Journal of Surgery

Prediction and Early Identification of Anastomotic Leaks after Colorectal Surgery

Abstract

Gabriel Popescu, Șerban Bancu, Daniela Sala, Radu Mircea Neagoe* and Mircea Mureșan

Anastomotic leaks (AL) still represent a major possibly life-threatening complication after colorectal surgery. The clinical presentation varies from mild symptoms to peritonitis and sepsis, which toughens the early diagnosis even for experienced surgeons. Numerous risk factors have been identified in the development of AL. The presence of bacterial strains such as Pseudomonas aeruginosa or Enterococcus faecalis are associated with higher AL rates, thus antibiotic prophylaxis seems to reduce complications. Male gender, advanced age, higher ASA fitness score, malnutrition and personal history of radiotherapy, diabetes mellitus and chronic kidney disease also lead to higher AL rates. The localization of the tumor also represents an important risk factor, as distal tumors have been identified as a predictor for AL. No differences have been found between open versus laparoscopic surgery as well as hand-sewn versus stapled anastomoses. The timing of the operation and the experience of the operating teams also affects both short and long-term. Early identification of AL is the key to reduction of mortality rates, thus scoring systems such as the Dutch Leakage Score have been developed and validated to aid surgeons for timely diagnosis. Modern imaging techniques and laboratory biomarkers further shorten the delay to a proper and early diagnosis. Computed tomography can identify even subclinical AL, leading to improved outcomes. Laboratory biomarkers such as C-reactive protein and procalcitonin are validated by large randomized studies as useful tools for exclusion of AL, possessing high negative predictive values.