Page 13 - Laparoscopic Journal - WJOLS

WJOLS

Anastomotic Leak in Laparoscopic Colorectal Surgery: Risk Factors and Prevention
multiple firings of the linear stapler, were significantly suggested a negative role of blood transfusions in the
37
associated with AL. Most probably, it will affect the outcome of patients with cancer. 19-22 Blood transfusions
blood supply to the anastomotic site. lead to depression of the immune system increasing the
Several studies confirmed that laparoscopic colorectal risk of postoperative infectious complications and the
surgery improved early postoperative outcomes in terms incidence of anastomotic fistulas. Study showed that
of reduced intraoperative blood loss, postoperative pain, blood transfusions increase the incidence of anastomotic
23
ileus and hospital stay. 8-10 abscess and poor healing of anastomoses. Study also
found that postoperative blood transfusion is an inde-
Men vs Women pendent predictive factor for anastomotic leakage. 24

Anastomotic leakage after colorectal anastomosis was American Society of
reported to be more common for men. Law et al reported Anesthesiologists (ASAs) Score
in their study male gender as a risk factor for AL after
11
low anterior resection. Rullier et al have showed that Most authors, the American Society of Anesthesiologists
fistula was 2.7 times higher in men compared to women (ASAs) score ≥ 3 was associated with an increased risk
after analyzing variables associated with AL in 272 con- for anastomotic leak. 25-28 Around the 2.5 times increased
6
secutive anterior resections. A systematic review and risk of anastomotic leak with every unit increase in the
29
meta-analysis of 4,580 patients and an analysis of 753 ASA score. Another author confirmed high ASA grade
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patients showed that men more to have anastomotic leak as independent risk factor for anastomotic leak. Medical
than women. 36,38 Lipska et al also showed in a study of comorbidities (pulmonary, cardiac, renal) are risk factor
541 patients that men are at a higher risk. The rate of AL for AL.
increases in men with previous abdominal surgery, rectal
cancer lower than 12 cm from the anal verge or prolonged operation Time
operating time. The risk of AL increased when two or Operating time ≥ 180 minutes identified as a risk factor.
more risk factors were present. 12
neoadjuvant Therapy and Steroid Therapy
Body Mass Index
Neoadjuvant therapy tended to be associated with the
Most of studies reported that body mass index (BMI) ≥ 25 development of AL. Preoperative chemotherapy reported
38
is risk factor for AL. 38 as risk factor for anastomotic leak. Chronic steroid therapy
was significantly associated with leaks. 14,18,31,32 In a study
Malnutritions
showed that, the incidence of AL was significantly higher in
Malnutrition can affect the healing process of the anasto- seven patients treated with long-term corticosteroids (50%
mosis. A study showed that significant effects on colonic leak) and in patients taking corticosteroids peroperatively
AL and wound infection can occur only with severe (19% leak). 33
13
degrees of malnutrition. Malnutrition exerts an adverse
effect on tissue healing by affecting processes, such as oTheR FACToRS
collagen synthesis or synthesis of sulfated mucopolysac- Data analysis demonstrated that AL was more common
charides or affecting fibroblast proliferation. Some studies in patients with tobacco abuse. Not significant with
have showed a relationship between preoperative serum Alcohol abuse. 36
albumin level and the occurrence of anastomotic fistulas
and the reduction of value of serum albumin in 5th POD ConCLuSIon
were the factors that were associated significantly with Colorectal anastomotic leak is one of the most common
the development of clinical AL. 6 complications of laparoscopic colorectal surgeries. In
Study reported a rate of 6.9% of fistula in patients with conclusion, tumor location ≤ 6 cm from the anal verge,
albumin level less than 3 mg/dl, and 2.8% incidence of tumor size > 5 cm, preservation of the left colic artery,
fistulae for the patients with the level of serum albumin male gender, severe malnutrition, BMI ≥ 25, preopera-
14
higher. Several studies reported a preoperative serum tive Neoadjuvant therapy and steroid therapy, ASA score
albumin level less than 3.5 g/dl to be a significant risk ≥ 3, tobacco abuse, operating time ≥ 180 minutes, pre-
factor for anastomotic leaks. 15-18 compression before stapler firing and multiple firing of
the stapler are associated with increase the risk of deve-
hemoglobin and Blood Transfusion
loping AL. On the other hand, Improve nutritional status,
The level of hemoglobin preoperatively and in 5th POD control comorbidities, stop smoking at least 2 weeks

was not significant risk factors. Recent studies have before surgery and preoperative use of mechanical bowel
World Journal of Laparoscopic Surgery, May-August 2015;8(2):43-47 45