Defining Anastomotic Leak and the Clinical Relevance of Leaks

Abstract

Surgeons universally dread gastrointestinal anastomotic leaks, yet the precise definition is not widely agreed on despite international consensus guidelines. Likewise, leaks are not uniformly reported which makes comparisons across studies flawed. Leak rates range from 1 to 3% for ileocolonic, 0.5 to 18% for colorectal, and 5 to 19% for coloanal anastomoses. The sequelae of an anastomotic leak vary but generally correlate with the need for a change in clinical management, from minimal changes to the need for reoperation. Short- and long-term outcomes can be life-altering or life-threatening. Temporary or permanent stomas may be necessary and low pelvic anastomotic leaks may affect bowel function. For cancer patients, leaks can delay treatment and negatively affect oncologic outcomes. In Crohn's patients, leaks are associated with higher recurrence rates. In essence, the lack of agreement on the definition of an anastomotic leak inhibits meaningful understand of its epidemiology, prevention, and treatment.

Keywords

definition - colorectal - anastomosis - leak - relevance

Disclaimers

This manuscript is original and neither published, accepted, or submitted for publication elsewhere.

Authors' Contributions

All authors have made (1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for import intellectual content; and (3) final approval of the version to be published.

Publikationsverlauf

Artikel online veröffentlicht:
01. Oktober 2021

• References

• 1 Bruce J, Krukowski ZH, Al-Khairy G, Russell EM, Park KG. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg 2001; 88 (09) 1157-1168
• 2 Rahbari NN, Weitz J, Hohenberger W. et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 2010; 147 (03) 339-351
• 3 Eckmann C, Kujath P, Schiedeck THK, Shekarriz H, Bruch H-P. Anastomotic leakage following low anterior resection: results of a standardized diagnostic and therapeutic approach. Int J Colorectal Dis 2004; 19 (02) 128-133
• 4 McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg 2015; 102 (05) 462-479
• 5 Daniel VT, Alavi K, Davids JS. et al. The utility of the delphi method in defining anastomotic leak following colorectal surgery. Am J Surg 2020; 219 (01) 75-79
• 6 Peel AL, Taylor EW. Surgical Infection Study Group. Proposed definitions for the audit of postoperative infection: a discussion paper. Ann R Coll Surg Engl 1991; 73 (06) 385-388
• 7 Frouws MA, Snijders HS, Malm SH. et al. Clinical relevance of a grading system for anastomotic leakage after low anterior resection: analysis from a national cohort database. Dis Colon Rectum 2017; 60 (07) 706-713
• 8 Kulu Y, Ulrich A, Bruckner T. et al; International Study Group of Rectal Cancer. Validation of the International Study Group of Rectal Cancer definition and severity grading of anastomotic leakage. Surgery 2013; 153 (06) 753-761
• 9 Ripollés-Melchor J, Ramírez-Rodríguez JM, Casans-Francés R. et al; POWER Study Investigators Group for the Spanish Perioperative Audit and Research Network (REDGERM). Association between use of enhanced recovery after surgery protocol and postoperative complications in colorectal surgery: the postoperative outcomes within enhanced recovery after surgery protocol (POWER) Study. JAMA Surg 2019; 154 (08) 725-736
• 10 Adams K, Papagrigoriadis S. Little consensus in either definition or diagnosis of a lower gastro-intestinal anastomotic leak amongst colorectal surgeons. Int J Colorectal Dis 2013; 28 (07) 967-971
• 11 van Rooijen SJ, Jongen AC, Wu Z-Q. et al. Definition of colorectal anastomotic leakage: a consensus survey among Dutch and Chinese colorectal surgeons. World J Gastroenterol 2017; 23 (33) 6172-6180
• 12 Smallwood N, Mutch MG, Fleshman JW. The failed anastomosis. In: Steele SR, Maykel JA, Champagne BJ, Orangio GR. eds. Complexities in Colorectal Surgery. New York, NY: Springer-Verlag; 2014: 277-304
• 13 Lim M, Akhtar S, Sasapu K. et al. Clinical and subclinical leaks after low colorectal anastomosis: a clinical and radiologic study. Dis Colon Rectum 2006; 49 (10) 1611-1619
• 14 Tan WP, Hong EY, Phillips B, Isenberg GA, Goldstein SD. Anastomotic leaks after colorectal anastomosis occurring more than 30 days postoperatively: a single-institution evaluation. Am Surg 2014; 80 (09) 868-872
• 15 Hedrick TL, Sawyer RG, Foley EF, Friel CM. Anastomotic leak and the loop ileostomy: friend or foe?. Dis Colon Rectum 2006; 49 (08) 1167-1176
• 16 Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 2007; 246 (02) 207-214
• 17 Mrak K, Uranitsch S, Pedross F. et al. Diverting ileostomy versus no diversion after low anterior resection for rectal cancer: A prospective, randomized, multicenter trial. Surgery 2016; 159 (04) 1129-1139
• 18 Chude GG, Rayate NV, Patris V. et al. Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Hepatogastroenterology 2008; 55 (86-87): 1562-1567
• 19 Wong K-S, Remzi FH, Gorgun E. et al. Loop ileostomy closure after restorative proctocolectomy: outcome in 1,504 patients. Dis Colon Rectum 2005; 48 (02) 243-250
• 20 Justiniano CF, Temple LK, Swanger AA. et al. Readmissions with dehydration after ileostomy creation: rethinking risk factors. Dis Colon Rectum 2018; 61 (11) 1297-1305
• 21 Chen SY, Stem M, Cerullo M. et al. Predicting the risk of readmission from dehydration after ileostomy formation: the dehydration readmission after ileostomy prediction score. Dis Colon Rectum 2018; 61 (12) 1410-1417
• 22 Li W, Stocchi L, Cherla D. et al. Factors associated with hospital readmission following diverting ileostomy creation. Tech Coloproctol 2017; 21 (08) 641-648
• 23 Bhama AR, Batool F, Collins SD, Ferraro J, Cleary RK. Risk factors for postoperative complications following diverting loop ileostomy takedown. J Gastrointest Surg 2017; 21 (12) 2048-2055
• 24 Wong NY, Eu KW. A defunctioning ileostomy does not prevent clinical anastomotic leak after a low anterior resection: a prospective, comparative study. Dis Colon Rectum 2005; 48 (11) 2076-2079
• 25 Chapman Jr. WC, Subramanian M, Jayarajan S. et al. First, do no harm: rethinking routine diversion in sphincter-preserving rectal cancer resection. J Am Coll Surg 2019; 228 (04) 547-556.e8
• 26 Reinke CE, Showalter S, Mahmoud NN, Kelz RR. Comparison of anastomotic leak rate after colorectal surgery using different databases. Dis Colon Rectum 2013; 56 (05) 638-644
• 27 Boccola MA, Buettner PG, Rozen WM. et al. Risk factors and outcomes for anastomotic leakage in colorectal surgery: a single-institution analysis of 1576 patients. World J Surg 2011; 35 (01) 186-195
• 28 McKenna NP, Bews KA, Cima RR, Crowson CS, Habermann EB. Development of a risk score to predict anastomotic leak after left-sided colectomy: which patients warrant diversion?. J Gastrointest Surg 2020; 24 (01) 132-143
• 29 Bertelsen CA, Andreasen AH, Jørgensen T, Harling H. Danish Colorectal Cancer Group. Anastomotic leakage after anterior resection for rectal cancer: risk factors. Colorectal Dis 2010; 12 (01) 37-43
• 30 Jung SH, Yu CS, Choi PW. et al. Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum 2008; 51 (06) 902-908
• 31 Delaney CP, Brady K, Woconish D, Parmar SP, Champagne BJ. Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery pathways. Am J Surg 2012; 203 (03) 353-355 , discussion 355–356
• 32 Platell C, Barwood N, Dorfmann G, Makin G. The incidence of anastomotic leaks in patients undergoing colorectal surgery. Colorectal Dis 2007; 9 (01) 71-79
• 33 Benoist S, Panis Y, Alves A, Valleur P. Impact of obesity on surgical outcomes after colorectal resection. Am J Surg 2000; 179 (04) 275-281
• 34 Veyrie N, Ata T, Muscari F. et al; French Associations for Surgical Research. Anastomotic leakage after elective right versus left colectomy for cancer: prevalence and independent risk factors. J Am Coll Surg 2007; 205 (06) 785-79
• 35 de Buck van Overstraeten A, Eshuis EJ, Vermeire S. et al. Short- and medium-term outcomes following primary ileocaecal resection for Crohn's disease in two specialist centres. Br J Surg 2017; 104 (12) 1713-1722
• 36 Lipska MA, Bissett IP, Parry BR, Merrie AEH. Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk. ANZ J Surg 2006; 76 (07) 579-585
• 37 Iesalnieks I, Kilger A, Glass H. et al. Intraabdominal septic complications following bowel resection for Crohn's disease: detrimental influence on long-term outcome. Int J Colorectal Dis 2008; 23 (12) 1167-1174
• 38 Neary PM, Aiello AC, Stocchi L. et al. High-risk ileocolic anastomoses for Crohn's disease: when is diversion indicated?. J Crohn's Colitis 2019; 13 (07) 856-863
• 39 Gutiérrez A, Rivero M, Martín-Arranz MD. et al. Perioperative management and early complications after intestinal resection with ileocolonic anastomosis in Crohn's disease: analysis from the PRACTICROHN study. Gastroenterol Rep (Oxf) 2019; 7 (03) 168-175
• 40 Jouvin I, Lefevre JH, Creavin B. et al; Saint-Antoine IBD Network. Postoperative morbidity risks following ileocolic resection for Crohn's disease treated with anti-TNF alpha therapy: a retrospective study of 360 patients. Inflamm Bowel Dis 2018; 24 (02) 422-432
• 41 Yamamoto T, Spinelli A, Suzuki Y. et al. Risk factors for complications after ileocolonic resection for Crohn's disease with a major focus on the impact of preoperative immunosuppressive and biologic therapy: A retrospective international multicentre study. United European Gastroenterol J 2016; 4 (06) 784-793
• 42 Waterland P, Athanasiou T, Patel H. Post-operative abdominal complications in Crohn's disease in the biological era: Systematic review and meta-analysis. World J Gastrointest Surg 2016; 8 (03) 274-283
• 43 Vignali A, Fazio VW, Lavery IC. et al. Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients. J Am Coll Surg 1997; 185 (02) 105-113
• 44 Nisar PJ, Lavery IC, Kiran RP. Influence of neoadjuvant radiotherapy on anastomotic leak after restorative resection for rectal cancer. J Gastrointest Surg 2012; 16 (09) 1750-1757
• 45 Karanjia ND, Corder AP, Bearn P, Heald RJ. Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum. Br J Surg 1994; 81 (08) 1224-1226
• 46 Ricciardi R, Roberts PL, Marcello PW, Hall JF, Read TE, Schoetz DJ. Anastomotic leak testing after colorectal resection: what are the data?. Arch Surg 2009; 144 (05) 407-411 , discussion 411–412
• 47 Weiser MR, Quah H-M, Shia J. et al. Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg 2009; 249 (02) 236-242
• 48 Trencheva K, Morrissey KP, Wells M. et al. Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients. Ann Surg 2013; 257 (01) 108-113
• 49 Matthiessen P, Hallböök O, Andersson M, Rutegård J, Sjödahl R. Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis 2004; 6 (06) 462-469
• 50 Kitaguchi D, Nishizawa Y, Sasaki T, Tsukada Y, Ikeda K, Ito M. Recurrence of rectal anastomotic leakage following stoma closure: assessment of risk factors. Colorectal Dis 2019; 21 (11) 1304-1311
• 51 Francone TD, Champagne B. Considerations and complications in patients undergoing ileal pouch anal anastomosis. Surg Clin North Am 2013; 93 (01) 107-143
• 52 Bach SP, Mortensen NJ. Ileal pouch surgery for ulcerative colitis. World J Gastroenterol 2007; 13 (24) 3288-3300
• 53 Fazio VW, Kiran RP, Remzi FH. et al. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Ann Surg 2013; 257 (04) 679-685
• 54 Kirat HT, Kiran RP, Oncel M, Shen B, Fazio VW, Remzi FH. Management of leak from the tip of the “J” in ileal pouch-anal anastomosis. Dis Colon Rectum 2011; 54 (04) 454-459
• 55 Lovegrove RE, Tilney HS, Heriot AG. et al. A comparison of adverse events and functional outcomes after restorative proctocolectomy for familial adenomatous polyposis and ulcerative colitis. Dis Colon Rectum 2006; 49 (09) 1293-1306
• 56 Bellows CF, Webber LS, Albo D, Awad S, Berger DH. Early predictors of anastomotic leaks after colectomy. Tech Coloproctol 2009; 13 (01) 41-47
• 57 Fouda E, El Nakeeb A, Magdy A, Hammad EA, Othman G, Farid M. Early detection of anastomotic leakage after elective low anterior resection. J Gastrointest Surg 2011; 15 (01) 137-144
• 58 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 (06) 1176-1185
• 59 Thornton M, Joshi H, Vimalachandran C. et al. Management and outcome of colorectal anastomotic leaks. Int J Colorectal Dis 2011; 26 (03) 313-320
• 60 Lim S-B, Yu CS, Kim CW, Yoon YS, Park IJ, Kim JC. Late anastomotic leakage after low anterior resection in rectal cancer patients: clinical characteristics and predisposing factors. Colorectal Dis 2016; 18 (04) O135-O140
• 61 Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA. Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg 2007; 245 (02) 254-258
• 62 Alves A, Panis Y, Trancart D, Regimbeau J-M, Pocard M, Valleur P. Factors associated with clinically significant anastomotic leakage after large bowel resection: multivariate analysis of 707 patients. World J Surg 2002; 26 (04) 499-502
• 63 Temple LK, Bacik J, Savatta SG. et al. The development of a validated instrument to evaluate bowel function after sphincter-preserving surgery for rectal cancer. Dis Colon Rectum 2005; 48 (07) 1353-1365
• 64 Gamagami R, Istvan G, Cabarrot P, Liagre A, Chiotasso P, Lazorthes F. Fecal continence following partial resection of the anal canal in distal rectal cancer: long-term results after coloanal anastomoses. Surgery 2000; 127 (03) 291-295
• 65 Carmona JA, Ortiz H, Perez-Cabañas I. Alterations in anorectal function after anterior resection for cancer of the rectum. Int J Colorectal Dis 1991; 6 (02) 108-110
• 66 Jorge JM, Wexner SD. Anorectal manometry: techniques and clinical applications. South Med J 1993; 86 (08) 924-931
• 67 Ashburn JH, Stocchi L, Kiran RP, Dietz DW, Remzi FH. Consequences of anastomotic leak after restorative proctectomy for cancer: effect on long-term function and quality of life. Dis Colon Rectum 2013; 56 (03) 275-280
• 68 Hallböök O, Sjödahl R. Anastomotic leakage and functional outcome after anterior resection of the rectum. Br J Surg 1996; 83 (01) 60-62
• 69 Nesbakken A, Nygaard K, Lunde OC. Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg 2001; 88 (03) 400-404
• 70 Hain E, Manceau G, Maggiori L, Mongin C, Prost À la Denise J, Panis Y. Bowel dysfunction after anastomotic leakage in laparoscopic sphincter-saving operative intervention for rectal cancer: a case-matched study in 46 patients using the low anterior resection score. Surgery 2017; 161 (04) 1028-1039
• 71 Breen EM, Schoetz Jr. DJ, Marcello PW. et al. Functional results after perineal complications of ileal pouch-anal anastomosis. Dis Colon Rectum 1998; 41 (06) 691-695
• 72 Parc Y, Ruppert R, Fuerst A. et al. Better function with a colonic J-Pouch or a side-to-end anastomosis?: a randomized controlled trial to compare the complications, functional outcome, and quality of life in patients with low rectal cancer after a J-pouch or a side-to-end anastomosis. Ann Surg 2019; 269 (05) 815-826
• 73 Marti WR, Curti G, Wehrli H. et al; Swiss Group for Clinical Cancer Research (SAKK), Section Surgery. Clinical outcome after rectal replacement with side-to-end, colon-J-pouch, or straight colorectal anastomosis following total mesorectal excision: a Swiss prospective, randomized, multicenter trial (SAKK 40/04). Ann Surg 2019; 269 (05) 827-835
• 74 Francone TD, Saleem A, Read TA. et al. Ultimate fate of the leaking intestinal anastomosis: does leak mean permanent stoma?. J Gastrointest Surg 2010; 14 (06) 987-992
• 75 Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 2011; 253 (05) 890-899
• 76 Branagan G, Finnis D. Wessex Colorectal Cancer Audit Working Group. Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum 2005; 48 (05) 1021-1026
• 77 Krarup P-M, Nordholm-Carstensen A, Jorgensen LN, Harling H. Anastomotic leak increases distant recurrence and long-term mortality after curative resection for colonic cancer: a nationwide cohort study. Ann Surg 2014; 259 (05) 930-938
• 78 Jang JH, Kim HC, Huh JW. et al. Anastomotic leak does not impact oncologic outcomes after preoperative chemoradiotherapy and resection for rectal cancer. Ann Surg 2019; 269 (04) 678-685
• 79 Fernández-Martos C, Pericay C, Aparicio J. et al. Phase II, randomized study of concomitant chemoradiotherapy followed by surgery and adjuvant capecitabine plus oxaliplatin (CAPOX) compared with induction CAPOX followed by concomitant chemoradiotherapy and surgery in magnetic resonance imaging-defined, locally advanced rectal cancer: Grupo cancer de recto 3 study. J Clin Oncol 2010; 28 (05) 859-865
• 80 Cercek A, Roxburgh CSD, Strombom P. et al. Adoption of total neoadjuvant therapy for locally advanced rectal cancer. JAMA Oncol 2018; 4 (06) e180071-e180071
• 81 Turrentine FE, Denlinger CE, Simpson VB. et al. Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks. J Am Coll Surg 2015; 220 (02) 195-206
• 82 Vonlanthen R, Slankamenac K, Breitenstein S. et al. The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients. Ann Surg 2011; 254 (06) 907-913
• 83 Healy MA, Mullard AJ, Campbell Jr. DA, Dimick JB. Hospital and payer costs associated with surgical complications. JAMA Surg 2016; 151 (09) 823-830