Management of anastomotic leakage after nondiverted large bowel resection

Background: The purpose of this study was to determine the natural history of anastomotic leakage after elective colorectal resection and supraperiton eal anastomosis without temporary stoma. Study Design: Medical records from 1990 to 1997 were studied; 655 consecuti ve patients underwent colonic or rectal resection (without stoma). Patients were divided into two groups: those with clinical anastomotic leakage conf irmed by laparotomy (group 1) and those without anastomotic leakage (group 2). postoperative clinical and biologic findings were compared between the two groups. Results: Anastomotic leakage occurred in 39 of 655 patients (6%). Clinicall y suspected anastomotic leakage was only confirmed by contrast radiography in 13 of 24 patients (54%), and by CT in 8 of 9 patients (89%). Significant ly more patients in group 1 than group 2 had the following: fever (> 38 deg rees C) on day 2 (p < 0.001); absence of bowel action on day 4 (p < 0.001); diarrhea before day 7 (p < 0.001); collection of more than 400 mt of fluid through abdominal drains from day 0 to day 3 (p < 0.01); renal failure on day 3 (p < 0.02); and leukocytosis after day 7 (p < 0.02). Among the 39 pat ients in group 1, 28 (71%) had at least one of these clinical or biologic m anifestations before day 5, but the mean delay for reoperation was only 8 d ays. The combination of signs observed before day 5 was associated with an increased risk of anastomotic leakage, from 18% with two signs to 67% with three signs. Overall mortality rate was 2% (13 of 655) and was significantly higher in g roup 1 than group 2: 5 of 39 (13%) versus 8 of 616 (1%, p < 0.001). In pati ents with anastomotic leakage, death occurred in 5 of 23 patients (22%) reo perated on after day 5, versus 0 of 11 patients (0%) reoperated on before d ay 5 (NS). Univariate anal)Isis showed that three clinical characteristics were associated with a significantly high risk of monality after reoperatio n for anastomotic leakage: age greater than 65 years (p < 0.01), American A nesthesiologist Association score greater than 3 (p < 0.05), and blood tran sfusions during the first operation (p < 0.02). Conclusions: In our study, some postoperative clinical and biologic signs w ere associated with a higher risk of anastomotic leakage. The knowledge of these findings might help in the early diagnosis and management of patients with anastomotic leakage after large bowel resection. (J Am Coll Surg 1999 ;189:554-559. (C) 1999 by the American College of Surgeons).