Anastomotic leakage after low anterior resection for rectal cancer: Facts, obscurity, and fiction

Abstract

The subject of anastomotic leakage after low anterior resection (LAR) for rectal cancer remains controversial. Risk factors have been discussed in several studies but the findings are often inconclusive. This review evaluates these studies and separates the known risk factors into those that are well documented, those that are obsolete, and those that require further research. We searched the Medline and PubMed databases using the keywords: "leakage," "low anterior resection," "rectal cancer," "risk factors," and their combinations. There were no language or publication year restrictions. References in published papers were also reviewed. Each risk factor was evaluated and discussed separately. The evidence suggests that low anastomoses are more prone to leakage. Other well-documented risk factors are male sex, smoking, and preoperative malnutrition. Routine mobilization of the splenic flexure and the use of a J-pouch seem to reduce the leakage rate. The effect of preoperative chemo-radiotherapy is under scrutiny. The indications for a protective stoma remain debatable. Omentoplasty, bowel preparation, the use of a drain, and tumor stage do not seem to affect the leakage rate. The type of operation (open or laparoscopic) and anastomosis (hand-sewn or stapled) is not crucial.

Rectal Cancer - Staging and Surgical Approach

“…They also concluded that the distance of the anastomosis from the anal verge has a significant impact on anastomotic failure rates. They recommend the routine mobilisation of the splenic flexure and anastomosis of the descending colon, instead of the sigmoid, to the rectal stump (Taflampas et al, 2009). The use of a colonic J-pouch seems to decrease the leakage rates after low anterior resection.…”

Drain vs No Drain After Colorectal Surgery

“…Although surgeons can expect that drain serves as an eye into the anastomosis [23], the anticipated warning function of prophylactic drain has been questioned. Urbach et al [7] showed in their meta-analysis that only 1 of 20 drains contained pus or enteric content at the time of diagnosis, resulting in a quite low sensitivity of 5% in detecting anastomotic leak.…”

“…The route of drain can turn into a fecal fistula during the postoperative period [23], and this process is a fundamental principle of non-surgical, conservative treatment for anastomotic leak (Fig. 2).…”

Benefit of extraperitonization to prevent septic intraabdominal complications after distal rectal cancer surgery

“…The incidence of clinically significant leakage after low anterior resection varies between 3% and 21%, but is thought to average 10%, or lower, when patients are operated by a high-volume surgeon. 7,8 Risk factors for anastomosis leakage like male sex, advanced age, overweight, low rectal cancer (10 cm from ano-rectal line), 3≥ Charlson index, high ligation of superior mesenteric artery, sepsis, neo-adjuvant chemotherapy, smoking, high American Society of Anesthesiologist (ASA) score, longer operative time (1.9), can be stratified by colon leakage score. 9,10 Intraoperative anastomosis check, good blood supply, tension free and meticulous operative technique are pre-requisites for better anastomosis healing.…”