Elsevier

Surgery

Volume 162, Issue 5, November 2017, Pages 1006-1016
Surgery

Colon/Rectum
Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: An institutional analysis of 800 patients

https://doi.org/10.1016/j.surg.2017.05.023Get rights and content

Background

Our aim was to assess whether the individual surgeon is an independent risk factor for anastomotic leak in double-stapled colorectal anastomosis after left colon and rectal cancer resection.

Methods

This retrospective analysis of a prospectively collected database consists of a consecutive series of 800 patients who underwent an elective left colon and rectal resection with a colorectal, double-stapled anastomosis between 1993 and 2009 in a specialized colorectal unit of a tertiary hospital with 7 participating surgeons. The main outcome variable was anastomotic leak, defined as leak of luminal contents from a colorectal anastomosis between 2 hollow viscera diagnosed radiologically, clinically, endoscopically, or intraoperatively. Pelvic abscesses were also considered to be an anastomotic leak. Radiologic examination was performed when there was clinical suspicion of leak.

Results

Anastomotic leak occurred in 6.1% of patients, of which 33 (67%) were treated operatively, 6 (12%) with radiologic drains, and 10 (21%) by medical treatment. Postoperative mortality rate was 2.9% for the whole group of 800 patients. In patients with anastomotic leak, mortality rate increased up to 16% vs 2.0% in patients without anastomotic leak (P < .0001). At multivariate analysis, rectal location of tumor, male sex, bowel obstruction preoperatively, tobacco use, diabetes, perioperative transfusion, and the individual surgeon were independent risk factors for anastomotic leak. The surgeon was the most important factor (mean odds ratio 4.9; range 1.0 to 13.5). The variance of anastomotic leak between the different surgeons was 0.56 in the logit scale.

Conclusion

The individual surgeon is an independent risk factor for leakage in double-stapled, colorectal, end-to-end anastomosis after oncologic left-sided colorectal resection.

Section snippets

Design, patients, and variables

Since 1993, the Multidisciplinary Colorectal Cancer Group of our Unit at a tertiary University Hospital has maintained a prospective database of all patients operated on for colorectal diseases. From January 1993 to December 2009, 1,598 patients were operated on electively at our unit for colorectal cancer, with curative intent. After exclusion of 487 patients with right or transverse colon cancer and 311 patients with no anastomosis or coloanal manual anastomosis, 800 consecutive patients who

Results

The present analysis included 800 patients with a mean age of 66.7 years; 385 patients (48.1%) presented left-sided or sigmoid colon cancer, while 415 had rectal cancer of which 156 (19.5%) were rectal cancer of the upper third, 173 (21.6%) of the mid third, and 86 (10.8%) of the lower third. Demographic, tumor, and operative data are detailed in Table I. Table II details patient data for each surgeon.

Anastomotic leak was diagnosed in 49 patients (6.1%), 11 of whom had a loop ileostomy

Discussion

In the present analysis, the individual surgeon is one of the most important independent risk factors for anastomotic leak in double-stapled colorectal anastomosis after cancer resection. In addition, several patient-related factors, such as male sex, malnourishment, and recent weight loss, hypoalbuminemia, high American Society of Anesthesiologists score, hypertension, obesity, smoking, and alcohol use have been associated previously with an increased risk of AL.10, 21, 22, 23, 24 Moreover,

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