Increased Local Recurrence and Reduced Survival From Colorectal Cancer Following Anastomotic Leak Systematic Review and Meta-Analysis
ABSTRACT To examine the long-term oncological impact of anastomotic leakage (AL) after restorative surgery for colorectal cancer using meta-analytical methods. Outcomes evaluated were local recurrence, distant recurrence, and survival.
Recurrence after potentially curative surgery for colorectal cancer remains a significant clinical problem and has a poor prognosis. AL may be a risk factor for disease recurrence, however available studies have been conflicting. A meta-analysis was conducted to investigate the impact of AL on disease recurrence and long-term survival.
Studies published between 1965 and 2009 evaluating the long-term oncological impact of AL were identified by an electronic literature search. Outcomes evaluated included local recurrence, distant recurrence, and cancer specific survival. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute odds ratio and 95% confidence intervals. Study heterogeneity was evaluated using Q statistics and I and publication bias assessed with funnel plots and Egger's test.
Twenty-one studies comprising 13 prospective nonrandomized studies, 1 prospective randomized, and 7 retrospective studies met the inclusion criteria, yielding a total of 21,902 patients. For rectal anastomoses, the odd ratios (OR) of developing a local recurrence when there was AL was 2.05 (95% CI = 1.51-2.8; P = 0.0001). For studies describing both colon and rectal anastomoses, the OR of local recurrence when there was an AL was 2.9 (95% CI = 1.78-4.71; P < 0.001). The OR of developing a distant recurrence after AL was 1.38 (95% CI = 0.96-1.99; P = 0.083). Long term cancer specific mortality was significantly higher after AL with an OR of 1.75 (95% CI = 1.47-2.1; P = 0.0001).
AL has a negative prognostic impact on local recurrence after restorative resection of rectal cancer. A significant association between colorectal AL and reduced long-term cancer specific survival was also noted. No association between AL and distant recurrence was found.
SourceAvailable from: Frank Denis Mcdermott[Show abstract] [Hide abstract]
ABSTRACT: Background Anastomotic leak (AL) represents a dreaded complication following colorectal surgery, with a prevalence of 1–19 per cent. There remains a lack of consensus regarding factors that may predispose to AL and the relative risks associated with them. The objective was to perform a systematic review of the literature, focusing on the role of preoperative, intraoperative and postoperative factors in the development of colorectal ALs.MethodsA systematic review was performed to identify adjustable and non-adjustable preoperative, intraoperative and postoperative factors in the pathogenesis of AL. Additionally, a severity grading system was proposed to guide treatment.ResultsOf 1707 papers screened, 451 fulfilled the criteria for inclusion in the review. Significant preoperative risk factors were: male sex, American Society of Anesthesiologists fitness grade above II, renal disease, co-morbidity and history of radiotherapy. Tumour-related factors were: distal site, size larger than 3 cm, advanced stage, emergency surgery and metastatic disease. Adjustable risk factors were: smoking, obesity, poor nutrition, alcohol excess, immunosuppressants and bevacizumab. Intraoperative risk factors were: blood loss/transfusion and duration of surgery more than 4 h. Stomas lessen the consequences but not the prevalence of AL. In the postoperative period, CT is the most commonly used imaging tool, with or without rectal contrast, and a C-reactive protein level exceeding 150 mg/l on day 3–5 is the most sensitive biochemical marker. A five-level classification system for AL severity and appropriate management is presented.Conclusion Specific risk factors and their potential correction or indications for stoma were identified. An AL severity score is proposed to aid clinical decision-making.British Journal of Surgery 02/2015; 102(5). DOI:10.1002/bjs.9697 · 5.21 Impact Factor
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ABSTRACT: Anastomotic leakage (AL) is a serious complication in laparoscopic rectal cancer surgery, and risk factors for AL are not well defined. Herein, we conducted a systematic review to quantify the clinicopathologic factors predictive for AL in patients who underwent laparoscopic anterior resection (LAR) for rectal cancer. A systematic search of electronic databases (PubMed, Embase, Cochrane CENTRAL, Scopus Database, and Wanfang Database) for studies published until August 2014 was performed. Cohort, case-control studies, and randomized controlled trials that examined clinical risk factors for AL were included. Fourteen studies (seven prospective and seven retrospective studies) involving 4580 patients met final inclusion criteria. From the pooled analyses, five demographic factors were found to be significantly associated with the development of AL, including male gender (OR 2.04, 95 % CI 1.50-2.77), BMI ≥25 kg/m(2) (OR 1.46, 95 % CI 1.00-2.14), ASA score >2 (OR 1.74, 95 % CI 1.04-2.93, P = 0.04), tumor size >5 cm (OR 1.63, 95 % CI 1.01-2.64, P = 0.05), and preoperative chemotherapy (OR 1.67, 95 % CI 1.10-2.55, P = 0.02). Four operative factors were significantly associated with increased risk of AL, including longer operative time (95 % CI 1.71-5.77, P = 0.0002), number of stapler firings ≥3 (OR 0.17, 95 % CI 0.07-0.41, P < 0.001), intra-operative transfusions/blood loss >100 mL (OR 3.79, 95 % CI 2.48-5.49, P < 0.001), and anastomosis level within 5 cm from the anal verge (OR 9.63, 95 % CI 3.05-30.43, P = 0.0001), while pelvic drain (OR 0.43, 95 % CI 0.19-0.94, P = 0.04) was significantly associated with a lower AL rate. Our analysis identified several clinicopathologic factors associated with AL in patients who underwent LAR. The knowledge of these risk factors may influence treatment- and procedure-related decisions and possibly reduce the leakage rate.
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ABSTRACT: Abstract AIM: Anastomotic leakage is a serious complication in restorative colorectal surgery. Anastomotic leakage and its subsequent management may have long-term impact on survival. This study aims to assess the impact of colorectal anastomotic leak (AL) on overall survival (OS) and disease-free survival (DFS). METHODS: A prospective database of 1,048 patients undergoing restorative colorectal cancer resections at St Mark's hospital between October 2004 and October 2013 was examined. RESULTS: The overall leak rate was 99/1,048 (9.4 %). 43 ALs were managed conservatively with antibiotics or radiological drainage and 56 with reoperations. OS was significantly reduced in the AL group treated with a reoperation (HR 2.74, 95 % CI 1.67-4.52, p < 0.001). AL was not significantly associated with worse DFS [conservatively managed AL's vs. no AL-HR 2.07 (95 % CI 1.05-4.10); reoperated AL's vs. no AL-HR 1.56 (95 % CI 0.81-2.99), overall p value = 0.058]. CONCLUSION: Patients who suffer anastomotic leaks requiring reoperations have worse OS compared to patients who do not leak, but there were no significant differences in DFS between patients who leaked and those who did not.World Journal of Surgery 12/2014; · 2.35 Impact Factor