Lower Limb Compartment Syndrome Among Colorectal Patients: Risk Factors and Proposed Guidelines

Lower limb compartment syndrome (LLCS) is a rare but potentially devastating complication of prolonged lithotomy positioning in colorectal surgery. The mechanisms appear to be related to prolonged pressure on muscle compartments, leading to hypoperfusion followed by reperfusion injury. This study aims to identify the incidence of LLCS after colorectal surgery and identify associated risk factors to inform evidence-based prevention strategies.

Adults from the American College of Surgeons NSQIP (2006 to 2022) undergoing colorectal surgery were included. The primary outcome was postoperative compartment syndrome leading to fasciotomy. Patients with concurrent vascular procedures and embolism diagnoses were excluded. The association between operative time and fasciotomy was assessed using multivariable logistic regression.

Among 773,981 patients, 35 underwent fasciotomy within 2 days of their colorectal procedure. The median operative time was 388 minutes (interquartile range 165 to 539) for the fasciotomy group and 162 minutes (interquartile range 113 to 320) for the nonfasciotomy group (p < 0.001). Adjusted multivariable analysis demonstrated a time-response relationship between operative time and fasciotomy as the odds of fasciotomy were 3.5-fold higher after 3 to 5 hours and increased with longer operative time. In addition, other factors associated with fasciotomy included age younger than 50 years, American Society of Anesthesiologists class IV to V, and preoperative transfusion.

Providers should exercise caution when operating on younger patients in lithotomy positions with an operative time more than 3 to 5 hours, as prolonged operative time is associated with an increased risk of fasciotomy. Improving awareness alongside the development of guidelines for routine intraoperative lower extremity assessment can facilitate early recognition and prevention of LLCS.