To validate and assess the pre-operative predictability of anastomotic leak using clonic leakage score in left sided colorectal restorative resection

Abstract

Background:Anastomotic leakage (AL) is one of the most serious and devastating post-operative complications of colorectal cancer surgery, therefore early diagnosis and treatment can prevent morbidity and mortality associated with it.

Objective: To validate and assess the preoperative predictability of anastomotic leak by colon leakage score in left side colorectal restorative resection in colorectal malignancies.

Participants: Total of 62 subjects of all age groups and both sexes who underwent restorative left sided colorectal resection for colorectal malignancies over a period of two years were included.

Study Design:Prospective-observational study

Methods:The prospective observational study was conducted at Sher-i-Kashmir Institute of Medical Sciences Soura, in Colorectal Division of General and Minimal Invasive Surgery.The patients with various Left sided colonic malignant conditions involving distal colon upto the anal canal were included after written informed consent.After detailed history and thorough clinical and systemic examination, all our patients were fully evaluated for the diagnosis and stage of the disease.The patients were categorized into three sub-groups as per the scoring system parameters of Colon Leakage Score.The patients who developed anastomotic leak postoperatively  were categorized into three sub-groups as per the line of management needed which is as under. Group A – needed no intervention; Group B – needed radiological intervention (USG guided drainage/ pigtail drainage) and  Group C – needed  re-laparotomy. The data was collected and analysed.

Results:Total of 62 subjects who underwent left-sided colorectal surgery were enrolled  and studied.  Carcinoma rectum (33.9%) was the most common diagnosed pathology followed by carcinoma sigmoid (30.6%), left transverse colon (19.4%), rectosigmoid (16.1%).  64.5% underwent laparoscopic surgery, 30.6% underwent open and 4.8% had to undergo laparoscopic assisted open surgery. Low anterior resection surgery was performed in 40.3% patients, anterior resection in 19.4%, left hemicolectomy in 17.7% and sigmoid colectomy in 14.5%. 50% patients underwent end to end anastomosis, 43.5% end to side and 6.5 side to side. Stapled anastomosis was used in 58.1% patients and hand sewn in 41.9% patients. Colon leakage score (CLS) was 4-9 in majority of patients (67.7%), with a meanof 6.2+2.87. Anastomotic leak was noted in 6 patients, of which 5 (83.3%) had CLS > 9 and 1 (16.7%) patient had CLS <9,with sensitivity of 83.3, specificity of 91.1, positive predictive value of 50.0, negative predictive value of 98.1, accuracy of 90.3. The difference observed was statistically significant with a p value of < 0.001. Conservative management was used in 6.5% patients while as 3.2% patient’s underwent re-exploration. In-hospital mortality (expired) was 1.6%, recurrence was seen in 6.5% patients while as 11.3% patients lost their follow up.

Conclusion:The colon leakage score (CLS) provides accurate prediction of anastamotic leak in patients who undergo left-sided colorectal cancer surgeries. It is simpleand easily available clinical tool that provides the necessary information for the intra-operative decision regarding whether  to construct a non-functional stoma or not . Confirmation of the value of this scoring system in a larger multi-centre series offers the potential to solve a difficult clinical problem.

Key Words:Colo rectal lesions, Anastomotic leak, Colon leakage score.