Anastomotic leak in colorectal surgery: a single surgeon's experience.

BACKGROUND: Anastomotic leakage following colorectal resection and anastomosis has been proposed as a colorectal surgical indicator. Leak rates after elective surgery vary and tend to be higher as anastomoses become lower. The present study audits leak rates and outcomes of patients undergoing colorectal surgery, under the care of a single surgeon, in two geographically different centres.

METHODS: Patients presenting to the University Colorectal Service in Wellington between 1975 and 1990 and patients presenting to the colorectal service at King Faisal Specialist Hospital (KFSH) between 1990 and 1999 were recorded in computerized databases. These databases were searched for patients who developed anastomotic leakage. The records of patients identified were examined in relation to diagnoses, presentation, primary operation, further surgery performed, and final outcome.

RESULTS: Two thousand and 11 patients were entered into the Wellington database and 1,348 were entered into the Riyadh database. Twenty-nine patients with a leaking anastomosis (3.6%) were identified. There were 19 male patients. The postoperative mortality rate in patients who did not leak was 1.7% but in patients who developed a leak after the same operation this rate was 24.1%. Most patients who sustained a leak had an original diagnosis of colorectal cancer. More non-leaking anastomoses were sutured. Sixteen patients with leaks (55.2%) received perioperative total parenteral nutrition (TPN) (9.2% in the no-leak group). Leaking anastomoses were associated with more postoperative respiratory problems (55.2% vs 24.0%) and wound infections (65.5% vs 14.8%). Of the 22 living patients, seven had no surgical intervention, 14 had stomata (two stomata were retained) and one patient with a localized leak was drained percutaneously. Five other patients in addition to having a stoma constructed were drained percutaneously. No patient developed an enteric fistula following leakage.

CONCLUSION: Anastomotic leakage may be minimized by ensuring that patients are as fit as possible prior to surgery, stomata are used liberally, particularly in emergency patients, and a good anastomotic technique is utilized at all times. Despite these precautions some patients will still develop a leak and if timely and appropriate action is taken the majority will survive and have their stomata closed.