Retrospective Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Dec 26, 2022; 10(36): 13321-13336
Published online Dec 26, 2022. doi: 10.12998/wjcc.v10.i36.13321
Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors
Giuseppe Brisinda, Maria Michela Chiarello, Gilda Pepe, Maria Cariati, Valeria Fico, Paolo Mirco, Valentina Bianchi
Giuseppe Brisinda, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
Giuseppe Brisinda, Department of Surgery, Università Cattolica S Cuore, Rome 00168, Italy
Maria Michela Chiarello, Department of Surgery, Azienda Sanitaria Provinciale di Cosenza, Cosenza 87100, Italy
Gilda Pepe, Valeria Fico, Paolo Mirco, Valentina Bianchi, Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
Maria Cariati, Department of Surgery, Azienda Sanitaria Provinciale di Crotone, Crotone 88900, Italy
Author contributions: Brisinda G contributed to the writing-original draft; Brisinda G, Chiarello MM and Bianchi V contributed to the conceptualization, methodology and writing-reviewing and editing; Brisinda G, Pepe G, Cariati M, Fico V and Mirco P contributed to the data curation; Brisinda G and Fico V contributed to the formal analysis; Fico V and Mirco P contributed to the investigation; All the authors read and approved the final manuscript.
Institutional review board statement: The study involves the analysis of clinical data. For this reason, the approval of the Institutional Board of the Ethics Committee was not required. The study did not lead to changes in the diagnosis and treatment of the disease in the patients under analysis.
Informed consent statement: All patients were informed about the treatment modalities at the time they were observed. Regarding the study, this is a retrospective analysis of anonymous clinical data.
Conflict-of-interest statement: The authors have no financial or personal relationships that may inappropriately influence this work. No funding body had any involvement in the preparation or content of this manuscript or in decision to submit for publication.
Data sharing statement: The authors confirm that the data supporting the findings of this study are available within the article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Giuseppe Brisinda, MD, Professor, Surgeon, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo Agostino Gemelli 8, Rome 00168, Italy. gbrisin@tin.it
Received: October 13, 2022
Peer-review started: October 13, 2022
First decision: November 6, 2022
Revised: November 8, 2022
Accepted: December 5, 2022
Article in press: December 5, 2022
Published online: December 26, 2022
Processing time: 74 Days and 10.9 Hours
ARTICLE HIGHLIGHTS
Research background

Anastomotic leakage (AL) is one of the most severe complications for rectal cancer (RC) surgery owing to its negative impact on both short- and long-term outcomes. The incidence reported in the literature has not significantly changed in recent decades despite constant improvements in the preoperative assessment of the patient as well as in the surgical technique.

Research motivation

In a previous study, we observed an increased rate of AL after end-to-end anastomosis compared to the end-to-side anastomosis technique. In consideration of these results, we did not use the end-to-end technique, preferring to perform the double stapling technique for rectal anastomosis.

Research objectives

In this study, we retrospectively reviewed our RC surgery cases, investigated frequency of AL, surgical procedures and clinical and pathological features to identify the risk factors for this complication.

Research methods

Patient-, disease- and treatment-related variables were analyzed. Patients were classified into two groups: patients with AL and patients without AL. The primary endpoint of the study was the detection of any independent risk factors for leakage. Secondary endpoints included the overall rate of leakage in the study population, the distribution of AL according to clinical severity grading and 30-d mortality and morbidity.

Research results

Data of 583 patients were analyzed. Mortality rate was 0.8%. It was higher in patients with AL. The incidence of AL was 10.4%. Patients who developed leakage were significantly older than patients without AL. A higher incidence of AL has been documented in patients with low serum albumin and low hemoglobin levels and in patients with a prognostic nutritional index score < 40 points. A higher incidence of leakage was observed in patients with poor bowel preparation compared to those with complete and appropriate bowel preparation and in patients receiving blood transfusions compared to those who did not require this therapy. Significant differences between the two groups were found to be related to the site of the anastomosis, stapled rectal resection firing more than one cartridge, the diameter of the circular stapler used, the vascular ligation site and type of mesorectal excision. The use of a transanastomotic tube resulted in a lower incidence of rate of AL compared to patients in whom this device was not used.

Research conclusions

AL after RC surgery is a fearsome complication with considerable mortality and morbidity. Many factors are related to the onset of leakage in the postoperative period. The evaluation of the prognostic nutritional index is very promising.

Research perspectives

The use of the transanastomotic tube prevents the formation of AL. This is a simple method that could avoid performing diverting ileostomies. The use of small diameter circular staplers should be considered in prospective randomized studies on a larger number of patients.