (OR 0,69; 95 % CI 0,58–0,82). Eine Propensity-Score-Matching-Analyse bestätigt den Vorteil der laparoskopischen gegenüber der offenen Operation hinsichtlich des Auftretens einer Anastomoseninsuffizienz.

Schlussfolgerung

Die laparoskopische kolorektale Resektion ist ein sicheres Verfahren und geht auch nach Ausgleich von patienten-, krankheits- und verfahrensbezogenen Faktoren mit einer geringeren Wahrscheinlichkeit der Entwicklung einer Anastomoseninsuffizienz einher.

Abstract

Background

Anastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With the widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic when compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopic versus open colorectal resection using a nationwide database with standardized definitions.

Methods

The 2012–2013 ACS-NSQIP targeted colectomy data were queried for all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by a propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak.

Results

Of 23,568 patients, 3.4% developed an anastomotic leak. Laparoscopic surgery was associated with a leak rate of 2.8% (n = 425) and open surgery, 4.5% (n = 378, p <0.0001). Patients who developed a leak were more likely to die within 30 days of surgery (5.7 vs 0.6%, p <0.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs 63 years, p = 0, p = 0.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, p <0.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95% CI 0.58–0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak.

Conclusion

Laparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease and procedure-related factors.

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Authors and Affiliations

  1. Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor: 8, NY 10032, New York City, USA

    A. C. A. Murray & R. P. Kiran

  2. Department of Biostatistics, Mailman School of Public Health, Columbia University, NY 10027, New York, USA

    C. Chiuzan & R. P. Kiran

Authors
  1. A. C. A. Murray
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  2. C. Chiuzan
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  3. R. P. Kiran
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Correspondence to R. P. Kiran.

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A.C. A. Murray, C. Chiuzan und R. P. Kiran geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Murray, A.C.A., Chiuzan, C. & Kiran, R.P. Gefahr der Anastomoseninsuffizienz nach laparoskopischer und offener kolorektaler Resektion. coloproctology 39, 171–178 (2017). https://doi.org/10.1007/s00053-016-0135-y

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