Int J Colorectal Dis (2015) 30:831–834 DOI 10.1007/s00384-015-2207-9
ORIGINAL ARTICLE
Rarity of late anastomotic leakage after low anterior resection of the rectum Hiromichi Maeda 1 & Ken Okamoto 1,2 & Tsutomu Namikawa 3 & Toyokazu Akimori 4 & Norihito Kamioka 4 & Mai Shiga 3 & Ken Dabanaka 3 & Kazuhiro Hanazaki 3 & Michiya Kobayashi 1,2
Accepted: 30 March 2015 / Published online: 11 April 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Background Late anastomotic leakage is reported to account for half of all anastomotic leakages after low anterior resection of the rectum. An important clinical question is whether late and early anastomotic leakages are different entities. Methods We retrospectively reviewed the medical records of patients who experienced anastomotic leakage after low anterior resection in two Japanese hospitals. The clinical characteristics were extracted and analyzed. Results During the study period, 179 patients underwent low anterior resection. A pelvic drainage tube was routinely utilized in all cases and was generally removed 4 to 6 days after the operation. Twenty-six patients had anastomotic leakage; the diagnosis was based on fecal contamination of the drainage in 24 cases. The median interval between operation and detection of anastomotic leakage was 3.5 days. Anastomotic leakage was diagnosed within 7 days of the operation in 25 cases and on postoperative day 20 (after hospital discharge) in one case. There was no instance of anastomotic leakage diagnosed more than 30 days after the operation. There was no relationship between clinical variables and days of leakage diagnosis.
* Hiromichi Maeda [email protected] 1
Cancer Treatment Center, Kochi Medical School Hospital, Kohasu, Oko-cho, Nankoku-city, Kochi 783-8505, Japan
2
Department of Human Health and Medical Sciences, Kochi Medical School, Kochi University, Kochi, Japan
3
Depatment of Surgery, Kochi Medical School, Kochi University, Kochi, Japan
4
Department of Surgery, Kochi Prefectural Hata Kenmin Hospital, Kochi, Japan
Conclusion The rarity of late anastomotic leakage in our study, compared with previous studies, may relate to the relatively extended period of pelvic drainage tube usage in our institutes, which likely shortens the interval before leakage diagnosis. Our results suggest that late anastomotic leakage is a delayed symptom of subtle early anastomotic leakage rather than a separate entity. Keywords Rectal cancer . Anastomotic leakage . Low anterior resection . Complication
Introduction Anastomotic leakage remains one of the most serious complications after low anterior resection (LAR) of the rectum. A systemic review by Snijders et al. [1] revealed that the overall rate of anastomotic leakage following LAR was 9 %, with a wide inter-study range (3 to 28 %).While knowing the rate of anastomotic leakage facilitates discussions of treatment options for rectal cancer, knowledge of its clinical features is important for the establishment of appropriate postoperative management. Furthermore, subclassification of anastomotic leakages may lead to different preventive methods for different types of anastomotic leakage. Late anastomotic leakage is variously defined as anastomotic leakage diagnosed after hospital discharge or diagnosed more than 30 days after the operation. In a study of anastomotic leakage following intestinal surgery, Hyman et al. [2] demonstrated that approximately half of the leakages occurred after hospital discharge. They suggested that the diagnosis of late anastomotic leakage was often difficult because the symptoms or radiological images or both were atypical. Similarly, Floodeen et al. [3] found that, among 45 patients who developed anastomotic leakage after low anterior resection of the
832
Int J Colorectal Dis (2015) 30:831–834
rectum, 40 % were diagnosed after hospital discharge, with the rest diagnosed during the initial hospital stay. Comparison of the early and late groups revealed that the operation time was significantly longer in the early leakage group and that the each group had a different distribution of leakage sites. Also, a smaller blood loss, a lower average BMI, and a higher rate of female gender in the late anastmotic leakage group were found. These findings may support the hypothesis that early and late anastomotic leakage are different entities [3]. However, another study performed by Morks et al. [4] did not show significant differences in patient characteristics or surgical factors between early and late (diagnosed ≥30 days after the operation) anastomotic leakage. Based on their results, Morks et al. speculated that, in some of the cases, subtle anastomotic leakage was asymptomatic or missed when it first occurred, and anastomotic leakage was diagnosed weeks later due to symptom development. Because the previous studies [3, 4] did not reach a definite conclusion as to whether early and late anastomotic leakage are distinct entities, further studies are required. Here, we retrospectively studied the clinical features of anastomotic leakage, including the timing of diagnosis, following low anterior resection of the rectum in two Japanese institutes. In this study, late anastomotic leakage is defined as anastomotic leakage diagnosed more than 30 days after the operation because this definition is not influenced by the timing of the hospital discharge. No attempt was made to Table 1
elucidate the risk factors and the causes of anastomotic leakage. Rather, the study focused on the relationship between postoperative management and the diagnosis of anastomotic leakage.
Methods Patients Patients who underwent low anterior resection for neoplasms of the rectum between January 2007 and December 2013 in Kochi Medical School Hospital, Japan, or between January 2009 and December 2013 in Hata Kenmin Hospital, Japan, were included in this study. The computerized medical records (both admission and outpatient records) of 179 patients were retrospectively reviewed and 26 patients with anastomotic leakage after low anterior resection were identified. Operative and postoperative management and follow-up Low anterior resection was performed with total mesorectal excision or tumor-specific mesorectal excision [5] and regional lymphadenectomy. End-to-end anastomosis was performed by using the double-stapling technique, and cases which necessitated transanal coloanal anastomosis were excluded from this study. In both institutes, the need for stoma creation was
Clinical characteristics of the patients with anastomotic leakage following LAR of the rectum
Clinical characteristics Anastomotic leakage (% of cases)
Age (year) Gender Tumor Stage Body mass index (kg/m2) Operation time (min) Estimated Blood loss (ml) Defunctioning ileostomy (% of cases)a Interval between operation and anastomotic leakage (days) Diagnostic sign
Relaparotomy (% of cases)
LAR low anterior resection a
Defunctioning ileostomy at the initial operation
Total Kochi Medical School Hospital Hata-Kenmin Hospital Median (range) Mean±SD Female/Male
14.5 % (26/179) 15.5 % (18/116) 12.7 % (8/63) 64 (35–84) 66.1±10.9 6/20
I/II/III/IV Mean±SD Mean±SD Mean±SD
7/11/5/3 22.8±2.20 282.0±93.3 225.5±300.0 15.4 % (4/26) 3.5 (1–20) 4.2±3.6 92.3 % (24/26) 3.8 % (1/26) 3.8 % (1/26) 34.6 % (9/26) 22.2 % (4/18) 62.5 % (5/8)
Median (range) Mean±SD Fecal contamination of drain Fever, abdominal pain Discharge from drain site Total Kochi Medical School Hospital Hata-Kenmin Hospital
Int J Colorectal Dis (2015) 30:831–834
833
Diagnosis of anastomotic leakage The diagnosis of anastomotic leakage was comprehensively made based on the content of the drainage tube, fever, abdominal pain, physical examination, and the results of computed tomography (CT). Rectal contrast enemas were not routinely performed to detect clinically asymptomatic anastomotic leakage (grade A anastomotic leakage [6]). Statistical analysis
Fig. 1 Histogram of patients with anastomotic leakage. The majority of the cases were diagnosed within 7 days after the operation; only one case was diagnosed later, on the 20th postoperative day
To find the relationship between the day of leakage diagnosis and the other clinical variables, unpaired t tests and correlation were performed using Microsoft Office Excel (Microsoft, Redmond, WA) and Kaleida Graph version 4.0 (Synergy Software, Reading, PA). A P value of less than 0.05 was considered to be statistically significant.
Results determined by each individual surgeon before or during the operation, without stipulation of a clear criterion. Water intake was usually allowed on the first postoperative day, and oral intake of solid food was initiated from the third to fifth postoperative day onward according to the surgeon’s decision. In all cases, at the end of the operation, a transcutaneous pelvic drainage tube was placed with the tip of the tube at the bottom of the pelvic cavity. The tube was removed after the start of oral intake, which was usually on the fourth to sixth postoperative day. When the postoperative course was uneventful, the patients were allowed to leave the hospital 10 to 14 days after the operation. After hospital discharge, all patients were periodically monitored for complications and tumor recurrence. Table 2
The characteristics of the patients with anastomotic leakage are summarized in Table 1. The median age was 64 years (range, 35–84 years) and male gender was predominant. The median interval between the operation and the diagnosis of anastomotic leakage was 3.5 days (range, 1 to 20 days). Most cases of anastomotic leakage were diagnosed within 7 days (Fig. 1) and the diagnosis was usually (24/26 cases) based on fecal contamination of the drainage tube. One case was diagnosed after hospital discharge; on the 20th postoperative day, the patient showed clinical signs of anastomotic leakage (sudden onset of fever, lower abdominal pain, and pain on urination). There was no significant relationship between the day of diagnosis and gender (P=0.72), use of defunctioning ileostomy at
Differences in surgical methods, postoperative managements, and consequences among three different studies
Study
Floodeen et al. [3]
Morks et al. [4]
Current study
Grade of anastomotic leakagea Number of cases of anastomotic leakage Definition of late anastomotic leakage % of late anastomotic leakage Frequently used anastomosis Defunctioning stoma Use of pelvic drainage Duration Common methods of diagnosis
Symptomatic (grades B, C) 45
All Grades (grades A–C) 28
Symptomatic (grades B, C) 26
Diagnosed after hospital discharge 40 % Not described 22 % 98 % Not described Rectal contrast study, CT
Diagnosed >30 days after operation 32 % SEA>EEA 46 % Not described Not described Physical examination, CT
Diagnosed >30 days after operation 0% EEA 15.4 % All cases 4–7 days when uneventful Drainage tube
SEA side-to-end anastomosis, EEA end-to-end anastomosis a
The International Study Group of Rectal Cancer classified anastomotic leakage into three categories. Grade A is asymptomatic anastomotic leakage, which is detected only on the imaging modalities. Grade B requires therapeutic intervention except laparotomy. Grade C requires relaparotomy
834
Int J Colorectal Dis (2015) 30:831–834
the initial operation (P=0.60), body mass index (P=0.182), operation time (P=0.50), or estimated blood loss (P=0.98).
In conclusion, we consider that the majority of cases of late anastomotic leakage are the late manifestation of early subtle anastomotic leakage rather than a distinct entity.
Discussion
Acknowledgments The authors thank Dr. Toshichika Kanagawa for supporting this research.
The present study revealed that the occurrence of late anastomotic leakage was quite rare in our two hospitals. Among the 26 cases of anastomotic leakage, there was no case of late anastomotic leakage according to the definition of diagnosis more than 30 days after the operation. Because these two hospitals recommended periodical follow-up and the majority of the patients followed the instruction, the probability that late anastomotic leakage was overlooked was quite low. We consider that the most significant difference between the previous two studies and ours is the length of time that the pelvic drainage tube was kept in place (Table 2). In our institutes, in all cases, a pelvic drainage tube was placed at the end of the operation. Usually, the drainage tube was used at least until the initiation of oral intake, which was 4 to 6 days after the operation. In their study, Floodeen et al. [3] stated that 98 % of the patients (44 out of 45 patients) received pelvic drainage. Although the timing of its removal was not clearly described, we speculate that the drainage tube was removed quite early after the operation because diagnosis of early anastomotic leakage largely relied on radiological modalities (CT scanning and/or rectal contrast enemas), digital palpation, and rectoscopy. Morks et al. [4] also described that the diagnosis of early leakage was based on the findings of physical examination and CT scans, suggesting early removal of the drainage tube or non-use of drainage tubes. Thus, the extended period of pelvic drainage tube placement in our institutes compared with those studied previously appears to have allowed us to detect cases of subtle anastomotic leakage before hospital discharge, which might have otherwise been detected after hospital discharge [2–4, 7]. Early diagnosis and swift treatment of anastomotic leakage is required to prevent fatal consequences. One solution is to retain the pelvic drainage tube for a longer time as in our institutes. In hospitals where the length of stay is quite short, hospital discharge with a drainage tube and continuous monitoring could be a choice; however, the risk of retrograde infection of the pelvis and incidental removal of the drainage tube should be taken into consideration. Another solution would be to find reliable biomarkers that predict anastomotic leakage early after the operation [8, 9]. Surgeons could also choose to make no anastomosis in patients with a higher risk of leakage or those in poor general condition.
Author contributions HM, KO, TA, MS, KD, and NK substantially contributed to acquisition of data, analysis, and interpretation of data. HM, TN, KH, and MK substantially contributed to study conception and design, analysis, interpretation of data, and writing the manuscript. All authors approved this manuscript. Conflicts of interest There is no conflict of interest.
References 1.
2.
3.
4.
5.
6.
7.
8.
9.
Snijders HS, Wouters MW, van Leersum NJ, Kolfschoten NE, Henneman D, de Vries AC, Tollenaar RA, Bonsing BA (2012) Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol 38:1013–1019 Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA (2007) Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg 245:254–258 Floodeen H, Hallböök O, Rutegård J, Sjödahl R, Matthiessen P (2013) Early and late symptomatic anastomotic leakage following low anterior resection of the rectum for cancer: are they different entities? Colorectal Dis 15:334–340 Morks AN, Ploeg RJ, Sijbrand Hofker H, Wiggers T, Havenga K (2013) Late anastomotic leakage in colorectal surgery: a significant problem. Colorectal Dis 15:e271–e275 Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, Killingback M, Lubowski DZ, Moore R, Penfold C, Savoca P, Stitz R, Tjandra JJ, American Society of Colon and Rectal Surgeons; Association of Coloproctology of Great Britain and Ireland; Coloproctology Surgical Society of Australia (2001) Consensus statement of definitions for anorectal physiology and rectal cancer. Colorectal Dis 3:272–275 Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S, den Dulk M, van de Velde C, Büchler MW (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147: 339–351 Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246:207–214 Pasternak B, Matthiessen P, Jansson K, Andersson M, Aspenberg P (2010) Elevated intraperitoneal matrix metalloproteinases-8 and -9 in patients who develop anastomotic leakage after rectal cancer surgery: a pilot study. Colorectal Dis 12:e93–e98 Fouda E, El Nakeeb A, Magdy A, Hammad EA, Othman G, Farid M (2011) Early detection of anastomotic leakage after elective low anterior resection. J Gastrointest Surg 15:137–144
ORIGINAL ARTICLE
Rarity of late anastomotic leakage after low anterior resection of the rectum Hiromichi Maeda 1 & Ken Okamoto 1,2 & Tsutomu Namikawa 3 & Toyokazu Akimori 4 & Norihito Kamioka 4 & Mai Shiga 3 & Ken Dabanaka 3 & Kazuhiro Hanazaki 3 & Michiya Kobayashi 1,2
Accepted: 30 March 2015 / Published online: 11 April 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Background Late anastomotic leakage is reported to account for half of all anastomotic leakages after low anterior resection of the rectum. An important clinical question is whether late and early anastomotic leakages are different entities. Methods We retrospectively reviewed the medical records of patients who experienced anastomotic leakage after low anterior resection in two Japanese hospitals. The clinical characteristics were extracted and analyzed. Results During the study period, 179 patients underwent low anterior resection. A pelvic drainage tube was routinely utilized in all cases and was generally removed 4 to 6 days after the operation. Twenty-six patients had anastomotic leakage; the diagnosis was based on fecal contamination of the drainage in 24 cases. The median interval between operation and detection of anastomotic leakage was 3.5 days. Anastomotic leakage was diagnosed within 7 days of the operation in 25 cases and on postoperative day 20 (after hospital discharge) in one case. There was no instance of anastomotic leakage diagnosed more than 30 days after the operation. There was no relationship between clinical variables and days of leakage diagnosis.
* Hiromichi Maeda [email protected] 1
Cancer Treatment Center, Kochi Medical School Hospital, Kohasu, Oko-cho, Nankoku-city, Kochi 783-8505, Japan
2
Department of Human Health and Medical Sciences, Kochi Medical School, Kochi University, Kochi, Japan
3
Depatment of Surgery, Kochi Medical School, Kochi University, Kochi, Japan
4
Department of Surgery, Kochi Prefectural Hata Kenmin Hospital, Kochi, Japan
Conclusion The rarity of late anastomotic leakage in our study, compared with previous studies, may relate to the relatively extended period of pelvic drainage tube usage in our institutes, which likely shortens the interval before leakage diagnosis. Our results suggest that late anastomotic leakage is a delayed symptom of subtle early anastomotic leakage rather than a separate entity. Keywords Rectal cancer . Anastomotic leakage . Low anterior resection . Complication
Introduction Anastomotic leakage remains one of the most serious complications after low anterior resection (LAR) of the rectum. A systemic review by Snijders et al. [1] revealed that the overall rate of anastomotic leakage following LAR was 9 %, with a wide inter-study range (3 to 28 %).While knowing the rate of anastomotic leakage facilitates discussions of treatment options for rectal cancer, knowledge of its clinical features is important for the establishment of appropriate postoperative management. Furthermore, subclassification of anastomotic leakages may lead to different preventive methods for different types of anastomotic leakage. Late anastomotic leakage is variously defined as anastomotic leakage diagnosed after hospital discharge or diagnosed more than 30 days after the operation. In a study of anastomotic leakage following intestinal surgery, Hyman et al. [2] demonstrated that approximately half of the leakages occurred after hospital discharge. They suggested that the diagnosis of late anastomotic leakage was often difficult because the symptoms or radiological images or both were atypical. Similarly, Floodeen et al. [3] found that, among 45 patients who developed anastomotic leakage after low anterior resection of the
832
Int J Colorectal Dis (2015) 30:831–834
rectum, 40 % were diagnosed after hospital discharge, with the rest diagnosed during the initial hospital stay. Comparison of the early and late groups revealed that the operation time was significantly longer in the early leakage group and that the each group had a different distribution of leakage sites. Also, a smaller blood loss, a lower average BMI, and a higher rate of female gender in the late anastmotic leakage group were found. These findings may support the hypothesis that early and late anastomotic leakage are different entities [3]. However, another study performed by Morks et al. [4] did not show significant differences in patient characteristics or surgical factors between early and late (diagnosed ≥30 days after the operation) anastomotic leakage. Based on their results, Morks et al. speculated that, in some of the cases, subtle anastomotic leakage was asymptomatic or missed when it first occurred, and anastomotic leakage was diagnosed weeks later due to symptom development. Because the previous studies [3, 4] did not reach a definite conclusion as to whether early and late anastomotic leakage are distinct entities, further studies are required. Here, we retrospectively studied the clinical features of anastomotic leakage, including the timing of diagnosis, following low anterior resection of the rectum in two Japanese institutes. In this study, late anastomotic leakage is defined as anastomotic leakage diagnosed more than 30 days after the operation because this definition is not influenced by the timing of the hospital discharge. No attempt was made to Table 1
elucidate the risk factors and the causes of anastomotic leakage. Rather, the study focused on the relationship between postoperative management and the diagnosis of anastomotic leakage.
Methods Patients Patients who underwent low anterior resection for neoplasms of the rectum between January 2007 and December 2013 in Kochi Medical School Hospital, Japan, or between January 2009 and December 2013 in Hata Kenmin Hospital, Japan, were included in this study. The computerized medical records (both admission and outpatient records) of 179 patients were retrospectively reviewed and 26 patients with anastomotic leakage after low anterior resection were identified. Operative and postoperative management and follow-up Low anterior resection was performed with total mesorectal excision or tumor-specific mesorectal excision [5] and regional lymphadenectomy. End-to-end anastomosis was performed by using the double-stapling technique, and cases which necessitated transanal coloanal anastomosis were excluded from this study. In both institutes, the need for stoma creation was
Clinical characteristics of the patients with anastomotic leakage following LAR of the rectum
Clinical characteristics Anastomotic leakage (% of cases)
Age (year) Gender Tumor Stage Body mass index (kg/m2) Operation time (min) Estimated Blood loss (ml) Defunctioning ileostomy (% of cases)a Interval between operation and anastomotic leakage (days) Diagnostic sign
Relaparotomy (% of cases)
LAR low anterior resection a
Defunctioning ileostomy at the initial operation
Total Kochi Medical School Hospital Hata-Kenmin Hospital Median (range) Mean±SD Female/Male
14.5 % (26/179) 15.5 % (18/116) 12.7 % (8/63) 64 (35–84) 66.1±10.9 6/20
I/II/III/IV Mean±SD Mean±SD Mean±SD
7/11/5/3 22.8±2.20 282.0±93.3 225.5±300.0 15.4 % (4/26) 3.5 (1–20) 4.2±3.6 92.3 % (24/26) 3.8 % (1/26) 3.8 % (1/26) 34.6 % (9/26) 22.2 % (4/18) 62.5 % (5/8)
Median (range) Mean±SD Fecal contamination of drain Fever, abdominal pain Discharge from drain site Total Kochi Medical School Hospital Hata-Kenmin Hospital
Int J Colorectal Dis (2015) 30:831–834
833
Diagnosis of anastomotic leakage The diagnosis of anastomotic leakage was comprehensively made based on the content of the drainage tube, fever, abdominal pain, physical examination, and the results of computed tomography (CT). Rectal contrast enemas were not routinely performed to detect clinically asymptomatic anastomotic leakage (grade A anastomotic leakage [6]). Statistical analysis
Fig. 1 Histogram of patients with anastomotic leakage. The majority of the cases were diagnosed within 7 days after the operation; only one case was diagnosed later, on the 20th postoperative day
To find the relationship between the day of leakage diagnosis and the other clinical variables, unpaired t tests and correlation were performed using Microsoft Office Excel (Microsoft, Redmond, WA) and Kaleida Graph version 4.0 (Synergy Software, Reading, PA). A P value of less than 0.05 was considered to be statistically significant.
Results determined by each individual surgeon before or during the operation, without stipulation of a clear criterion. Water intake was usually allowed on the first postoperative day, and oral intake of solid food was initiated from the third to fifth postoperative day onward according to the surgeon’s decision. In all cases, at the end of the operation, a transcutaneous pelvic drainage tube was placed with the tip of the tube at the bottom of the pelvic cavity. The tube was removed after the start of oral intake, which was usually on the fourth to sixth postoperative day. When the postoperative course was uneventful, the patients were allowed to leave the hospital 10 to 14 days after the operation. After hospital discharge, all patients were periodically monitored for complications and tumor recurrence. Table 2
The characteristics of the patients with anastomotic leakage are summarized in Table 1. The median age was 64 years (range, 35–84 years) and male gender was predominant. The median interval between the operation and the diagnosis of anastomotic leakage was 3.5 days (range, 1 to 20 days). Most cases of anastomotic leakage were diagnosed within 7 days (Fig. 1) and the diagnosis was usually (24/26 cases) based on fecal contamination of the drainage tube. One case was diagnosed after hospital discharge; on the 20th postoperative day, the patient showed clinical signs of anastomotic leakage (sudden onset of fever, lower abdominal pain, and pain on urination). There was no significant relationship between the day of diagnosis and gender (P=0.72), use of defunctioning ileostomy at
Differences in surgical methods, postoperative managements, and consequences among three different studies
Study
Floodeen et al. [3]
Morks et al. [4]
Current study
Grade of anastomotic leakagea Number of cases of anastomotic leakage Definition of late anastomotic leakage % of late anastomotic leakage Frequently used anastomosis Defunctioning stoma Use of pelvic drainage Duration Common methods of diagnosis
Symptomatic (grades B, C) 45
All Grades (grades A–C) 28
Symptomatic (grades B, C) 26
Diagnosed after hospital discharge 40 % Not described 22 % 98 % Not described Rectal contrast study, CT
Diagnosed >30 days after operation 32 % SEA>EEA 46 % Not described Not described Physical examination, CT
Diagnosed >30 days after operation 0% EEA 15.4 % All cases 4–7 days when uneventful Drainage tube
SEA side-to-end anastomosis, EEA end-to-end anastomosis a
The International Study Group of Rectal Cancer classified anastomotic leakage into three categories. Grade A is asymptomatic anastomotic leakage, which is detected only on the imaging modalities. Grade B requires therapeutic intervention except laparotomy. Grade C requires relaparotomy
834
Int J Colorectal Dis (2015) 30:831–834
the initial operation (P=0.60), body mass index (P=0.182), operation time (P=0.50), or estimated blood loss (P=0.98).
In conclusion, we consider that the majority of cases of late anastomotic leakage are the late manifestation of early subtle anastomotic leakage rather than a distinct entity.
Discussion
Acknowledgments The authors thank Dr. Toshichika Kanagawa for supporting this research.
The present study revealed that the occurrence of late anastomotic leakage was quite rare in our two hospitals. Among the 26 cases of anastomotic leakage, there was no case of late anastomotic leakage according to the definition of diagnosis more than 30 days after the operation. Because these two hospitals recommended periodical follow-up and the majority of the patients followed the instruction, the probability that late anastomotic leakage was overlooked was quite low. We consider that the most significant difference between the previous two studies and ours is the length of time that the pelvic drainage tube was kept in place (Table 2). In our institutes, in all cases, a pelvic drainage tube was placed at the end of the operation. Usually, the drainage tube was used at least until the initiation of oral intake, which was 4 to 6 days after the operation. In their study, Floodeen et al. [3] stated that 98 % of the patients (44 out of 45 patients) received pelvic drainage. Although the timing of its removal was not clearly described, we speculate that the drainage tube was removed quite early after the operation because diagnosis of early anastomotic leakage largely relied on radiological modalities (CT scanning and/or rectal contrast enemas), digital palpation, and rectoscopy. Morks et al. [4] also described that the diagnosis of early leakage was based on the findings of physical examination and CT scans, suggesting early removal of the drainage tube or non-use of drainage tubes. Thus, the extended period of pelvic drainage tube placement in our institutes compared with those studied previously appears to have allowed us to detect cases of subtle anastomotic leakage before hospital discharge, which might have otherwise been detected after hospital discharge [2–4, 7]. Early diagnosis and swift treatment of anastomotic leakage is required to prevent fatal consequences. One solution is to retain the pelvic drainage tube for a longer time as in our institutes. In hospitals where the length of stay is quite short, hospital discharge with a drainage tube and continuous monitoring could be a choice; however, the risk of retrograde infection of the pelvis and incidental removal of the drainage tube should be taken into consideration. Another solution would be to find reliable biomarkers that predict anastomotic leakage early after the operation [8, 9]. Surgeons could also choose to make no anastomosis in patients with a higher risk of leakage or those in poor general condition.
Author contributions HM, KO, TA, MS, KD, and NK substantially contributed to acquisition of data, analysis, and interpretation of data. HM, TN, KH, and MK substantially contributed to study conception and design, analysis, interpretation of data, and writing the manuscript. All authors approved this manuscript. Conflicts of interest There is no conflict of interest.
References 1.
2.
3.
4.
5.
6.
7.
8.
9.
Snijders HS, Wouters MW, van Leersum NJ, Kolfschoten NE, Henneman D, de Vries AC, Tollenaar RA, Bonsing BA (2012) Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol 38:1013–1019 Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA (2007) Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg 245:254–258 Floodeen H, Hallböök O, Rutegård J, Sjödahl R, Matthiessen P (2013) Early and late symptomatic anastomotic leakage following low anterior resection of the rectum for cancer: are they different entities? Colorectal Dis 15:334–340 Morks AN, Ploeg RJ, Sijbrand Hofker H, Wiggers T, Havenga K (2013) Late anastomotic leakage in colorectal surgery: a significant problem. Colorectal Dis 15:e271–e275 Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, Killingback M, Lubowski DZ, Moore R, Penfold C, Savoca P, Stitz R, Tjandra JJ, American Society of Colon and Rectal Surgeons; Association of Coloproctology of Great Britain and Ireland; Coloproctology Surgical Society of Australia (2001) Consensus statement of definitions for anorectal physiology and rectal cancer. Colorectal Dis 3:272–275 Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S, den Dulk M, van de Velde C, Büchler MW (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147: 339–351 Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246:207–214 Pasternak B, Matthiessen P, Jansson K, Andersson M, Aspenberg P (2010) Elevated intraperitoneal matrix metalloproteinases-8 and -9 in patients who develop anastomotic leakage after rectal cancer surgery: a pilot study. Colorectal Dis 12:e93–e98 Fouda E, El Nakeeb A, Magdy A, Hammad EA, Othman G, Farid M (2011) Early detection of anastomotic leakage after elective low anterior resection. J Gastrointest Surg 15:137–144
