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Risk factors for anastomotic leakage after anterior resection of the rectum
Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Avdelningen för kirurgi. Östergötlands Läns Landsting, Kirurgi- och onkologicentrum, Kirurgiska kliniken i Östergötland med verksamhet i Linköping, Norrköping och Motala.
University Hospital Örebro, Örebro, Sweden.
University Hospital Örebro, Örebro, Sweden.
Visa övriga samt affilieringar
2004 (Engelska)Ingår i: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 6, nr 6, s. 462-469Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Objective. Surgical technique and peri-operative management of rectal carcinoma have developed substantially in the last decades. Despite this, morbidity and mortality after anterior resection of the rectum are still important problems. The aim of this study was to identify risk factors for anastomotic leakage in anterior resection and to assess the role of a temporary stoma and the need for urgent re-operations in relation to anastomotic leakage.

Patients and methods. In a nine-year period, from 1987 to 1995, a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. A random sample of 432 of these patients was analysed (sample size 6.3%). The associations between death and 10 patient-and surgery-related variables were studied by univariate and multivariate analysis. Data were obtained by review of the hospital files from all patients.

Results. The incidence of symptomatic clinically evident anastomotic leakage was 12% (53/432). The 30-day mortality was 2.1% (140/6833). The rate of mortality associated with leakage was 7.5%. A temporary stoma was initially fashioned in 17% (72/432) of the patients, and 15% (11/72) with a temporary stoma had a clinical leakage, compared with 12% (42/360) without a temporary stoma, not significant. Multivariate analysis showed that low anastomosis (≤ 6 cm), pre-operative radiation, presence of intra-opcrative adverse events and male gender were independent risk factors for leakage. The risk for permanent stoma after leakage was 25%. Females with stoma leaked in 3% compared to men with stoma who leaked in 29%. The median hospital stay for patients Arithout leakage was 10 days (range 5-61 days) and for patients with leakage 22 days (3-110 days).

Conclusion. In this population based study, 12% of the patients had symptomatic anastomotic leakage after anterior resection of the rectum. Postoperative 30-day mortality was 2.1%. Low anastomosis, pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for symptomatic anastomotic leakage in the multivariate analysis. There was no difference in the use of temporary stoma in patients with or without anastomotic leakage.

Ort, förlag, år, upplaga, sidor
2004. Vol. 6, nr 6, s. 462-469
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
URN: urn:nbn:se:liu:diva-28273DOI: 10.1111/j.1463-1318.2004.00657.xLokalt ID: 13380OAI: oai:DiVA.org:liu-28273DiVA, id: diva2:249077
Tillgänglig från: 2009-10-09 Skapad: 2009-10-09 Senast uppdaterad: 2017-12-13Bibliografiskt granskad
Ingår i avhandling
1. Rectal cancer surgery: Defunctioning stoma, anastomotic leakage and postoperative monitoring
Öppna denna publikation i ny flik eller fönster >>Rectal cancer surgery: Defunctioning stoma, anastomotic leakage and postoperative monitoring
2006 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

The understanding of the mesorectal spread in rectal cancer has lead to wide acceptance of total mesorectal excision (TME) as the surgical technique of choice for carcinoma in the lower and mid rectum. While oncological results and survival have improved with TME-surgery, morbidity and mortality remain important issues. The most feared complication is symptomatic anastomotic leakage. The aim of this thesis was to focus on the role of the defunctioning stoma, risk factors, and postoperative monitoring in regard to anastomotic leakage in sphincter saving resection of the rectum.

Intraoperative adverse events were analysed in a retrospective population based case-control study in which all patients who underwent elective anterior resection in Sweden between 1987 and 1995, and who died within 30 days or during the initial hospital stay (n=140), were compared with patients chosen at random (n=423) who underwent the same operation during the same period, but survived the operation. Intraoperative adverse events were more frequent in those who died, and reconstruction of an anastomosis judged unsatisfactory by the surgeon improved the outcome.

In a population based retrospective case-control study, risk factors for symptomatic anastomotic leakage were investigated in randomly chosen sample of patients who underwent anterior resection in Sweden between 1987 and 1995 (n=432). Twelve per cent of the patients developed symptomatic leakage, and 25% of the patients with leakage ended up with a permanent stoma. In multivariate regression analysis, low anastomosis, preoperative radiotherapy, male gender and intraoperative adverse events were independent riskfactors for anastomotic leakage.

In a randomised multicentre trial patients operated with sphincter saving TME¨surgery for rectal cancer were randomised to a defunctioning stoma (n=116) or not (n=118). The overall rate symptomatic leakage was 19%. Patienst without a defunctioning stoma leaked in 28% and patients with a defunctioing stoma in 10%, a statistically significant difference (p<0.001) not previously demonstrated in any randomised trial of adequate size.

Postoperative monitoring with computed tomography scan (CT-scan) on postoperative day 2 and 7, and C-reactive protein (CRP) daily in 33 patients operated on with anterior resection of the rectum, demonstrated larger pelvic fluid collections in patients with leakage before the leakage was clinically diagnosed. CRP was increased from postoperative day 2 and onwards in patients in whom clinical leakage was diagnosed on median postoperative day 8.

In 23 patients who underwent anterior resection of the rectum, intraperitoneal metabolism was investigated using microdialysis technique measuring the carbohydrate metabolites lactate, pyruvate and glucose. Intraperitoneal cytokines IL-6, IL-10 and TNF-α were collected through a pelvic drain and analysed. In patients who developed leakage, the latate/pyruvate ratio was increased near the anastomosis on postoperative day 5 and 6, as well as IL-6 and IL-10 which were increased postoperatively day 1 and 2, while TNF-α was higher on day 1.

Ort, förlag, år, upplaga, sidor
Linköping: Linköping University Electronci Press, 2006. s. 72
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 940
Nyckelord
Anterior resection of the rectum, total mesorectal excision, TME, anastomotic leakage, defunctioning stoma, risk factors, intraoperative adverse events, population based study, postoperative monitoring, CT-scan microdialysis, cytokines
Nationell ämneskategori
Kirurgi
Identifikatorer
urn:nbn:se:liu:diva-7695 (URN)91-85497-80-0 (ISBN)
Disputation
2006-04-20, Wilandersalen, Universitetssjukhuset i Örebro, Örebro, 09:15 (Engelska)
Opponent
Handledare
Tillgänglig från: 2006-11-06 Skapad: 2006-11-06 Senast uppdaterad: 2009-12-03Bibliografiskt granskad

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Matthiessen, PeterHallböök, OlofSjödahl, Rune

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