Laparoscopic surgery may decrease the risk of clinical anastomotic leakage and a nomogram to predict anastomotic leakage after anterior resection for rectal cancer

Hongtu Zheng,Zhenyu Wu,Sanjun Cai,Shanjing Mo,Weixing Dai,Ye Xu,Fangqi Liu,Yuchen Wu

doi:10.1007/s00384-018-3199-z

Abstract

IntroductionAnastomotic leakage is still one of the most dreaded complications after anterior resection for rectal cancer. This study aimed to identify risk factors for anastomotic leakage and to create a nomogram for precise prediction of anastomotic leakage after anterior resection for rectal cancer.MethodsTwo thousand six hundred eighteen consecutive patients who underwent anterior resection for rectal cancer with primary anastomosis, with or without diverting stoma, were retrospectively analyzed as a training dataset. Univariate and multivariable Cox regression analyses were used to determine independent risk factors associated with anastomotic leakage. A nomogram was constructed to predict anastomotic leakage. Data containing 611 patients were prospectively collected as a test dataset. The performance of the nomogram was evaluated by using a bootstrapped-concordance index and calibration plots.ResultsThe rate of clinical anastomotic leakage was 9.3% in the training dataset. Multivariate analysis identifies the following variables as independent risk factors for anastomotic leakage: gender (male) (odds ratio (OR) = 2.286), distance of tumor to anal verge (OR = 0.791), tumor size (OR = 1.175), operating time (OR = 1.009), diabetes mellitus (OR = 1.704), laparoscopic surgery (OR = 0.445), anastomotic bleeding (OR = 13.46), and diverting stoma (OR = 0.386). We created a nomogram with high discriminative ability (concordance index, 0.722). The area under the curve value, which evaluated the predictive performance of external validation, was 0.723.ConclusionsA protective diverting stoma and laparoscopic surgery significantly decrease the risk of anastomotic leakage. Our nomogram was a useful tool for precise prediction of anastomotic leakage after anterior resection for rectal cancer.

Highlights

Anastomotic leakage is still one of the most dreaded complications after anterior resection for rectal cancer
The following variables were found to be associated with Anastomotic leakage (AL) in univariate analysis: distance of tumor to anal verge, tumor size, duration of operation, preoperative hemoglobin level, blood loss, male, diabetes mellitus, bowel obstruction, ASA score, laparoscopic surgery, and anastomotic bleeding
The following variables were identified as independent risk factors of AL in multivariate analysis: gender (P < 0.0001, odds ratio (OR) = 2.286), distance of tumor to anal verge (P < 0.0001, OR = 0.791), tumor size (P = 0.006, OR = 1.175), operating time (P < 0.001, OR = 1.009), diabetes mellitus (P = 0.041, OR = 1.704), laparoscopic surgery (P = 0.004, OR = 0.445), anastomotic bleeding (P < 0.001, OR = 13.46), diverting stoma (P < 0.001, OR = 0.386) (Table 2)

Summary

Introduction

Anastomotic leakage is still one of the most dreaded complications after anterior resection for rectal cancer. The incidence of colorectal cancer has significantly increased [1]. Anterior resection (AR), as known as Dixon operation, is the major surgical treatment for rectal cancer. Anastomotic leakage (AL) is still the most dreaded surgical complication following AR, with an incidence rate of 1.6–20.5% [2,3,4,5,6,7,8,9,10,11]. Studies have shown that AL increases local recurrence rates and reduces cancer-specific survival [12, 16], which may be due to a delay of adjuvant therapy in patients with AL

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