A Systematic Review of Anastomotic Leakage Associated Risk Factors Following Laparoscopic Anterior Resection

Shayan Arshed, MBBS, MSc1, Emin Amiraslanov1, Romi Navaratnam2, Bijendra Patel1. 1Barts Cancer Institute, 2North Middlesex University Hospital

Introduction:

Anastomotic leakage after rectal cancer resection is a dire complication associated with local recurrence, morbidity, and mortality. Unlike conventional open approach, literature on risk factors for leakage after laparoscopic colorectal surgery is only limited; and there is no consensus on the important risk factors. The aim of this systematic review was to identify and evaluate the risk factors leading to anastomotic leakage after laparoscopic anterior resection.

Methods and Procedures:

A descriptive review was designed using following databases for literature search: MEDLINE, Embase, Web of Knowledge, Cochrane Library and the reference lists of relevant articles. Relevant free text words and MeSH terms, with Boolean operators were used and an explicit inclusion and exclusion criteria was adapted for screening.

Results:

A total of 11 studies were included. The evaluation found an overall anastomotic leakage rate of 6.9% (227/3299). Following risk factors (Table) showed high incidence of leakage:

Risk Factors Leading to Leakage
No. Risk Factor Total Patients Overall Incidence of Leakage (%)
1 Male Gender 1732 153 (8.8)
2 ASA Class III 167 15 (9)
3 Advanced Tumour Stage (TNM ≥ III) 381 52 (7.6)
4 Large Tumour Size (≥ 4 cm) 1167 101 (8.7)
5

Low Tumour Location (≤ 10 cm from anal verge)

929 85 (9.1)
6 Multiple Firings of Linear Stapler (≥ 3) 226 33 (14.6)
7

Level of Anastomosis (≤ 5 cm from anal verge)

143 24 (16.8)
8

Long Operative Times (≥ 220 min)

1152 109 (9.5)
9

Preoperative Neoadjuvant Chemoradiation

318 29 (9.1)
10

Perioperative Blood Transfusion

121 27 (22.3)
11

Conversion to Open Surgery

44 5 (11.4)
12

Splenic Flexure Mobilisation done

1102 85 (7.7)

Patients with a protective stoma and those operated in the 2nd half of the study time period showed a low incidence of leakage (4.9%, 23/367 and 7.6%, 22/288 respectively).

Conclusions:

Based on best available evidence; male gender, patient with severe systemic disease or in worse condition, advanced tumour stage, large tumour, low lying tumour, multiple stapler firings, low anastomosis, long operative time, preoperative chemoradiation, blood transfusion, conversion to open surgery and mobilising the splenic flexure are important risk factors leading to leakage. However, improved surgeon learning curve and diverting stoma reduce the incidence of leakage. Awareness of these 12 leakage causing risk factors will help devise individualised treatment plans for patients; such as a defunctioning stoma might be mandatory if one or more of these important risk factors are present, as this might avert leakage.

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