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Anastomotic leakage

Anastomotic leakage. Risk Factors POW Journal Club: 14 May 2007 Sanjay Warrier. Anastomotic leakage. Patient factors – nutrition, ischaemia, comorbidities, bowel preparation, obesity. age, sex. Operator factors – stapled versus handsewn anastomosis. Surgical variability. Aim.

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Anastomotic leakage

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  1. Anastomotic leakage Risk Factors POW Journal Club: 14 May 2007 Sanjay Warrier

  2. Anastomotic leakage • Patient factors – nutrition, ischaemia, comorbidities, bowel preparation, obesity. age, sex. • Operator factors – stapled versus handsewn anastomosis. Surgical variability.

  3. Aim • Review patient dependent factors. • Surgical variability will be there. Identify patient risk factors in colorectal disease that may alter clinical management. • Aim to chose an article which had a conclusion which would be of clinical significance • Recent publication within the last 5 years.

  4. Paper choice • No recent prospective studies designed review risk factors • Choice: Diseases of the colon and rectum 2003. • Risk factors for anastomotic leakage after left sided colorectal resection with rectal anastomosis

  5. Methods • Case control retrospective analysis • 10 year period • Identify all anastomotic leaks:44 • Control group obtained from same registrary.

  6. Inclusion/exclusion criteria • Inclusion: All patients operated on for leakage. • Control group: same surgeons performed the operations in leakage and control group. Patients chosen with same age, sex, type of cancer and operation. • Exclusion: Patients not operated on for suspected leakage.

  7. Methods • Data review on 88 patients • Nutritional status on admission determined. Malnourished if albumin<35g/l, weight loss >5kg in few months. • Obesity BMI > 27kg/m2 • Anemia defined as HB< 110 umol • Creatinine <110 umol/1 and serum bilirubin <20umol/l

  8. Methods continued • Medical illnesses; diabetes, cardiovascular disease, lung disease, renal disease, cerebrovascular accident. • Previous abdominal surgery, alcohol consumption, smoking, pre operative use of steroids, type of intestinal preparation and antibiotic prophylaxis. • Surgical factors: type of surgery, mobilisation of splenic flexure, type of anastomosis( stapled, sutured), technique of stapling (single/double), size of stapler, completeness of doughnuts, distance of anastomosis from the anal verge, use of drain, operation time and need for blood transfusion.

  9. Analysis Continuous variables - analysed students t test. Categorical variables – pearson chi squared test Odds ratio used to calculate degree of association between risk factors and group ( case/control). Logistic regression model used for multivariate analysis.

  10. Results • Anastomotic leakage : 44 patients, reoperation at 8+/- 5days • 25 of 44 radiological evidence of leakage:15 had signs of local and 10 diffuse peritonitis • Remaining 19 were operated on for signs of diffuse generalized peritonitis. • All 44 patients were treated surgically

  11. Results • Patients in leakage group were more often malnourished (17/44) than in control group (2/44: p- 0.0001) • mean albumin was 33.8 in leakage group, and 38 in control group • Other biochemical values did not differ significantly

  12. Results • Use of alcohol – 14/44 (leakage group) and 6/44(control group) (OR: 6.1, pvalue:0.001). • Low anastomosis – was 12/44(leakage group) and 5/44(control group) • Blood transfusions (p=0.0001) and intra operative contamination (p=0.002) were more common in leakage group • No statistical difference with drain usage, use of single or double stapling, emergency operation or mobilisation of splenic flexure.

  13. Results • Number of risk factors were significantly higher in leakage group. • 5 risk factors ( 100%) • 4 risk factors ( 87%) • 3 risk factors (76%)

  14. Conclusion • Malnutrition, weight loss, use of alcohol, blood transfusions, intraoperative contamination and distance from anal verge were statistically significant risk factors • Multiple risk factors increase the chance of anastomotic leakage. • Recommend use of protective stoma in low rectal anastomoses whenever patient has three or more risk factors

  15. Comment • Small number study • Aim to look at patient related risk factors. • Definition of anastomotic leakage. • Study design • Definition of malnutrition definitive but not entirely accurate ( albumin<35g/L). Weight loss related to a figure(>5kg) rather than body mass index • Alcohol consumption not quantified. Blood transfusions not obviously documented as preoperative analysis.

  16. Anastomotic leakage • Rullier et al 1998 BJS: 1980 to 1995 look at 272 consecutive anterior resection. Statistical significant risk for distance from verge ( less than 5cm from rectum), also more likely in men( 2.7 times more likely). • Lipska et al ANZ Journal of Surgery :July 2006, 535 patients in single colorectal unit 1999 – 2004. All colonic anastomosis. Anastomotic leakage rate of 6.5%. • Statistical significant results for male, history of abdominal surgery and low level of cancer. Increased rates of leak with hypoalbuminemic patients and those who Etoh or smoke but no statistical significance. Blood transfusion not shown to be a factor.

  17. Anastomotic leakage • Yeh et al. Annals of surgery 2005. Risk factors after elective anterior resection. Statistical significant for level of anastomosis and leakage, and also male patients. • Pre operative hypoalbuminemia lost statistical significance in final regression model. Higher rate of leakage in those with poor bowel preparation.

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