By Professor Dion Morton
Hosted in Vienna last month, the annual ESCP meeting presents a valuable and effective platform at which to engage with the surgical community about what is undoubtedly the main complication of colorectal surgery — namely anastomotic leak.
MBChB, FRCS (Eng), MD -
Institute of Cancer and
Genomic Sciences at
University of Birmingham
Whilst there has been considerable improvements and progress in colorectal surgery in terms of minimally invasive procedures and reducing patient harm — which is starting to realise real patient benefit — sadly the same cannot be said when it comes to the major life-threatening complication of anastomotic leak.
Recent international surveys and cohort studies have shown that the leak rate is 6-9% of patients1,2,3,4, which is far higher than we would like. Moreover, the leak rate is highly variable between centres worldwide — suggesting that we can make considerable improvement by reducing that variation and sharing good practice.
The ACPGBI meeting serves as a fantastic opportunity to refocus our colorectal surgical community on what is, one of the most frightening complications that can arise from our treatments.
An anastomosis is a complex procedure and there are many factors that will influence its success. What we need to do as a community is work together to identify the main patient and surgeon factors and investigate how can we optimise the use of instruments in theatre, so that failure of anastomosis — and the likelihood of anastomotic leak — is minimised.
It‘s a stressful time for any surgeon when a patient suffers an anastomotic leak; it puts an enormous strain on the whole surgical team and on the health service resources — but I would emphasise that the biggest strain is on the patient, who may well spend many months or even years recovering from such an insult.
Following an uncomplicated anastomosis, a patient may be well enough to go home within three days, but if an anastomotic leak occurs, it’s highly likely they would require weeks of treatment. During that time, the patient is likely to have to go back into theatre and may require a stoma, and may experience additional and hazardous procedures to mitigate the complications.
In terms of the burden on health service resources, the cost varies from thousands of pounds to tens of thousands of pounds, should a patient require repeated procedures in theatre. Our major international surveys have shown that if a patient undergoes a right-sided bowel anastomosis, which is the procedure we consider to be the least traumatic, the mortality rate is at the 1-2% level if the patient doesn't have any problems. Yet, if the patient has major problems, such as a significant leak that is clinically detected and requires management, their mortality will increase fivefold5. That’s a very frightening statistic and one that we surgeons are only too aware of.
From the ESCP, we've run three cohort studies of about 12,000 patients across Europe and beyond which have confirmed that leak rates are higher than expected. One of the studies showed there were many different techniques for making a straightforward join between the colon and the small bowel1. It is difficult to justify such variation, and there is no evidence to suggest patients are benefiting as a result5. Our view is that variation in clinical practice and procedure introduces more risk to the patient — to put it simply, if we're all doing subtly different things, it becomes very difficult to evaluate what's right and what's wrong.
One such area variation exists is in the use of instruments. There are many technologies that are being employed to improve anastomotic technique, including the development of staplers. For right-sided anastomosis, in the region of 61%+1 of anastomosis are carried out using surgical staplers and these devices tend to standardise technique. Staplers also allow the anastomosis to be performed faster5; which can reduce contamination at the operation site. Yet, our cohort studies1,3 of right-sided anastomosis, have shown staples can have an adverse effect on outcome if the patient is compromised, and the bowel is less healthy - for example, in an emergency setting. In such cases, staples seem to have around a 1.5 times higher rate of anastomotic failure when compared to hand sewn anastomosis. Having now analysed this in thousands of patients across some 35 countries, we’ve concluded that we can better guide surgeons as to when the use of staples is advocated and when they ought to consider using sutures instead.
To that end, we've started a global dialogue with thousands of surgeons emphasising the need to work together to reduce the amount of variation in our clinical techniques, so we can better evaluate and standardise what we're doing for the benefit of our patients. Where anastomotic leak is concerned, harmonisation of practice is critical — and has become something of a catchphrase for us. We are now looking to develop a common understanding of anastomotic practice and evaluate this across the globe in the EAGLE trial.
Modern technology and social media have allowed us to join together as a surgical community in a way that has never before been possible. We are now accessing many thousands of surgeons who are participating in studies to improve the care and outcomes for their patients. These opportunities to engage and share best practice have only really become available in the last few years and I believe we're starting to exploit this media advancement for the benefit of patients for the first time; it's a very exciting time.
For patients and surgeons, an anastomotic failure or leak is the most frightening and stressful complication that can occur. As a community, we have the ability to work together to systematically reduce the anastomotic leak rate, minimise variation and standardise our practice — and substantially improve the outcomes for many thousands of patients worldwide. I don't think that's an opportunity that any colorectal surgeon would pass up.
1 The 2015 European Society of Coloproctology collaborating group. Relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit. Colorectal Disease 2017;19:296-311
2 Sammour T, Cohen L, Karunatillake A, Lewis M, Lawrence M, Hunter A,Moore J, Thomas M. Validation of an online risk calculator for the prediction of anastomotic leak after colon cancer surgery and preliminary exploration of artificial intelligence‑based analytics. Techniques in Coloproctology 2017;21:10-17
3 Glasbey J, Rosario Asteria C, Robertson AG. The impact of stapling technique and surgeon specialism on anastomotic failure after right-sided colorectal resection: An international multi-centre, prospective audit. Colorectal Disease 2018;20(11):1028-1040
4Frasson M, Flor-Lorente B, Ramos Rodriguez JL. Risk Factors for Anastomotic Leak After Colon Resection for Cancer. Annals of Surgery 2015; 262(2):321-330
5 Ramzi A, Bordeianou L.G., Sylla P. Renewed assessment of the stapled anastomosis with the increasing role of laparoscopic colectomy for colon cancer. Surgical Endoscopy 2015;29(9):2675-82
This article is the work of the author and may not necessarily reflect the views of Ethicon.
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