Reducing Anastomotic Leakage in Oncologic Colorectal Surgery: An Evidence-Based Review

Abstract

Background: Anastomotic leak rates following colorectal anastomosis range from 4 to 26%, and the development of a leak is known to be correlated with worse prognosis after a curative resection for colorectal cancer. In addition, anastomotic leakage has been associated with increased mortality and risk of permanent stoma. While techniques to improve the leakage rates in colorectal surgery have been described, these have largely been through isolated case series. We sought to undertake an evidence-based approach to reviewing the use of such techniques. Methods: A systematic review of the literature was performed, evaluating the current evidence for techniques to improve leakage following colorectal anastomosis. Results: There is Level I evidence to support the use of intra-operative leak testing, defunctioning ileostomy and drain tube insertion in the correct settings, including those associated with poor patient, disease and/or operative factors. There is no clear evidence to support the use of handsewn techniques, stapling techniques or laparoscopy over other techniques. Conclusion: Reductions in morbidity and mortality from colorectal anastomotic leaks can be gained by performing intraoperative leak testing, defunctioning ileostomy and drain tube insertion in the correct settings. The technique for performing the anastomosis remains at the discretion of the surgeon and largely depends on experience, patient characteristics and the operative setting, rather than there being any clear evidence for one technique over another. New techniques and devices that overcome drawbacks in current practice are consistently being developed and tested, making further risk reduction in colorectal anastomosis of great future promise.