Risk factors for anastomotic leakage after low anterior resection without diversional stomas*

Abstract

Abstract Objective The most important complication after low anterior resection (LAR) for mid-low rectal cancer is symptomatic anastomotic leakage (AL). More than one-third of patients with rectal cancer who underwent LAR will have functional stomas during primary operation. The aim of this retrospective study was to evaluate the risk factors associated with clinical AL following LAR without diversional stomas. Methods Between 2012 and 2017, information about 578 consecutive patients with rectal tumors less than 12 cm from the anal verge who underwent LAR without diversional stomas by the same surgical team was collected retrospectively. A standardized extraperitonealized anastomosis and pelvic drainage were conducted for all patients during primary operations, and the outcome of interest was clinical AL. The associations between AL and 14 patient-related and surgical variables were examined by both univariate chi-square test and multivariate logistic regression analysis. Results The AL rate was 7.27% (42 of 578). Univariate and multivariate analyses showed that male sex (P = 0.018), mid-low rectal cancer (located 10 cm or less above the anal verge) (P = 0.041), presence of diabetes (odds ratio = 2.117), longer duration of operation (odds ratio = 1.890), and intraoperative contamination (odds ratio = 2.163) were risk factors of AL for LAR without diversional stoma and independently predictive of clinical AL. Nearly 83.3% (35 of 42) of leakage could be cured by persistent pelvic irrigation-suction-drainage without surgical intervention. Only 7 patients (16.7%) with severe complications, such as peritonitis, and fistula, required reoperation, and functional stoma was used as a salvage treatment. Conclusion From the findings of this retrospective survey, we identified that mid-low rectal cancer and male sex were independent risk factors for developing clinical AL after LAR without diversional stomas, as well as longer duration of operation, presence of diabetes, and contamination of the operative field. Moreover, we deemed that LAR without diversional stomas for mid-low rectal cancers was safe, effective, and feasible. Extraperitonealized anastomosis and pelvic drainage obtained a relatively low rate of AL and avoided unnecessary functional stomas. Pelvic irrigation-suction-drainage was an effective procedure to resolve AL, and functional stoma was potentially used as a salvage modality for serious leakage.