Skip to main content

Advertisement

Log in

Nomogram for predicting anastomotic leakage after low anterior resection for rectal cancer

  • Original Article
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

Anastomotic leakage after low anterior resection for rectal cancer is a critical problem. Many risk factors have been suggested and surgical techniques have improved, but anastomotic leakage remains a major postoperative challenge. This study sought to create a nomogram for precise prediction of anastomotic leakage after low anterior resection for rectal cancer.

Methods

We used data of 936 patients that had been prospectively collected by the Japanese Society for Colon and Rectal Cancer between June 2010 and February 2013. Risk factors for anastomotic leakage were identified by multivariate logistic regression analysis and used to create a nomogram. The performance of the nomogram was evaluated by using a bootstrapped-concordance index and calibration plots.

Results

Sex, preoperative serum albumin, tumor location and diameter, and simultaneous resection of other organs were identified as significantly associated factors that could be combined for accurate prediction of anastomotic leakage. We created a nomogram for anastomotic leakage by using these risk factors. The area under the curve was 0.72 (95% confidence interval 0.67–0.76). The nomogram had a bootstrapped-concordance index of 0.72 and was well calibrated.

Conclusions

Our nomogram was a useful tool for precise prediction of anastomotic leakage after low anterior resection for rectal cancer.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. 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(3):355–358. https://doi.org/10.1046/j.1365-2168.1998.00615.x

    Article  CAS  PubMed  Google Scholar 

  2. Enker WE, Merchant N, Cohen AM, Lanouette NM, Swallow C, Guillem J, Paty P, Minsky B, Weyrauch K, Quan SHQ (1999) Safety and efficacy of low anterior resection for rectal cancer: 681 consecutive cases from a specialty service. Ann Surg 230(4):544–552. https://doi.org/10.1097/00000658-199910000-00010

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. 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. Color Dis 7:51–57

    Article  CAS  Google Scholar 

  4. Branagan G, Finnis D (2005) Prognosis after anastomotic leakage in colorectal surgery. Dis Colon rectum 48(5):1021–1026. https://doi.org/10.1007/s10350-004-0869-4

  5. Merkel S, Wang WY, Schmidt O, Dworak O, Wittekind C, Hohenberger W et al (2001) Locoregional recurrence in patients with anastomotic leakage after anterior resection for rectal carcinoma. Color Dis 3(3):154–160. https://doi.org/10.1046/j.1463-1318.2001.00232.x

    Article  CAS  Google Scholar 

  6. Yeh CY, Changchien CR, Wang JY, Chen JS, Chen HH, Chiang JM, Tang R (2005) Pelvic drainage and other risk factors for leakage after elective anterior resection in rectal cancer patients: a prospective study of 978 patients. Ann Surg 241(1):9–13

    PubMed  PubMed Central  Google Scholar 

  7. 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(2):92–96. https://doi.org/10.1016/S0002-9610(00)00252-X

    Article  CAS  PubMed  Google Scholar 

  8. Peeters KC, Tollenaar RA, Marijnen CA, Klein Kranenbarg E, Steup WH, Wiggers T et al (2005) Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 92(2):211–216. https://doi.org/10.1002/bjs.4806

    Article  CAS  PubMed  Google Scholar 

  9. Battersby NJ, Bouliotis G, Emmertsen KJ, Juul T, Glynne-Jones R, Branagan G, Christensen P, Laurberg S, Moran BJ (2017) Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score. Gut [Epub ahead of print]:gutjnl-2016-312695. https://doi.org/10.1136/gutjnl-2016-312695

  10. Newton AD, Li J, Jeganathan AN, Mahmoud NN, Epstein AJ, Paulson EC (2016) A nomogram to predict lymph node positivity following neoadjuvant chemoradiation in locally advanced rectal cancer. Dis Colon rectum 59(8):710–717. https://doi.org/10.1097/DCR.0000000000000638

  11. Hoshino N, Hasegawa S, Hida K, Kawada K, Ganeko R, Sugihara K, Sakai Y (2016) Nomogram for predicting recurrence in stage II colorectal cancer. Acta Oncol 55(12):1414–1417. https://doi.org/10.1080/0284186X.2016.1223881

    Article  PubMed  Google Scholar 

  12. Russell MC, You YN, Hu CY, Cormier JN, Feig BW, Skibber JM, Rodriguez-Bigas MA, Nelson H, Chang GJ (2013) A novel risk-adjusted nomogram for rectal cancer surgery outcomes. JAMA Surg 148(8):769–777. https://doi.org/10.1001/jamasurg.2013.2136

    Article  PubMed  PubMed Central  Google Scholar 

  13. Jwa E, Kim JH, Han S, Park JH, Lim SB, Kim JC et al (2014) Nomogram to predict ypN status after chemoradiation in patients with locally advanced rectal cancer. Br J Cancer 111(2):249–254. https://doi.org/10.1038/bjc.2014.256

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. 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(2):186–194. https://doi.org/10.1016/j.jamcollsurg.2014.10.017

    Article  PubMed  Google Scholar 

  15. 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(7):2848–2856. https://doi.org/10.1007/s00464-015-4566-2

    Article  PubMed  Google Scholar 

  16. Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S, den Dulk M, van de Velde C, Büchler MW (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147(3):339–351. https://doi.org/10.1016/j.surg.2009.10.012

    Article  PubMed  Google Scholar 

  17. http://r-project.org/Accessed 6 January 2017

  18. https://cran.r-project.org/web/packages/rms/Accessed 6 January 2017

  19. Kawada K, Sakai Y (2016) Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis. World J Gastroenterol 22(25):5718–5727. https://doi.org/10.3748/wjg.v22.i25.5718

    Article  PubMed  PubMed Central  Google Scholar 

  20. Frasson M, Flor-Lorente B, Rodriguez JL, Granero-Castro P, Hervás D, Alvarez Rico MA et al (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(2):321–330. https://doi.org/10.1097/SLA.0000000000000973

    Article  PubMed  Google Scholar 

  21. Yao HH, Shao F, Huang Q, Wu Y, Qiang Zhu Z, Liang W (2014) Nomogram to predict anastomotic leakage after laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis for rectal cancer. Hepato-Gastroenterology 61(133):1257–1261

    PubMed  Google Scholar 

  22. Haskins IN, Baginsky M, Amdur RL, Agarwal S (2016) Preoperative hypoalbuminemia is associated with worse outcomes in colon cancer patients. Clin Nutr [Epub ahead of print]

  23. Lai CC, You JF, Yeh CY, Chen JS, Tang R, Wang JY, Chin CC (2011) Low preoperative serum albumin in colon cancer: a risk factor for poor outcome. Int J Color Dis 26(4):473–481. https://doi.org/10.1007/s00384-010-1113-4

    Article  Google Scholar 

  24. Parthasarathy M, Greensmith M, Bowers D, Groot-Wassink T (2017) Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17518 patients. Color Dis 19(3):288–298. https://doi.org/10.1111/codi.13476

    Article  CAS  Google Scholar 

  25. Rosello S, Cervantes A (2015) Extending neoadjuvant chemotherapy in rectal cancer. Lancet Oncol 16(8):880–881. https://doi.org/10.1016/S1470-2045(15)00092-3

    Article  PubMed  Google Scholar 

  26. Matsumoto T, Hasegawa S, Zaima M, Inoue N, Sakai Y (2015) Outcomes of neoadjuvant chemotherapy without radiation for rectal cancer. Dig Surg 32(4):275–283. https://doi.org/10.1159/000430469

    Article  CAS  PubMed  Google Scholar 

  27. Koike J, Funahashi K, Yoshimatsu K, Yokomizo H, Kan H, Yamada T, Ishida H, Ishibashi K, Saida Y, Enomoto T, Katsumata K, Hisada M, Hasegawa H, Koda K, Ochiai T, Sakamoto K, Shiokawa H, Ogawa S, Itabashi M, Kameoka S (2017) Efficacy and safety of neoadjuvant chemotherapy with oxaliplatin, 5-fluorouracil, and levofolinate for T3 or T4 stage II/III rectal cancer: the FACT trial. Cancer Chemother Pharmacol 79(3):519–525. https://doi.org/10.1007/s00280-017-3243-7

  28. Glynne-Jones R, Hava N, Goh V, Bosompem S, Bridgewater J, Chau I et al (2015) Bevacizumab and Combination Chemotherapy in rectal cancer Until Surgery (BACCHUS): a phase II, multicentre, open-label, randomised study of neoadjuvant chemotherapy alone in patients with high-risk cancer of the rectum. BMC Cancer 15(1):764. https://doi.org/10.1186/s12885-015-1764-1

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The following is a list of participating surgeons and centers: K. Komori (Aichi Cancer Center Hospital, Aichi), J. Okuda (Osaka Medical College Hospital, Osaka), K. Otsuka (Iwate Medical University School of Medicine, Iwate), A. Kanazawa (Japanese Red Cross Osaka Hospital, Osaka), M. Ueno (Cancer Institute Hospital, Tokyo), T. Masaki (Kyorin University Hospital, Tokyo), E. Otsuji (Kyoto Prefectural University of Medicine, Kyoto), T. Kusumi (Keiyukai Sapporo Hospital, Hokkaido), K. Minami (National Hospital Organization Kyusyu Cancer Center, Fukuoka), T. Kobatake (National Hospital Organization Shikoku Cancer Center, Ehime), Y. Nishimura (Saitama Cancer Center, Saitama), K. Sakamoto (Juntendo University Hospital, Tokyo), K. Sugihara (Tokyo Medical and Dental University, Tokyo), S. Kameoka (Tokyo Women’s Medical University Hospital, Tokyo), Y. Saida (Toho University Ohashi Medical Center, Tokyo), N. Tomita (Hyogo College of Medicine, Hyogo), M. Yoshimitsu (Hiroshima City Asa Hospital, Hiroshima), K. Hase (National Defence Medical College Hospital, Saitama), M. Hamada (Kochi Health Sciences Center, Kochi), M. Ito (National Cancer Center Hospital East, Chiba), K. Maeda (Fujita Health University School of Medicine, Aichi), Y. Kinugasa (Shizuoka Cancer Center Hospital, Shizuoka), M. Ota (Yokohama City University Medical Center, Kanagawa), M. Shiozawa (Kanagawa Cancer Center, Kanagawa), H. Horie (School of Medicine, Jichi Medical University, Tochigi), H. Yamaue (Wakayama Medical University, School of Medicine, Wakayama), H. Ike (Saiseikai Yokohamashi Nanbu Hospital, Kanagawa), N. Takiguchi (Chiba Cancer Center, Chiba), H. Yamagami (Sapporo-Kosei General Hospital, Hokkaido), S. Nishikawa (Aomori Prefectural Central Hospital, Aomori), Y. Akagi (Kurume University School of Medicine, Fukuoka), M. Ohue (Osaka Medical Center for Cancer and Cardiovascular Disease, Osaka), and M. Watanabe (Kitasato University School of Medicine, Kanagawa).

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Koya Hida.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human rights

This study was approved by the Ethics Committee of JSCCR and by the institutional review board of each participating hospital. Informed consent was obtained from all patients.

Electronic supplementary material

Table S1

(DOCX 40 kb)

Fig. S1

Nomogram for grades B and C anastomotic leakage after low anterior resection for rectal cancer. To estimate the probability of grades B and C anastomotic leakage, mark patient values on each axis, draw a straight line perpendicular to the point axis, and sum the points of all variables. Next, mark the sum on the total point axis and draw a straight line perpendicular to the probability axis. NR, no residual tumor (GIF 58 kb)

High resolution (EPS 1237 kb)

Fig. S2

Receiver operating characteristic curve for the prediction model of grades B and C anastomotic leakage. Area under the curve was 0.71 (95% confidence interval 0.67–0.76) (GIF 21 kb)

High resolution (EPS 831 kb)

Fig. S3

Calibration of the nomogram for grades B and C anastomotic leakage. The x-axis shows the predicted probability of grades B and C anastomotic leakage, and the y-axis shows the observed probability of grades B and C anastomotic leakage. (GIF 35 kb)

High resolution (EPS 853 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hoshino, N., Hida, K., Sakai, Y. et al. Nomogram for predicting anastomotic leakage after low anterior resection for rectal cancer. Int J Colorectal Dis 33, 411–418 (2018). https://doi.org/10.1007/s00384-018-2970-5

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-018-2970-5

Keywords

Navigation