Elsevier

Surgery

Volume 147, Issue 3, March 2010, Pages 339-351
Surgery

Original Communication
Definition and grading of anastomotic leakage following anterior resection of the rectum: A proposal by the International Study Group of Rectal Cancer

https://doi.org/10.1016/j.surg.2009.10.012Get rights and content

Background

Anastomotic leakage represents a major complication after anterior resection of the rectum. The incidence of anastomotic leakage varies considerably among clinical studies in part owing to the lack of a standardized definition of this complication. The aim of the present article was to propose a definition and severity grading of anastomotic leakage after anterior rectal resection.

Methods

After a literature review a consensus definition and severity grading of anastomotic leakage was developed within the International Study Group of Rectal Cancer.

Results

Anastomotic leakage should be defined as a defect of the intestinal wall at the anastomotic site (including suture and staple lines of neorectal reservoirs) leading to a communication between the intra- and extraluminal compartments. Severity of anastomotic leakage should be graded according to the impact on clinical management. Grade A anastomotic leakage results in no change in patients’ management, whereas grade B leakage requires active therapeutic intervention but is manageable without re-laparotomy. Grade C anastomotic leakage requires re-laparotomy.

Conclusion

The proposed definition and clinical grading is applicable easily in the setting of clinical studies. It should be applied in future reports to facilitate valid comparison of the results of different studies.

Section snippets

Methods

An extensive literature search of the Medline database was conducted to identify available definitions of anastomotic leakage after anterior resection of the rectum. Furthermore, we sought whether a definition of anastomotic leakage had already been generally accepted and adopted within scientific reports on anterior resection. Using the following search terms we searched the Medline database for the period of the past 5 years: (Resection AND [rectum OR rectal] OR proctectomy). Clinical studies

Review of the literature

The literature search to detect available definitions yielded 1,995 references. Of these, a total of 59 articles providing a definition of anastomotic leakage after anterior resection were evaluated critically. Most definitions consisted of a clinical suspicion based on the patient's symptoms, which was subsequently confirmed by further diagnostic tests or direct evidence of anastomotic leakage during operative exploration (Table I). Routine postoperative radiologic tests were only performed in

Discussion

Randomized, controlled trials and meta-analyses are considered the reference tools to generate and summarize evidence on the benefits and harms of certain treatments,45, 46 Uniform, procedure-specific definitions of outcome variables are, however, the prerequisite for comparing the results of different studies. After anterior rectal resection with primary anastomosis, anastomotic leakage represents the major cause of postoperative morbidity and has a substantive impact on the patients’

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    • Cited by (0)

    Members of the International Study Group of Rectal Cancer (ISREC): Markus W. Büchler (Heidelberg, Germany), Marcel den Dulk (Leiden, The Netherlands), Richard J. Heald (Basingstoke, United Kingdom), Werner Hohenberger (Erlangen, Germany), Torbjörn Holm (Stockholm, Sweden), Søren Laurberg (Aarhus, Denmark), Yoshihiro Moriya (Tokyo, Japan), Emmanuel Tiret (Paris, France), Nuh N. Rahbari (Heidelberg, Germany), Cornelis van de Velde (Leiden, The Netherlands), Jürgen Weitz (Heidelberg, Germany), and W. Douglas Wong (New York, NY).

    N.N.R. and J.W. contributed equally to this work.

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