Ryan Hendrix, MD1, Larson Erb, MD2, Lucy Greenberg, BS2, Turner Osler, MD2, Neil Hyman, MD3, Edward Borrazzo, MD2. 1University of Massachusetts Medical Center, 2University of Vermont Medical Center, 3University of Chicago Medical Center
Introduction: Anastomotic leak is a serious but uncommon complication of gastrointestinal surgery. Early diagnosis remains difficult as patients often fail to present with overt symptomatology. We have previously shown that abnormal vital signs as defined by the American College of Chest Physicians (ACCP) criteria are ubiquitous after bowel resection with anastomosis and therefore of limited value in detecting post-operative leak.* Given the less invasive nature of laparoscopy and its diminished impact on the body’s physiologic response, we sought to challenge these findings specifically in laparoscopy. We hypothesized that vital signs would be less abnormal after laparoscopic operations than after open procedures, and as a result, vital signs would be more predictive of anastomotic leak following laparoscopic colectomy.
Methods and Procedures: A retrospective case series evaluating consecutive patients undergoing bowel resection with anastomosis at a tertiary-care academic medical center from July 2009 to June 2014 was performed. Bowel resection cases were identified using CPT codes, and a total of 170,642 vital sign values (HR, RR, Tmax, SBPmin) and 4,868 values WBC count values were retrospectively abstracted from the electronic medical record, representing the complete post-operative course of the entire patient cohort. Using commercially available statistical software, vital signs of patients who developed an anastomotic leak as defined by findings at reoperation or on radiographic imaging were compared to those with uncomplicated clinical courses.
Results: A total of 1,059 patients underwent bowel resection during the study period (777 open and 282 laparoscopic). In the laparoscopic group, there were 20 anastomotic leaks (7.1%). Average vital signs and WBC count were significantly different between uncomplicated cases and those developing an anastomotic leak most notably on postoperative day 3: Tmax (p < .001), pulse (p < .0001), SBPmin (p < .006), respirations (p < .001), and WBC count (p < .057).
Conclusions: Abnormal vital signs on post-operative day 3 are indicative of an anastomotic leak after laparoscopic colectomy with anastomosis.
* J Am Coll Surg. 2014 Jun;218(6):1195-9.