Abstract
Background
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.
Methods
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.
Results
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/m2 (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.
Conclusion
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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References
Polliand C, Barrat C, Champault G (2005) Laparoscopic resection of low rectal cancer with a mean follow-up of seven years. Surg Laparosc Endosc Percutan Tech 15:144–148
Kim SH, Park IJ, Joh YG, Hahn KY (2006) Laparoscopic resection for rectal cancer: a prospective analysis of thirty-month follow-up outcomes in 312 patients. Surg Endosc 20:1197–1202
Kuroyanagi H, Akiyoshi T, Oya M, Fujimoto Y, Ueno M, Yamaguchi T, Muto T (2009) Laparoscopic-assisted anterior resection with double-stapling technique anastomosis: safe and feasible for lower rectal cancer? Surg Endosc 23:2197–2202
Milsom JW, de Oliveira O, Trencheva KI Jr, Pandey S, Lee SW, Sonoda T (2009) Long-term outcomes of patients undergoing curative laparoscopic surgery for mid and low rectal cancer. Dis Colon Rectum 52:1215–1222
Lujan J, Valero G, Hernandez Q, Sanchez A, Frutos MD, Parrilla P (2009) Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer. Br J Surg 96:982–989
Ströhlein MA, Grützner KU, Jauch KW, Heiss MM (2008) Comparison of laparoscopic vs. open access surgery in patients with rectal cancer: a prospective analysis. Dis Colon Rectum 51:385–391
Scheidbach H, Schneider C, Konradt J, Bärlehner E, Köhler L, Wittekind Ch, Köckerling F (2002) Laparoscopic abdominoperineal resection and anterior resection with curative intent for carcinoma of the rectum. Surg Endosc 16:7–13
Branagan G, Finnis D, Wessex Colorectal Cancer Audit Working Group (2005) Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum 48:1021–1026
den Dulk M, Marijnen CA, Collette L, Putter H, Påhlman L, Folkesson J, Bosset JF, Rödel C, Bujko K, van de Velde CJ (2009) Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg 96:1066–1075
Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P (2011) Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 253:890–899
Kawada K, Hasegawa S, Hida K, Hirai K, Okoshi K, Nomura A, Kawamura J, Nagayama S, Sakai Y (2014) Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis. Surg Endosc 28:2988–2995
Kim JS, Cho SY, Min BS, Kim NK (2009) Risk factors for anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique. J Am Coll Surg 209:694–701
Akiyoshi T, Ueno M, Fukunaga Y, Nagayama S, Fujimoto Y, Konishi T, Kuroyanagi H, Yamaguchi T (2011) Incidence of and risk factors for anastomotic leakage after laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis for rectal cancer. Am J Surg 202:259–264
Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N (2008) Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection. Int J Colorectal Dis 23:703–707
Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:1–6
Wells GA, Shea B, O’Connell D (2006) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. Ottawa Health Research Institute (OHRI), Ottawa
Higgins JPT, Green S (eds) (2009) Cochrane handbook for systematic reviews of interventions. Version 5.0.2. Wiley, New York. The Cochrane Collaboration. www.cochrane-handbook.org. Accessed 2008 June
Park JS, Choi GS, Kim SH, Kim HR, Kim NK, Lee KY, Kang SB, Kim JY, Lee KY, Kim BC, Bae BN, Son GM, Lee SI, Kang H (2013) Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg 257:665–671
Yamamoto S, Fujita S, Akasu T, Inada R, Moriya Y, Yamamoto S (2012) Risk factors for anastomotic leakage after laparoscopic surgery for rectal cancer using a stapling technique. Surg Laparosc Endosc Percutan Tech 22:239–243
Choi DH, Hwang JK, Ko YT, Jang HJ, Shin HK, Lee YC, Lim CH, Jeong SK, Yang HK (2010) Risk factors for anastomotic leakage after laparoscopic rectal resection. J Korean Soc Coloproctol 26:265–273
Huh JW, Kim HR, Kim YJ (2010) Anastomotic leakage after laparoscopic resection of rectal cancer: the impact of fibrin glue. Am J Surg 199:435–441
Joh YG, Kim SH, Hahn KY, Stulberg J, Chung CS, Lee DK (2009) Anastomotic leakage after laparoscopic protectomy can be managed by a minimally invasive approach. Dis Colon Rectum 52:91–96
Kang J, Lee HB, Cha JH, Hur H, Min BS, Baik SH, Kim NK, Sohn SK, Lee KY (2013) Feasibility and impact on surgical outcomes of modified double-stapling technique for patients undergoing laparoscopic anterior resection. J Gastrointest Surg 17:771–775
Ning W, Meng FQ, Pei DP, Qin L, Wang WY (2012) Analysis of risk factors for anastomotic leakage after laparoscopic radical resection on rectal cancer. J China Jpn Friendsh Hosp 26:265–267
Zhang CS, Cai FB, Wei D (2012) Analysis of risk factors for anastomotic leakage in laparoscopic anterior resection of rectal cancer. J Henan Univ Sci Technol 30:253–254
Hidaka E, Ishida F, Mukai S, Nakahara K, Takayanagi D, Maeda C, Takehara Y, Tanaka JI, Kudo SE (2014) Efficacy of transanal tube for prevention of anastomotic leakage following laparoscopic low anterior resection for rectal cancers: a retrospective cohort study in a single institution. Surg Endosc. doi:10.1007/s00464-014-3740-2
Zhao HF, Wang ZG, Ruan CP (2013) Prevention and management of anastomotic leakage following laparoscopic low anterior resection for rectal cancers. Zhejiang J Trauma Surg 18:102–104
Paun BC, Cassie S, MacLean AR, Dixon E, Buie WD (2010) Postoperative complications following surgery for rectal cancer. Ann Surg 251:807–818
Kang CY, Halabi WJ, Chaudhry OO, Nguyen V, Pigazzi A, Carmichael JC, Mills S, Stamos MJ (2013) Risk factors for anastomotic leakage after anterior resection for rectal cancer. JAMA Surg 148:65–71
Whelan RL, Franklin M, Holubar SD, Donahue J, Fowler R, Munger C, Doorman J, Balli JE, Glass J, Gonzalez JJ, Bessler M, Xie H, Treat M (2003) Postoperative cell mediated immune response is better preserved after laparoscopic vs open colorectal resection in humans. Surg Endosc 17:972–978
Jörgren F, Johansson R, Damber L, Lindmark G (2011) Anastomotic leakage after surgery for rectal cancer: a risk factor for local recurrence, distant metastasis and reduced cancer-specific survival? Colorectal Dis 13:272–283
Kuroyanagi H, Oya M, Ueno M, Fujimoto Y, Yamaguchi T, Muto T (2008) Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection. Surg Endosc 22:557–561
Hilsabeck JR (1982) The presacral space as a collector of fluid accumulations following rectal anastomosis: tolerance of rectal anastomosis to closed suction pelvic drainage. Dis Colon Rectum 25:680–684
Peeters KC, Tollenaar RA, Marijnen CA, ranenbarg EK, Steup WH, Wiggers T, Rutten HJ, van de Velde CJ, Dutch Colorectal Cancer Group (2005) Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 92:211–216
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
Eriksen MT, Wibe A, Norstein J, Haffner J, Wiig JN, Norwegian Rectal Cancer Group (2005) Anastomotic leakage following routine mesorectal excision for rectal cancer in a national cohort of patients. Colorectal Dis 7:51–57
Lefebure B, Tuech JJ, Bridoux V, Costaglioli B, Scotte M, Teniere P, Michot F (2008) Evaluation of selective defunctioning stoma after low anterior resection for rectal cancer. Int J Colorectal Dis 23:283–288
Hüser N, Michalski CW, Erkan M, Schuster T, Rosenberg R, Kleeff J, Friess H (2008) Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg 248:52–60
Acknowledgments
This study was supported by Grants from National Natural Science Foundation of China (No. 81301790). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Disclosures
Drs. Hui Qu, Yao Liu, and Dong-song Bi have no conflicts of interest or financial ties to disclose.
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Qu, H., Liu, Y. & Bi, Ds. Clinical risk factors for anastomotic leakage after laparoscopic anterior resection for rectal cancer: a systematic review and meta-analysis. Surg Endosc 29, 3608–3617 (2015). https://doi.org/10.1007/s00464-015-4117-x
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DOI: https://doi.org/10.1007/s00464-015-4117-x