Minimally invasive colectomy and the risk of anastomotic leak

Introduction

With the current development of robotic assisted, natural orifice and single-incision surgery, the finer details of the original minimally invasive surgery are being explored with comparisons made to open surgery. This is of unquestionable importance for the continued development of the laparoscopic approach for better patient care. In March 2016, this journal published a paper entitled “Risk of anastomotic leak after laparoscopic versus open colectomy” in which the authors proposed a reduced odds of developing an anastomotic leak with laparoscopic surgery in a cohort of 23,568 patients undergoing colectomy (1). The results were compelling read but how realistic is the conclusion that the operative approach can alter intestinal healing?

The nature of leaks

Anastomotic leaks contribute significantly to patient morbidity and mortality and thus are the most dreaded complications following colectomy. Leaks often present in the initial postoperative phase, heralded by abdominal pain, pyrexia, and haemodynamic changes or instability or, on occasion, by more subtle indicators such as failure to progress or prolonged gastrointestinal quiescence (2). Quoted rates of leak range from 2–23% (1,3,4) with a mortality of 5–16% (2,3,5).

Multifactorial risk factors and heterogeneity of diagnosis, management and even in definition of anastomotic leaks combined with primarily retrospective available data make the assessment of this topic difficult (1,6). To each surgeon, the definition of an anastomotic leak is often clear in their understanding with a combination of clinical signs, laboratory, and radiological or re-operative findings (6,7). A definition may not necessarily align appropriate diagnosis with management. Should leaks be defined, for example, as a breach of the surgical junction of hollow viscera with or without active output, then logically it must be proven radiologically or operatively with the first step being clinical suspicion (6). This latter entity remains constant however the lack of specificity leads to a list of clinical signs including abdominal pain or distention, peritonitis, tachycardia or arrhythmia, pyrexia and drain output (faecal, purulent).

Routine postoperative blood tests may yield a leukocytosis or elevated C-Reactive protein (8). CT scan may not yield a radiological leak (3,9,10). Scoring or grading systems for risk prediction, diagnosis and stratification for management purposes are available (3,8,11,12).

Management will be driven by the suspicion or proof of a leak guided by surgical opinion, experience, and patient conditions. At this point the most important treatment window (of prevention) has already passed. Is this where choosing laparoscopy can assist in avoiding leaks?

Leak risks

Risk factors for leaks are multifactorial and can be recognised as patient, operation or surgeon specific. Preoperative non-modifiable risk factors include male gender, metastatic disease, comorbidities (ASA score >2) (4-6,13,14). Patients with significant comorbidities may not be selected for laparoscopic approach due to the longer length of anesthetic required in some cases. Modifiable patient risk factors include smoking cessation, obesity reduction, alcohol cessation, minimising immune modulating agents, non-steroidal anti-inflammatory drugs and reversing malnutrition (4,13). Optimisation and modifications made may profoundly improve patient overall conditions and thus reduce the risk of anastomotic leak.

Operative factors that are case specific include more distal anastomoses and emergency surgery which may cause a surgeon to decide upon an open procedure or more likely to fashion a defunctioning stoma. Increased inotropic support has been implicated with anastomotic leak as is increased blood loss and blood transfusion (4). Once again healthier patients will land on the more favourable side of these factors being more resilient, requiring less inotropic support, or blood transfusion. Operative time is a risk factor for leaks although this could be related to other factors such as the use of laparoscopy or indeed the surgeon’s workload and proficiency (13).

Surgical technique provides multiple potential pitfalls for anastomotic leak to occur. A well trained surgeon will know to limit anastomotic tension, ischemia, contamination, operative time, blood loss and hypothermia. Limiting these factors will logically contribute to a better anastomosis. However, anastomotic tension, ischemia, and local contamination may be difficult to objectively measure (6,15). Proficiency in technique is often attributed to the surgeon’s experience, caseload, and level of institutional care (16,17). A hand sewn anastomosis may have an increased rate of leak versus stapled ileocolic anastomoses, however this is controversial as shown within a recent observational study of 3,208 patients (18,19). Leak limiting techniques such as omentoplasty or mesenteric buttressing are often employed by specialist surgeons (20,21).

Laparoscopic confounders

The heterogeneity of definition, diagnosis, and management of anastomotic leaks combined with complex interaction of patient and operative factors causing leaks can lead to challenges in research to establish laparoscopic superiority on this topic. Studies of laparoscopy versus open bowel resections tend to be observational and retrospective carrying a risk of selection bias by matching surgical approach to individual patients, and information biases caused by under-reporting of complications and coding differences. Randomised control trials do not show significant superiority (22,23).

Many articles supporting the superiority of laparoscopy in preventing anastomotic leaks will also recognise major confounders amongst patient groups (1). In general, patients offered laparoscopy are younger with fewer comorbidities. Despite the cost effectiveness of laparoscopy and development of affordable reusable equipment, centres that offer specialised laparoscopic surgery tend to be more widely available in wealthy populations globally (24,25). These factors provide a selection bias which should be considered.

Could laparoscopy prevent leaks?

When one considers the benefits laparoscopy provides to each patient, an improvement in specific general outcomes may in fact contribute to specific outcomes (26). Laparoscopy allows for faster recovery time and thus shorter hospital stay (27,28). The requirement of less opiate analgesia due to minimal invasive approaches allows for faster intestinal and overall recovery (29,30).

Lower immune dysfunction and faster normalisation of the surgical stress response with laparoscopy may assist with anastomotic healing and integrity (31). Microbiome alterations and bacterial translocation can be less with laparocopic surgery to assist with recovery and prevent infective or inflammatory progression (32,33). Warmed carbon dioxide sometimes provided by laparoscopy potentially leads to less peritoneal injury having been associated with decreased clinical complications including anastomotic leaks (34).

The optimisation of these factors may be the major contributors to anastomotic success however they are difficult to assess objectively and in isolation. Advances in technology such as enhanced angiographic imaging can provide quality feedback at the time of anastomotic creation (35). Other methods of answering the specific questions relating to anastomotic leak will need to be developed to truly establish superiority on this multifaceted topic.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned and reviewed by the Section Editor Wanglin Li (Department of Gastrointestinal Surgery, Guangzhou First People’s Hospital, Guangzhou Medical University, Guangzhou Digestive Disease Center, Guangzhou, China).

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ales.2017.07.11). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Murray AC, Chiuzan C, Kiran RP. Risk of anastomotic leak after laparoscopic versus open colectomy. Surg Endosc 2016;30:5275-82. [Crossref] [PubMed]
2. Hyman N, Manchester TL, Osler T, et al. Anastomotic Leaks After Intestinal Anastomosis: It's Later Than You Think. Ann Surg 2007;245:254-8. [Crossref] [PubMed]
3. Gessler B, Eriksson O, Angenete E. Diagnosis, treatment, and consequences of anastomotic leakage in colorectal surgery. Int J Colorectal Dis 2017;32:549-56. [Crossref] [PubMed]
4. McDermott FD, Heeney A, Kelly ME, et al. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg 2015;102:462-79. [Crossref] [PubMed]
5. Bakker IS, Grossmann I, Henneman D, et al. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014;101:424-32. [Crossref] [PubMed]
6. Kingham TP, Pachter HL. Colonic Anastomotic Leak: Risk Factors, Diagnosis, and Treatment. J Am Coll Surg 2009;208:269-78. [Crossref] [PubMed]
7. Bruce J, Krukowski ZH, Al-Khairy G, et al. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg 2001;88:1157-68. [Crossref] [PubMed]
8. Rahbari NN, Weitz J, Hohenberger W, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: A proposal by the International Study Group of Rectal Cancer. Surgery 2010;147:339-51. [Crossref] [PubMed]
9. Nicksa GA, Dring RV, Johnson KH, et al. Anastomotic leaks: what is the best diagnostic imaging study? Dis Colon Rectum 2007;50:197-203. [Crossref] [PubMed]
10. Habib K, Gupta A, White D, et al. Utility of contrast enema to assess anastomotic integrity and the natural history of radiological leaks after low rectal surgery: systematic review and meta-analysis. Int J Colorectal Dis 2015;30:1007-14. [Crossref] [PubMed]
11. Dekker JW, Liefers GJ, de Mol van Otterloo JC, et al. Predicting the risk of anastomotic leakage in left-sided colorectal surgery using a colon leakage score. J Surg Res 2011;166:e27-34. [Crossref] [PubMed]
12. den Dulk M, Noter SL, Hendriks ER, et al. Improved diagnosis and treatment of anastomotic leakage after colorectal surgery. Eur J Surg Oncol 2009;35:420-6. [Crossref] [PubMed]
13. Kirchhoff P, Clavien PA, Hahnloser D. Complications in colorectal surgery: risk factors and preventive strategies. Patient Saf Surg 2010;4:5. [Crossref] [PubMed]
14. Law WI, Chu KW, Ho JW, et al. Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision. Am J Surg 2000;179:92-6. [Crossref] [PubMed]
15. Vignali A, Gianotti L, Braga M, et al. Altered microperfusion at the rectal stump is predictive for rectal anastomotic leak. Dis Colon Rectum 2000;43:76-82. [Crossref] [PubMed]
16. Archampong D, Borowski D, Wille-Jørgensen P, et al. Workload and surgeon’s specialty for outcome after colorectal cancer surgery. Cochrane Database Syst Rev 2012; [Crossref] [PubMed]
17. Biondo S, Kreisler E, Millan M, et al. Impact of surgical specialization on emergency colorectal surgery outcomes. Arch Surg 2010;145:79-86. [Crossref] [PubMed]
18. Choy PY, Bissett IP, Docherty JG, et al. Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database Syst Rev 2007;Cd004320 [PubMed]
19. European Society of Coloproctology collaborating group. The relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit. Colorectal Dis 2015;2017. [Epub ahead of print].
20. Mohan HM, Winter DC. Autobuttressing of colorectal anastomoses using a mesenteric flap. Updates Surg 2013;65:333-5. [Crossref] [PubMed]
21. Hao XY, Yang KH, Guo TK, et al. Omentoplasty in the prevention of anastomotic leakage after colorectal resection: a meta-analysis. Int J Colorectal Dis 2008;23:1159-65. [Crossref] [PubMed]
22. Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365:1718-26. [Crossref] [PubMed]
23. Group TCOoSTS. A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer. N Engl J Med 2004;350:2050-9. [Crossref] [PubMed]
24. Turrentine FE, Denlinger CE, Simpson VB, et al. Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks. J Am Coll Surg 2015;220:195-206. [Crossref] [PubMed]
25. Laudicella M, Walsh B, Munasinghe A, et al. Impact of laparoscopic versus open surgery on hospital costs for colon cancer: a population-based retrospective cohort study. BMJ Open 2016;6:e012977 [Crossref] [PubMed]
26. Ohtani H, Tamamori Y, Arimoto Y, et al. A Meta-Analysis of the Short- And Long-Term Results of Randomized Controlled Trials That Compared Laparoscopy-Assisted and Open Colectomy for Colon Cancer. J Cancer 2012;3:49-57. [Crossref] [PubMed]
27. Odermatt M, Flashman K, Khan J, et al. Laparoscopic-assisted abdominoperineal resection for low rectal cancer provides a shorter length of hospital stay while not affecting the recurrence or survival: a propensity score-matched analysis. Surg Today 2016;46:798-806. [Crossref] [PubMed]
28. Lian L, Kalady M, Geisler D, et al. Laparoscopic colectomy is safe and leads to a significantly shorter hospital stay for octogenarians. Surg Endosc 2010;24:2039-43. [Crossref] [PubMed]
29. Farinetti A, Bonetti LR, Migaldi M, et al. A comparative analysis between laparoscopy and open colectomy: assessment of perioperative and oncological outcomes. Ann Ital Chir 2015;86:35-41. [PubMed]
30. Chen W, Chung HH, Cheng JT. Opiate-induced constipation related to activation of small intestine opioid mu2-receptors. World J Gastroenterol 2012;18:1391-6. [Crossref] [PubMed]
31. Karantonis FF, Nikiteas N, Perrea D, et al. Evaluation of the effects of laparotomy and laparoscopy on the immune system in intra-abdominal sepsis--a review. J Invest Surg 2008;21:330-9. [Crossref] [PubMed]
32. Shan CX, Ni C, Qiu M, et al. Influence of laparoscopy vs. laparotomy on bacterial translocation and systemic inflammatory responses in a porcine model with peritonitis. J Invest Surg 2014;27:73-80. [Crossref] [PubMed]
33. Schietroma M, Pessia B, Carlei F, et al. Intestinal permeability, systemic endotoxemia, and bacterial translocation after open or laparoscopic resection for colon cancer: a prospective randomized study. Int J Colorectal Dis 2013;28:1651-60. [Crossref] [PubMed]
34. Peng Y, Zheng M, Ye Q, et al. Heated and humidified CO2 prevents hypothermia, peritoneal injury, and intra-abdominal adhesions during prolonged laparoscopic insufflations. J Surg Res 2009;151:40-7. [Crossref] [PubMed]
35. Vallance A, Wexner S, Berho M, et al. A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery. Colorectal Dis 2017;19:O1-O12. [Crossref] [PubMed]