Risk Factors for Anastomotic Leakage Following Total or Subtotal Colectomy

J. Ocaña P. Pastor-Peinado P. Abadía A. Ballestero D. Ramos JC. García-Pérez JM. Fernández-Cebrián J. Die About the authors

Abstract

Introduction

A higher rate of anastomotic leakage (AL) is reported after ileosigmoid anastomosis (ISA) or ileorectal anastomosis (IRA) in total or subtotal colectomy (TSC) compared with colonic or colorectal anastomosis. Themain aimof the present studywas to assess potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity.

Methods

We identified 180 consecutive patients in a prospective referral, single center database, in which 83 of the patients underwent TSC with ISA or IRA. Data regarding the clinical characteristics, surgical treatment, and outcome were assessed to determine their association with the cumulative incidence of AL and surgical morbidity.

Results

Ileosigmoid anastomosis was performed in 51 of the patients (61.5%) and IRA in 32 patients (38.6%). The cumulative incidence of ALwas 15.6% (13 of 83 patients). A higher AL rate was found in patients under 50 years-old (p=0.038), in the electivelaparoscopic approach subgroup (p=0.049), and patients in the inflammatory bowel disease (IBD) subgroup (p=0.009). Furthermore, 14 patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA.

Discussion

A relatively high incidence of AL after TSC was observed in a relatively safe surgical procedure. Our findings suggest that the risk of AL may be higher in IBD patients. According to our results, identifying risk factors prior to surgerymay improve short-term outcomes.

Keywords:
total or subtotal colectomy; ileorectal anastomosis; ileosigmoid anastomosis; anastomotic leakage

Introduction

Ileorectal anastomosis (IRA) and ileosigmoid anastomosis (ISA) following total or subtotal colectomy (TSC) are mainly performed in inflammatory bowel disease (IBD)—Crohn's disease, ulcerative colitis, and indeterminate colitis—familiar adenomatous polyposis or colonic polyposis syndromes, and colorectal cancer (CRC). Less frequently, TSC is performed in cases of refractory constipation and ischemic colitis.11 Raahave D, Loud FB, Christensen E, Knudsen LL. Colectomy for refractory constipation. Scand J Gastroenterol 2010;45(05): 592-602 22 Moszkowicz D, Mariani A, Trésallet C, Menegaux F. Ischemic colitis: the ABCs of diagnosis and surgical management. J Visc Surg 2013;150(01):19-28 33 Washington C, Carmichael JC. Management of ischemic colitis. Clin Colon Rectal Surg 2012;25(04):228-235

Anastomotic leakage (AL) is a significant complication, associated with increased mortality, reoperation, and derivative morbidity44 Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014;101 (04):424-432, discussion 432 55 Elton C, Makin G, Hitos K, Cohen CRG. Mortality, morbidity and functional outcome after ileorectal anastomosis. Br J Surg 2003; 90(01):59-65 and is also related to poor long-term outcomes in oncological resections.66 Mirnezami A,Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 2011;253(05):890-899 77 LawWL, ChoiHK, LeeYM,Ho JWC, Seto CL. Anastomotic leakage is associated with poor long-termoutcome in patients after curative colorectal resection for malignancy. J Gastrointest Surg 2007;11 (01):8-15 88 Lu ZR, Rajendran N, Lynch AC, Heriot AG, Warrier SK. Anastomotic leaks after restorative resections for rectal cancer compromise cancer outcomes and survival. Dis Colon Rectum 2016;59(03): 236-244 Even though IRA and ISA are anatomically easy to perform—pelvic dissection is not mandatory, there is no tension at the anastomosis, and a blood supply is theoretically ensured—a higher risk of AL is reported after IRA or ISA (6.5–21%)44 Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014;101 (04):424-432, discussion 432 55 Elton C, Makin G, Hitos K, Cohen CRG. Mortality, morbidity and functional outcome after ileorectal anastomosis. Br J Surg 2003; 90(01):59-65 99 Duclos J, Lefevre JH, LefrançoisM, et al. Immediate outcome, longterm function and quality of life after extended colectomy with ileorectal or ileosigmoid anastomosis. Colorectal Dis 2014;16 (08):O288-O296 when compared with colonic or colorectal anastomosis, which has a lower AL rate, mainly under 15%.44 Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014;101 (04):424-432, discussion 432 1010 2015 European Society of Coloproctology Collaborating Group. Predictors for Anastomotic Leak, Postoperative Complications, and Mortality After Right Colectomy for Cancer: Results From an International Snapshot Audit. Dis Colon Rectum 2020;63(05): 606-618 1111 Platell C, Barwood N, Dorfmann G, Makin G. The incidence of anastomotic leaks in patients undergoing colorectal surgery. Colorectal Dis 2007;9(01):71-79 Regardless of the indication,1212 Nakamura T. Are complications of TSC with ileorectal anastomosis related to the original disease? Am Surg 2001 similar AL rates are seen after TSC in IBD (4–12%),1313 Pastore RLO, Wolff BG, Hodge D. Total abdominal colectomy and ileorectal anastomosis for inflammatory bowel disease. Dis Colon Rectum 1997;40(12):1455-1464 1414 Loftus EV Jr, Delgado DJ, Friedman HS, Sandborn WJ. Colectomy and the incidence of postsurgical complications among ulcerative colitis patients with private health insurance in the United States. Am J Gastroenterol 2008;103(07):1737-1745 polyposis (20%)1515 Björk J, Åkerbrant H, Iselius L, et al. Outcome of primary and secondary ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis. Dis Colon Rectum 2001;44(07):984-992 and colon cancer (6–21%).44 Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014;101 (04):424-432, discussion 432 1616 Segelman J, Mattsson I, Jung B, Nilsson PJ, Palmer G, Buchli C. Risk factors for anastomotic leakage following ileosigmoid or ileorectal anastomosis. Colorectal Dis 2018;20(04):304-311 Reducing AL rates might improve short and long term as well as functional outcomes after IRA or ISA. There is not enough evidence of determining factors for AL following colectomy with IRA or ISA. The main aim of the present study was to assess the potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity.

Methods

Patients

All consecutive patients who underwent ISA or IRA following TSC between January 2013 and December 2019 were retrospectively identified from the prospective database of a tertiary referral center in the Ramón y Cajal University Hospital, Madrid, Spain. In case of missing data, patients' records were reviewed. We defined ISA as an anastomosis higher than promontory level, and anastomosis below this level was considered as IRA. The main indications for colectomy in eligible patients were CRC, IBD, polyposis syndromes, and refractory constipation. We defined AL as a defect in the integrity of the intestinal wall at the anastomotic site leading to a communication of the intra- and extraluminal, or to a pelvic abscess adjacent to the anastomosis, according to the definition set by the International Study Group of Rectal Cancer.1717 Rahbari NN,Weitz J, HohenbergerW, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 2010;147(03):339-351 1818 Kulu Y, Ulrich A, Bruckner T, et al; International Study Group of Rectal Cancer. Validation of the International Study Group of Rectal Cancer definition and severity grading of anastomotic leakage. Surgery 2013;153(06):753-761 When the AL required no active therapeutic intervention, they were classified as grade A. When the AL required active therapeutic intervention (such as antibiotics and percutaneous drainage), but was manageable without relaparotomy, they were classified as grade B. The AL requiring reintervention were classified as grade C. There was a postoperative follow-up of 90 days. Postoperative morbidity and mortality were considered within 90 days after surgery. The Clavien-Dindo classification of morbidity was used to grade postoperative complications.1919 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240(02): 205-213 Readmission was considered within 90 days in those patients who presented surgical-associated morbidity, excluding other diagnosis. Patients under 18-years-old, terminal ileostomy after TSC, and two-stage procedure (IRA or ISA with diverting ileostomy) were excluded. The anastomosis was performed according to the surgeon's preference. Demographic and clinical data were collected from each patient, including age, gender, physical status according to the American Society of Anesthesiologists' (ASA) classification, presence of cardiovascular disease, diabetes mellitus, chronic kidney failure, or other underlying diseases, planning of operation (emergent/elective), and preoperative total proteins. Surgical approach, operative variables, and type of anastomosis (handsewn or stapler) were also collected.

Statistical Analysis

The results are reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.2020 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JPSTROBE Initiative. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. Int J Surg 2014; 12(12):1495-1499 Continuous variables were reported as the median and interquartile range, whereas categorical variables were reported as the number of patients and percentage. A univariate analysis was performed to assess the association between dependent variables (AL and postoperative morbidity) and independent variables (ISA or IRA, patients' and surgical data): continuous variables and discrete variables were analyzed by the U Mann-Whitney test and the χ2 test, respectively. Statistical significance was indicated by a p-value < 0.05 (2-tailed test). The IBM SPSS Statistics for Windows, Version 22.0 software (IBM, CorpArmonk, NY, USA) was used for the analyses.

Results

Of the 180 patients identified in the database (Fig. 1), 92 were excluded as they did not have bowel reconstruction with ISA or IRA, and another 5 patients already had diverting stoma. The remaining 83 patients were included and assessed in the study. Demographic characteristics and preoperative data according to AL are shown in Table 1. The cumulative incidence of AL was 15.6% (13 of 83), with 1 patient having grade A, 1 patient grade B, and 11 patients grade C. A higher rate of AL was found in patients under 50 years-old (p = 0.038). Surprisingly, no comorbidities were found to be correlated with AL in the univariate analysis. The main indication for surgery was colon cancer (n = 63; 75.9%). Colonic polyposis (n = 3; 3.6%), IBD (n = 15; 18.1%), and refractory constipation (n = 2, 2.4%) were other reasons for surgery. Whereas the AL rate was significantly higher in the IBD group (p.0.009), no significant AL rate differences were found in the emergent surgery group (25% vs 13.4%; p=0.27).

Table 1
Baseline and preoperative data, and anastomosis leakage

Fig. 1
Flowchart of selection.

All surgical data is shown in Table 2. Ileosigmoid anastomosis was performed in 51 patients (61.5%), and IRA was used in 32 patients (38.6%). No significant differences in AL rate (p = 0.21) were found between IRA and ISA. The anastomosis technique (handsewn vs. stapler, 10.3% vs. 18%) and the type of anastomosis were also found not to be predictors of AL, with p = 0.31 and p = 0.57 respectively. Laparoscopic surgery was performed in 19 of the 83 patients (22.9%). In the elective surgery subgroup, laparoscopic approach had higher AL rate than open surgery (27.8% vs. 8.2%), with p = 0.049.

Table 2
Operative data and anastomosis leakage

Surgical morbidity according to patient and surgical data is shown in Table 3. Of the 83 patients, 38 (45.8%) had no surgical complications within 90 days postoperatively (Table 4). None of the assessed potential predictors of morbidity were found to be significant. Fourteen patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA (moderate-severe). The distribution of exposures according to AL grade was assessed (Table 3), and no potential predictors were found to be statistically significant. There weren't any deaths within 90 days after surgery. Only 2 patients were readmitted (2.4%) in the follow-up.

Table 3
Baseline data and operative characteristics in surgical morbidity

Table 4
Postoperative morbidity and complications

Discussion

In the present study of risk factors for AL and morbidity following TSC with ISA or IRA, the overall AL rate was 15.6%. No mortality event was recorded within 90 days postoperatively, which is similar to previous reports, with a mortality rate under 5%99 Duclos J, Lefevre JH, LefrançoisM, et al. Immediate outcome, longterm function and quality of life after extended colectomy with ileorectal or ileosigmoid anastomosis. Colorectal Dis 2014;16 (08):O288-O296 1616 Segelman J, Mattsson I, Jung B, Nilsson PJ, Palmer G, Buchli C. Risk factors for anastomotic leakage following ileosigmoid or ileorectal anastomosis. Colorectal Dis 2018;20(04):304-311 in recently published series. The mortality rate might be higher in emergent surgery.2121 Hennekinne-Mucci S, Tuech JJ, Bréhant O, et al. Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma. Int J Colorectal Dis 2006;21(06):538-541 The range of AL after IRA or ISA is widely variable depending of the study design.55 Elton C, Makin G, Hitos K, Cohen CRG. Mortality, morbidity and functional outcome after ileorectal anastomosis. Br J Surg 2003; 90(01):59-65 2222 O'Riordan JM, O'Connor BI, Huang H, et al. Long-term outcome of colectomy and ileorectal anastomosis for Crohn's colitis. Dis Colon Rectum 2011;54(11):1347-1354 2323 Boccola MA, Buettner PG, Rozen WM, et al. Risk factors and outcomes for anastomotic leakage in colorectal surgery: a single- institution analysis of 1576 patients. World J Surg 2011;35 (01):186-195 The occurrence of AL in the present study was similar to the findings reported by Segelman et al., who found an AL rate of 13.2% after TSC with ISA or IRA, reporting a significantly lower AL rate (7%) in two-stage procedures (loop ileostomy); Duclos et al. also reported a significant AL rate of 7%. It might be due to a high rate of two-stage procedures (20%), whereas in a nationwide register study, an AL rate of 13.4% was reported following TSC in colon cancer.44 Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014;101 (04):424-432, discussion 432 Even though including two-stage procedures had improved our final results, we decided in the study design to exclude those patients to avoid potential bias in the risk factors for AL detection. In previous published reports of emergent TSC in obstructed left colon cancer, an incredible low AL rate was reported, under 10%.2424 Torralba JA, Robles R, Parrilla P, et al. TSC vs. intraoperative colonic irrigation in the management of obstructed left colon carcinoma. Dis Colon Rectum 1998 2525 Stephenson BM, Shandall AA, Farouk R, Griffith G. Malignant leftsided large bowel obstruction managed by subtotal/total colectomy. Br J Surg 1990;77(10):1098-1102 2626 Ross S, Krukowski ZH,Munro A, Russell IT. Single-stage treatment for malignant left-sided colonic obstruction: A prospective randomized clinical trial comparing TSC with segmental resection following intraoperative irrigation. Br J Surg 1995 The heterogeneity of AL in the literature might be due to a discrepancy in the definition of AL. In our study, we adopted the definition set by the International Study Group of Rectal Cancer1717 Rahbari NN,Weitz J, HohenbergerW, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 2010;147(03):339-351 to be able to compare our results with those previously reported by others who use the same definition.1616 Segelman J, Mattsson I, Jung B, Nilsson PJ, Palmer G, Buchli C. Risk factors for anastomotic leakage following ileosigmoid or ileorectal anastomosis. Colorectal Dis 2018;20(04):304-311

The impact of the anastomosis (ISA or ISA) on AL is controversial. Segelman et al.1616 Segelman J, Mattsson I, Jung B, Nilsson PJ, Palmer G, Buchli C. Risk factors for anastomotic leakage following ileosigmoid or ileorectal anastomosis. Colorectal Dis 2018;20(04):304-311 did not find any statistical difference in one of the most recent studies (XX). In our study, there was no difference in the rate of AL between ISA and IRA, showing that the height of the anastomosis might not have a critical relevance. The difference between ISA and IRA was assessed in elective surgery, and no statistical differences were found. Even though the operation records were difficult to analyze when trying to identify which vessels were preserved, anastomosis involving the distal segment of the small bowel often has sufficient blood supply. On the other hand, in benign diseases, the superior rectal artery can be preserved, allowing sufficient blood perfusion to the anastomosis. It is still unclear if there is an impact of high ligation of the inferior mesenteric artery in the AL rate.2727 Yamamoto T, Keighley MRB. Proctocolectomy is associated with a higher complication rate but carries a lower recurrence rate than total colectomy and ileorectal anastomosis in Crohn colitis. Scand J Gastroenterol 1999;34(12):1212-1215 2828 Krarup PM, Nordholm-Carstensen A, Jorgensen LN, Harling H. Association of comorbidity with anastomotic leak, 30-day mortality, and length of stay in elective surgery for colonic cancer: A nationwide cohort study. Dis Colon Rectum 2015;58(07):668-676 2929 Sparreboom CL, van Groningen JT, Lingsma HF, et al; Dutch Colo Rectal Audit group. Different risk factors for early and late colorectal anastomotic leakage in a nationwide audit. Dis Colon Rectum 2018;61(11):1258-1266 3030 Sciuto A, Merola G, De Palma GD, et al. Predictive factors for anastomotic leakage after laparoscopic colorectal surgery.World J Gastroenterol 2018;24(21):2247-2260 Likewise, the impact of the perfusion of the distal part of ISA or IRA in the AL rate is also controversial.

A great number of studies have been published about risk factors for AL after colectomy,44 Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014;101 (04):424-432, discussion 432 1010 2015 European Society of Coloproctology Collaborating Group. Predictors for Anastomotic Leak, Postoperative Complications, and Mortality After Right Colectomy for Cancer: Results From an International Snapshot Audit. Dis Colon Rectum 2020;63(05): 606-618 1111 Platell C, Barwood N, Dorfmann G, Makin G. The incidence of anastomotic leaks in patients undergoing colorectal surgery. Colorectal Dis 2007;9(01):71-79 2828 Krarup PM, Nordholm-Carstensen A, Jorgensen LN, Harling H. Association of comorbidity with anastomotic leak, 30-day mortality, and length of stay in elective surgery for colonic cancer: A nationwide cohort study. Dis Colon Rectum 2015;58(07):668-676 2929 Sparreboom CL, van Groningen JT, Lingsma HF, et al; Dutch Colo Rectal Audit group. Different risk factors for early and late colorectal anastomotic leakage in a nationwide audit. Dis Colon Rectum 2018;61(11):1258-1266 3030 Sciuto A, Merola G, De Palma GD, et al. Predictive factors for anastomotic leakage after laparoscopic colorectal surgery.World J Gastroenterol 2018;24(21):2247-2260 but the majority are focused on colorectal cancer patients. The results of IRA or ISA after TSC are mixed with other anastomosis sites, and the reported results are hardly clear and conclusive. In contrast to previous studies, we have not found any association between AL rates and the ASA score, gender, diabetes mellitus, and other comorbidities.44 Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014;101 (04):424-432, discussion 432 1010 2015 European Society of Coloproctology Collaborating Group. Predictors for Anastomotic Leak, Postoperative Complications, and Mortality After Right Colectomy for Cancer: Results From an International Snapshot Audit. Dis Colon Rectum 2020;63(05): 606-618 2929 Sparreboom CL, van Groningen JT, Lingsma HF, et al; Dutch Colo Rectal Audit group. Different risk factors for early and late colorectal anastomotic leakage in a nationwide audit. Dis Colon Rectum 2018;61(11):1258-1266 3131 Trencheva K, Morrissey KP, Wells M, et al. Identifying important predictors for anastomotic leak after colon and rectal resection: prospectivestudyon616patients.AnnSurg2013;257(01):108-113 3232 Lin X, Li J, ChenW, et al. Diabetes and risk of anastomotic leakage after gastrointestinal surgery. J Surg Res 2015;196(02):294-301 3333 McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL,Winter DC. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg 2015;102(05):462-479 The absence of this association may be explained due to an important percentage of AL having occurred in IBD patients, who most often corresponded to young patients without other comorbidities. Therefore, in elderly patients who underwent emergent TSC in obstructed or perforated colon cancer, ileostomy was preferably performed. In our study, we found patients under 50-years-old as predictors of AL (p = 0.038). This may be because young IBD patients who underwent TSC might have a poorer clinical situation. Furthermore, young patients who presented emergent TSC were more eligible to primary anastomosis, with the assumption of higher risk of AL, thus avoiding stoma creation.

No difference was identified in relation to AL when using handsewn or stapler anastomosis, which was similar to the findings of a Cochrane review and a recent meta-analysis showing no superiority of either technique.3434 Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos D. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2012;(02):CD003144 3535 Naumann DN, Bhangu A, Kelly M, Bowley DM. Stapled versus handsewn intestinal anastomosis in emergency laparotomy: a systemic review and meta-analysis. Surgery 2015;157(04):609-618 The types of stapler anastomosis (circular vs. linear) and anastomosis placement were also assessed, and no association with AL was found. It is still unclear if anastomosis placement might be associated with AL.3434 Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos D. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2012;(02):CD003144 3535 Naumann DN, Bhangu A, Kelly M, Bowley DM. Stapled versus handsewn intestinal anastomosis in emergency laparotomy: a systemic review and meta-analysis. Surgery 2015;157(04):609-618 In our study, we found the laparoscopic approach in elective surgery as a predictor to AL (p = 0.049). No difference has been reported between laparoscopic and open colectomies in colon cancer and IBD.3636 Watanabe K, Funayama Y, Fukushima K, Shibata C, Takahashi KI, Sasaki I. Hand-assisted laparoscopic vs. open TSC for severe ulcerative colitis. Dis Colon Rectum 2009 3737 VeldkampR, Kuhry E, HopWC, et al; COlon cancer Laparoscopic or Open Resection Study Group (COLOR) Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 2005;6(07):477-484 Furthermore, our findings might be explained by the difficulty of proper placement of the small bowel over the distal stump in the laparoscopic approach. Often, the small bowel can be rotated, and it may produce insufficient perfusion or increased tension over the anastomosis. Further studies are needed to assess the potential impact factor of ISA or IRA in the laparoscopic approach on the AL rate.

In our study, we found higher AL rates in IBD patients when compared with other indications (p = 0.009; OR: 3.88). Although Nakamura et al. reported no differences in morbidity according to the underlying disease,1212 Nakamura T. Are complications of TSC with ileorectal anastomosis related to the original disease? Am Surg 2001 some authors found a high rate of morbidity in IBD patients, from 20 to 32%.55 Elton C, Makin G, Hitos K, Cohen CRG. Mortality, morbidity and functional outcome after ileorectal anastomosis. Br J Surg 2003; 90(01):59-65 1313 Pastore RLO, Wolff BG, Hodge D. Total abdominal colectomy and ileorectal anastomosis for inflammatory bowel disease. Dis Colon Rectum 1997;40(12):1455-1464 1414 Loftus EV Jr, Delgado DJ, Friedman HS, Sandborn WJ. Colectomy and the incidence of postsurgical complications among ulcerative colitis patients with private health insurance in the United States. Am J Gastroenterol 2008;103(07):1737-1745 2727 Yamamoto T, Keighley MRB. Proctocolectomy is associated with a higher complication rate but carries a lower recurrence rate than total colectomy and ileorectal anastomosis in Crohn colitis. Scand J Gastroenterol 1999;34(12):1212-1215 Segelman et al. used two-stage procedures in IBD patients more often than in the other indications.1616 Segelman J, Mattsson I, Jung B, Nilsson PJ, Palmer G, Buchli C. Risk factors for anastomotic leakage following ileosigmoid or ileorectal anastomosis. Colorectal Dis 2018;20(04):304-311 Further studies about AL risk in total or subtotal colectomies with IRA or ISA in IBD patients are needed to stratify the risk of AL and other postoperative complications. If a high risk of AL is estimated, two-stage surgery (loop ileostomy) may be performed, as it has been shown to be a protective factor against AL.1616 Segelman J, Mattsson I, Jung B, Nilsson PJ, Palmer G, Buchli C. Risk factors for anastomotic leakage following ileosigmoid or ileorectal anastomosis. Colorectal Dis 2018;20(04):304-311 Further studies are necessary regarding the value of indocyanine green to prevent AL, improving the assessment of the rectal stump's blood supply.

Overall, the morbidity was 45.8%, including medical and surgical postoperative morbidity within 90 days. No statistical differences were found in the severity of morbidity according to underlying diseases or other surgical data. Duclos et al. reported a lower morbidity rate of 19.5%.99 Duclos J, Lefevre JH, LefrançoisM, et al. Immediate outcome, longterm function and quality of life after extended colectomy with ileorectal or ileosigmoid anastomosis. Colorectal Dis 2014;16 (08):O288-O296 Even in emergency colectomy, lower rates were reported (15%), with a high mortality rate of 9.7%.2121 Hennekinne-Mucci S, Tuech JJ, Bréhant O, et al. Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma. Int J Colorectal Dis 2006;21(06):538-541 This heterogeneity of the reported morbidity rates shows the importance of reporting the results in detail so they can be accurately assessed. In the present report, cases of AL after IRA or ISA were often clinically severe (grade C). The same findings are reported after TSC by Duclos et al., 6.8% from a morbidity rate of 19.5%,99 Duclos J, Lefevre JH, LefrançoisM, et al. Immediate outcome, longterm function and quality of life after extended colectomy with ileorectal or ileosigmoid anastomosis. Colorectal Dis 2014;16 (08):O288-O296 and by Bakker et al., who reported a mortality rate of 13% for AL following TSC.44 Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014;101 (04):424-432, discussion 432

The strength of the present study is that it is one of the largest series published in last years focused on restorative TSC. Even though a great effort has been made to correct possible bias in the study design, its retrospective nature will have introduced an element of bias. A large cohort, including various types of indications for surgery, might cause confusion, but it can help assess the impact of the pathology on the results. Possible confounders, such as two-stage procedures or delayed ISA or IRA, have been excluded from the study. The deep assess of the surgical morbidity may not have enough power in this sample. For this reason, large multicenter prospective studies should be made to determine pathology and surgical data impact on the type of morbidity. The applied definition criteria for AL may underdiagnose AL, as not all suspicions of AL were identified by a radiological examination with rectal contrast.

The global AL rate of 15.6% after TSC in this study shows a high frequency of leakage after a relatively safe surgical procedure. Our findings suggest that, in IBD patients, the risk of AL may be higher. According to our results, identifying risk factors prior to surgery may improve short-term negative outcomes.

References

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    Elton C, Makin G, Hitos K, Cohen CRG. Mortality, morbidity and functional outcome after ileorectal anastomosis. Br J Surg 2003; 90(01):59-65
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    Mirnezami A,Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 2011;253(05):890-899
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    LawWL, ChoiHK, LeeYM,Ho JWC, Seto CL. Anastomotic leakage is associated with poor long-termoutcome in patients after curative colorectal resection for malignancy. J Gastrointest Surg 2007;11 (01):8-15
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    Lu ZR, Rajendran N, Lynch AC, Heriot AG, Warrier SK. Anastomotic leaks after restorative resections for rectal cancer compromise cancer outcomes and survival. Dis Colon Rectum 2016;59(03): 236-244
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    Duclos J, Lefevre JH, LefrançoisM, et al. Immediate outcome, longterm function and quality of life after extended colectomy with ileorectal or ileosigmoid anastomosis. Colorectal Dis 2014;16 (08):O288-O296
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    2015 European Society of Coloproctology Collaborating Group. Predictors for Anastomotic Leak, Postoperative Complications, and Mortality After Right Colectomy for Cancer: Results From an International Snapshot Audit. Dis Colon Rectum 2020;63(05): 606-618
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    Platell C, Barwood N, Dorfmann G, Makin G. The incidence of anastomotic leaks in patients undergoing colorectal surgery. Colorectal Dis 2007;9(01):71-79
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    Nakamura T. Are complications of TSC with ileorectal anastomosis related to the original disease? Am Surg 2001
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    Pastore RLO, Wolff BG, Hodge D. Total abdominal colectomy and ileorectal anastomosis for inflammatory bowel disease. Dis Colon Rectum 1997;40(12):1455-1464
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    Loftus EV Jr, Delgado DJ, Friedman HS, Sandborn WJ. Colectomy and the incidence of postsurgical complications among ulcerative colitis patients with private health insurance in the United States. Am J Gastroenterol 2008;103(07):1737-1745
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  • Funding

    No funding or grant was received for the preparation of this manuscript.

Publication Dates

  • Publication in this collection
    03 June 2022
  • Date of issue
    Jan-Mar 2022

History

  • Received
    22 Mar 2021
  • Accepted
    06 Aug 2021
  • Published
    17 Jan 2022
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