The failed gastrointestinal anastomosis: an inevitable catastrophe?

There is a great deal of conflicting data regarding risk factors for anastomotic leakage, with most studies being small and looking only at anastomoses performed at one level of the gastrointestinal (GI) tract. Surgeons have looked at patient and technical variables with inconsistent findings. The purpose of this study was to evaluate the incidence, possible predictive factors, and results of treatment of anastomotic dehiscence in patients undergoing operations at all levels of the GI tract.

We evaluated the records of 2,842 patients undergoing esophagogastrectomy, total or partial gastrectomy, enterectomy, and partial or subtotal colectomy over a 12-year period. Complete demographic data, comorbidity, and details regarding anastomotic technique were collected on all patients sustaining leaks along with diagnostic methods used, treatment modalities, and outcomes data. Using age and gender-matched case control methodology, we compared patients sustaining an anastomotic leak to those undergoing successful anastomoses.

Fifty-one of 2,842 patients (1.8%), ranging from 1.1% of enterectomy patients to 4.8% of total gastrectomy patients, sustained an anastomotic dehiscence. Foregut procedures were accompanied by a significantly increased rate of leakage, and depending on location, diagnosis was made between the 6th and 9th postoperative day. For each procedure, deaths from factors other than leakage far exceeded deaths from leaks. Standard risk stratifiers did not predict occurrence of leakage. Overall, 24% of patients sustaining a leak died, and this complication necessitated multiple reoperations and significantly increased length of hospital stay.

In view of these findings, standard preoperative strategies to prepare these patients for operation may prove unsuccessful, because minimizing the incidence of anastomotic leaks will have little overall impact on survival. In addition, efforts to accomplish early hospital discharge may prove hazardous, because many of these patients manifest their leaks later in the postoperative period than is generally assumed. Improved management of GI tract disruption, including aggressive attempts at diagnosis, ICU care, antibiotics, and nutritional support may further increase survival in these patients.