Skip to main content
SpringerLink
Log in

Development of a Risk Score to Predict Anastomotic Leak After Left-Sided Colectomy: Which Patients Warrant Diversion?

  • 2019 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Anastomotic leak is a feared complication after left-sided colectomy, but its risk can potentially be reduced with the use of a diverting ostomy. However, an ostomy has its own associated negative sequelae; therefore, it is critical to appropriately identify patients to divert. This is difficult in practice since many risk factors for anastomotic leak exist and outside factors bias this decision. We aimed to develop and validate a risk score to predict an individual’s risk of anastomotic leak and aid in the decision.

Methods

The American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted PUF was queried from 2012 to 2016 for patients undergoing elective left-sided resection for malignancy, benign neoplasm, or diverticular disease. Multivariable logistic regression identified predictors of anastomotic leak in non-diverted patients, and a risk score was developed and validated.

Results

38,475 patients underwent resection with an overall anastomotic leak rate of 3%. Independent risk factors for anastomotic leak included younger age, male sex, tobacco use, and omission of combined bowel preparation. A risk score incorporating independent predictors demonstrated excellent calibration. There was strong visual correspondence between predicted and observed anastomotic leak rates. 3960 patients underwent resection with diversion, yet over half of these patients had a predicted leak rate of less than 4%.

Conclusion

A novel risk score can be used to stratify patients according to anastomotic leak risk after elective left-sided resection. Intraoperative calculation of scores for patients can help guide surgical decision-making in both diverting the highest risk patients and avoiding diversion in low-risk patients.

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

Access this article

Log in via an institution

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

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014; 101: 424–32; discussion 32.

    Article  CAS  Google Scholar 

  2. Bretagnol F, Panis Y, Rullier E, Rouanet P, Berdah S, Dousset B, et al. Rectal cancer surgery with or without bowel preparation: The French GRECCAR III multicenter single-blinded randomized trial. Ann Surg 2010; 252: 863–8.

    Article  Google Scholar 

  3. Kream J, Ludwig KA, Ridolfi TJ, Peterson CY. Achieving low anastomotic leak rates utilizing clinical perfusion assessment. Surgery 2016; 160: 960–7.

    Article  Google Scholar 

  4. Levack M, Berger D, Sylla P, Rattner D, Bordeianou L. Laparoscopy decreases anastomotic leak rate in sigmoid colectomy for diverticulitis. Arch Surg 2011; 146: 207–10.

    Article  Google Scholar 

  5. Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 2007; 246: 207–14.

    Article  Google Scholar 

  6. Hammond J, Lim S, Wan Y, Gao X, Patkar A. The burden of gastrointestinal anastomotic leaks: an evaluation of clinical and economic outcomes. J Gastrointest Surg 2014; 18: 1176–85.

    Article  Google Scholar 

  7. Turrentine FE, Denlinger CE, Simpson VB, Garwood RA, Guerlain S, Agrawal A, et al. Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks. J Am Coll Surg 2015; 220: 195–206.

    Article  Google Scholar 

  8. Tan WS, Tang CL, Shi L, Eu KW. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg 2009; 96: 462–72.

    Article  CAS  Google Scholar 

  9. Mrak K, Uranitsch S, Pedross F, Heuberger A, Klingler A, Jagoditsch M, et al. Diverting ileostomy versus no diversion after low anterior resection for rectal cancer: A prospective, randomized, multicenter trial. Surgery 2016; 159: 1129–39.

    Article  Google Scholar 

  10. Chun LJ, Haigh PI, Tam MS, Abbas MA. Defunctioning loop ileostomy for pelvic anastomoses: predictors of morbidity and nonclosure. Dis Colon Rectum 2012; 55: 167–74.

    Article  Google Scholar 

  11. Messaris E, Sehgal R, Deiling S, Koltun WA, Stewart D, McKenna K, et al. Dehydration is the most common indication for readmission after diverting ileostomy creation. Dis Colon Rectum 2012; 55: 175–80.

    Article  Google Scholar 

  12. Sciuto A, Merola G, De Palma GD, Sodo M, Pirozzi F, Bracale UM, et al. Predictive factors for anastomotic leakage after laparoscopic colorectal surgery. World J Gastroenterol 2018; 24: 2247–60.

    Article  Google Scholar 

  13. Moug SJ, Henderson N, Tiernan J, Bisset CN, Ferguson E, Harji D, et al. The colorectal surgeon’s personality may influence the rectal anastomotic decision. Colorectal Dis 2018; 20: 970–80.

    Article  CAS  Google Scholar 

  14. MacDermid E, Young CJ, Young J, Solomon M. Decision-making in rectal surgery. Colorectal Dis 2014; 16: 203–8.

    Article  CAS  Google Scholar 

  15. Frasson M, Flor-Lorente B, Rodriguez JL, Granero-Castro P, Hervas D, Alvarez Rico MA, et al. 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 2015; 262: 321–30.

    Article  Google Scholar 

  16. Rencuzogullari A, Benlice C, Valente M, Abbas MA, Remzi FH, Gorgun E. Predictors of Anastomotic Leak in Elderly Patients After Colectomy: Nomogram-Based Assessment From the American College of Surgeons National Surgical Quality Program Procedure-Targeted Cohort. Dis Colon Rectum 2017; 60: 527–36.

    Article  Google Scholar 

  17. Dekker JW, Liefers GJ, de Mol van Otterloo JC, Putter H, Tollenaar RA. Predicting the risk of anastomotic leakage in left-sided colorectal surgery using a colon leakage score. J Surg Res 2011; 166: e27–34.

    Article  Google Scholar 

  18. Moons KG, Harrell FE, Steyerberg EW. Should scoring rules be based on odds ratios or regression coefficients? J Clin Epidemiol 2002; 55: 1054–5.

    Article  Google Scholar 

  19. Sullivan LM, Massaro JM, D’Agostino RB, Sr. Presentation of multivariate data for clinical use: The Framingham Study risk score functions. Stat Med 2004; 23: 1631–60.

    Article  Google Scholar 

  20. Sammour T, Lewis M, Thomas ML, Lawrence MJ, Hunter A, Moore JW. A simple web-based risk calculator (www.anastomoticleak.com) is superior to the surgeon’s estimate of anastomotic leak after colon cancer resection. Tech Coloproctol 2017; 21: 35–41.

    Article  CAS  Google Scholar 

  21. Ihnat P, Gunkova P, Peteja M, Vavra P, Pelikan A, Zonca P. Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection. Surg Endosc 2016; 30: 4809–16.

    Article  Google Scholar 

  22. Phatak UR, Kao LS, You YN, Rodriguez-Bigas MA, Skibber JM, Feig BW, et al. Impact of ileostomy-related complications on the multidisciplinary treatment of rectal cancer. Ann Surg Oncol 2014; 21: 507–12.

    Article  Google Scholar 

  23. Zaimi I, Sparreboom CL, Lingsma HF, Doornebosch PG, Menon AG, Kleinrensink GJ, et al. The effect of age on anastomotic leakage in colorectal cancer surgery: A population-based study. J Surg Oncol 2018; 118: 113–20.

    Article  Google Scholar 

  24. Midura EF, Hanseman D, Davis BR, Atkinson SJ, Abbott DE, Shah SA, et al. Risk factors and consequences of anastomotic leak after colectomy: a national analysis. Dis Colon Rectum 2015; 58: 333–8.

    Article  Google Scholar 

  25. Richards CH, Campbell V, Ho C, Hayes J, Elliott T, Thompson-Fawcett M. Smoking is a major risk factor for anastomotic leak in patients undergoing low anterior resection. Colorectal Dis 2012; 14: 628–33.

    Article  CAS  Google Scholar 

  26. Kiran RP, Murray AC, Chiuzan C, Estrada D, Forde K. Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg 2015; 262: 416–25; discussion 23–5.

    Article  Google Scholar 

  27. Hayden DM, Mora Pinzon MC, Francescatti AB, Saclarides TJ. Patient factors may predict anastomotic complications after rectal cancer surgery: Anastomotic complications in rectal cancer. Ann Med Surg (Lond) 2015; 4: 11–6.

    Article  Google Scholar 

  28. Qin Q, Ma T, Deng Y, Zheng J, Zhou Z, Wang H, et al. Impact of Preoperative Radiotherapy on Anastomotic Leakage and Stenosis After Rectal Cancer Resection: Post Hoc Analysis of a Randomized Controlled Trial. Dis Colon Rectum 2016; 59: 934–42.

    Article  Google Scholar 

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

    Article  Google Scholar 

  30. Jung SH, Yu CS, Choi PW, Kim DD, Park IJ, Kim HC, et al. Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum 2008; 51: 902–8.

    Article  Google Scholar 

  31. Pasic F, Salkic NN. Predictive score for anastomotic leakage after elective colorectal cancer surgery: a decision making tool for choice of protective measures. Surg Endosc 2013; 27: 3877–82.

    Article  Google Scholar 

  32. Rojas-Machado SA, Romero-Simo M, Arroyo A, Rojas-Machado A, Lopez J, Calpena R. Prediction of anastomotic leak in colorectal cancer surgery based on a new prognostic index PROCOLE (prognostic colorectal leakage) developed from the meta-analysis of observational studies of risk factors. Int J Colorectal Dis 2016; 31: 197–210.

    Article  CAS  Google Scholar 

  33. Migaly J, Bafford AC, Francone TD, Gaertner WB, Eskicioglu C, Bordeianou L, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Use of Bowel Preparation in Elective Colon and Rectal Surgery. Dis Colon Rectum 2019; 62: 3–8.

    Article  Google Scholar 

  34. Liu Y, Wan X, Wang G, Ren Y, Cheng Y, Zhao Y, et al. A scoring system to predict the risk of anastomotic leakage after anterior resection for rectal cancer. J Surg Oncol 2014; 109: 122–5.

    Article  Google Scholar 

  35. Leahy J, Schoetz D, Marcello P, Read T, Hall J, Roberts P, et al. What is the risk of clinical anastomotic leak in the diverted colorectal anastomosis? J Gastrointest Surg 2014; 18: 1812–6.

    Article  Google Scholar 

  36. Bergquist JR, Thiels CA, Etzioni DA, Habermann EB, Cima RR. Failure of Colorectal Surgical Site Infection Predictive Models Applied to an Independent Dataset: Do They Add Value or Just Confusion? J Am Coll Surg 2016; 222: 431–8.

    Article  Google Scholar 

  37. Cima RR, Bergquist JR, Hanson KT, Thiels CA, Habermann EB. Outcomes are Local: Patient, Disease, and Procedure-Specific Risk Factors for Colorectal Surgical Site Infections from a Single Institution. J Gastrointest Surg 2017; 21: 1142–52.

    Article  Google Scholar 

Download references

Acknowledgments

The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery provides salary support for Dr. Habermann and Ms. Bews and in kind support for Dr. McKenna. Dr. McKenna receives salary support from the Mayo Clinic Clinical Investigator Training Program. These funding sources did not affect our investigation.

Funding

This publication was made possible by CTSA Grant Number UL1 TR002379 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH).

Author information

Authors and Affiliations

  1. Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA

    Nicholas P. McKenna & Elizabeth B. Habermann

  2. The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA

    Nicholas P. McKenna, Katherine A. Bews, Robert R. Cima & Elizabeth B. Habermann

  3. Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA

    Robert R. Cima

  4. Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA

    Cynthia S. Crowson & Elizabeth B. Habermann

Authors
  1. Nicholas P. McKenna
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Katherine A. Bews
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Robert R. Cima
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cynthia S. Crowson
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Elizabeth B. Habermann
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Nicholas McKenna—conception and design of the work, interpretation of the data for the work, drafting of the work, final approval of the version to be published, and agree to be held accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Katherine Bews—acquisition and analysis of the data for the work, revising it critically for important intellectual content, final approval of the version to be published, and agree to be held accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Robert Cima—interpretation of the data for the work, revising it critically for important intellectual content, final approval of the version to be published, and agree to be held accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Cynthia Crowson—analysis and interpretation of the data for the work, revising it critically for important intellectual content, final approval of the version to be published, and agree to be held accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Elizabeth Habermann—conception and design of the work, interpretation of the data for the work, revising it critically for important intellectual content, final approval of the version to be published, and agree to be held accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Nicholas P. McKenna.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflicts of interest.

Disclaimer

The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official view of NIH.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

McKenna, N.P., Bews, K.A., Cima, R.R. et al. Development of a Risk Score to Predict Anastomotic Leak After Left-Sided Colectomy: Which Patients Warrant Diversion?. J Gastrointest Surg 24, 132–143 (2020). https://doi.org/10.1007/s11605-019-04293-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-019-04293-y

Keywords

Search

Navigation