Rectal cancer surgery is still evolving and various resection techniques such as laparoscopy, robotics, or transanal minimally invasive surgery have been introduced (1). However, establishing intestinal continuity following tumor resection is an unchanged part of rectal cancer surgery (2). Colorectal anastomosis is performed by stapled or hand-sewn method between the proximal colon and rectal stump (3).
Anastomotic leakage is one of most devastating complication after rectal cancer resection. Anastomotic leakage compromises immediate postoperative outcomes and, although controversial, oncologic outcomes. Earlier studies have reported that anastomotic leakage increases local recurrence rate (4-6) or local and distant recurrence rates (7-9). In some studies, anastomotic leakage deteriorated overall (5,7,10) and disease-specific survivals (5,8,9). Recently, Hain et al. (11) investigated the impact of anastomotic leakage on oncological outcomes after rectal cancer surgery. Laparoscopic total mesorectal excision was performed in all patients (n=428) and anastomotic leakage was occurred in 120 patients (28%). Based on multivariate analyses, symptomatic anastomotic leakage was an independent risk factor for local recurrence-free survival (odds ratio =2.13). However, asymptomatic anastomotic leakage was not a meaningful risk factor for local recurrence-free survival. In their series, 28% of anastomotic leakage rate (symptomatic: n=70, 16% and asymptomatic: n=50, 12%) is somewhat high when compared to previous studies (12,13). This reason may be due to difference in definition of anastomotic leakage or study population.
Unfortunately, the mechanism for unfavorable survival rate has not been clearly elucidated. Potential mechanisms have been suggested that anastomotic leakage may cause implantation of occult tumor cells around the anastomosis site (14). Stress response following anastomotic leakage can suppress the function of cytotoxic T cells and natural killer cells and thereby promote cancer cell survival (15). Inflammatory reaction is related to cancer development and progression. Infectious condition by anastomotic leakage can induce systemic inflammatory response and thereby promote disease recurrence (16). In addition, anastomotic leakage may preclude appropriate adjuvant chemotherapy. Occurrence of postoperative complications such as anastomotic leakage is associated with the lack of chemotherapy or delayed commencement of chemotherapy (6). To understand the impact of anastomotic leakage on oncologic outcomes, underlying mechanism should be revealed. Future study should be directed to translational or prospective clinical studies.
Conflicts of Interest: The authors have no conflicts of interest to declare.
- Kim NK, Kim YW, Cho MS. Total mesorectal excision for rectal cancer with emphasis on pelvic autonomic nerve preservation: Expert technical tips for robotic surgery. Surg Oncol 2015;24:172-80. [Crossref] [PubMed]
- Kim IY, Kim BR, Kim YW. Applying reinforcing sutures to stapled colorectal anastomosis after low anterior resection for rectal cancer. Eur J Surg Oncol 2015;41:808-9. [Crossref] [PubMed]
- Kim YW, Kim IY. The new stapler device is good, but needs more evaluation. Ann Coloproctol 2014;30:59. [Crossref] [PubMed]
- Ptok H, Marusch F, Meyer F, et al. Impact of anastomotic leakage on oncological outcome after rectal cancer resection. Br J Surg 2007;94:1548-54. [Crossref] [PubMed]
- Branagan G, Finnis D. Wessex Colorectal Cancer Audit Working Group. Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum 2005;48:1021-6. [Crossref] [PubMed]
- Kim IY, Kim BR, Kim YW. The impact of anastomotic leakage on oncologic outcomes and the receipt and timing of adjuvant chemotherapy after colorectal cancer surgery. Int J Surg 2015;22:3-9. [Crossref] [PubMed]
- Kube R, Mroczkowski P, Granowski D, et al. Anastomotic leakage after colon cancer surgery: a predictor of significant morbidity and hospital mortality, and diminished tumour-free survival. Eur J Surg Oncol 2010;36:120-4. [Crossref] [PubMed]
- Eberhardt JM, Kiran RP, Lavery IC. The impact of anastomotic leak and intra-abdominal abscess on cancer-related outcomes after resection for colorectal cancer: a case control study. Dis Colon Rectum 2009;52:380-6. [Crossref] [PubMed]
- Law WL, Choi HK, Lee YM, et al. Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy. J Gastrointest Surg 2007;11:8-15. [Crossref] [PubMed]
- Marra F, Steffen T, Kalak N, et al. Anastomotic leakage as a risk factor for the long-term outcome after curative resection of colon cancer. Eur J Surg Oncol 2009;35:1060-4. [Crossref] [PubMed]
- Hain E, Maggiori L, Manceau G, et al. Oncological impact of anastomotic leakage after laparoscopic mesorectal excision. Br J Surg 2017;104:288-95. [Crossref] [PubMed]
- Paun BC, Cassie S, MacLean AR, et al. Postoperative complications following surgery for rectal cancer. Ann Surg 2010;251:807-18. [Crossref] [PubMed]
- Kim NK, Kim YW, Min BS, et al. Operative safety and oncologic outcomes of anal sphincter-preserving surgery with mesorectal excision for rectal cancer: 931 consecutive patients treated at a single institution. Ann Surg Oncol 2009;16:900-9. [Crossref] [PubMed]
- Walker KG, Bell SW, Rickard MJ, et al. Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer. Ann Surg 2004;240:255-9. [Crossref] [PubMed]
- Hensler T, Hecker H, Heeg K, et al. Distinct mechanisms of immunosuppression as a consequence of major surgery. Infect Immun 1997;65:2283-91. [PubMed]
- McMillan DC, Canna K, McArdle CS. Systemic inflammatory response predicts survival following curative resection of colorectal cancer. Br J Surg 2003;90:215-9. [Crossref] [PubMed]
Cite this article as: Kim YW, Kim BR. The influence of anastomotic leakage on patients’ outcomes after rectal cancer surgery. Ann Laparosc Endosc Surg 2017;2:89.