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Climent et al. Mini-invasive Surg 2018;2:45 I http://dx.doi.org/10.20517/2574-1225.2018.62 Page 3 of 13

Table 2. Risk factors associated with anastomotic leakage
Modifiable risk factors Non-modifiable risk factors
Smoking or previous smoking Male gender
Obesity Age > 60 years
Alcohol (> 21 units per week) Previous radiotherapy
Neoadjuvant radiotherapy ASA grade score > II
Immunosuppressant treatment Comorbidities
Malnutrition Diabetes mellitus
Preoperative weight loss > 10% Renal disease
Hypoalbuminemia COPD
Vascular disease
Emergency surgery
Distal anastomosis
Advanced neoplasia
Intraoperative blood loss > 100 mL
Blood transfusion
ASA: American Society of Anaesthesiologists; COPD: chronic obstructive pulmonary disease

the literature, which makes comparison difficult, but it is widely agreed that an AL is a breach in a surgical
[17]
anastomosis between two hollow viscera, with or without luminal content extravasation . Male gender
and low anastomosis are risk factors of AL after an anterior resection; probably because of narrower
pelvis in the male, and suboptimal blood supply for distal anastomoses [17-19] . In a multivariate analysis
performed with data from the Swedish rectal cancer registry, level of anastomosis ≤ 6 cm, American
[19]
Society of Anaesthesiologists grade > 2, and severe bleeding were identified as risk factors of AL . Other
risk factors associated with AL are immunosuppression, obesity, current or previous heavy smoking and
[18]
malnutrition [17,18] [Table 2]. Preoperative radiotherapy was previously postulated as being etiologic , but
larger randomised controlled trials, such as The Medical Research Council CR07 and National Cancer
Institute of Canada Clinical Trials Group C016 showed no difference of AL between patients undergoing
anterior resection with or without neoadjuvant radiotherapy with patients who had postoperative
[20]
chemoradiotherapy .
The use of preoperative mechanical bowel preparation, remains controversial, and a recent review of 1,369
patients who underwent elective rectal cancer resection demonstrated a significantly lower rate of clinical
[21]
anastomotic leak in the group who had surgery without mechanical bowel preparation . The value of a
defunctioning stoma is still not clear. Some studies defend that a diverting stoma does not prevent AL,
rather it facilitates management of the consequences of a leak; therefore, the use of a diverting stoma is
[19]
a safe option in high-risk patients . However, two meta-analyses [22,23] reported a significant benefit of
defunctioning stoma reducing the rate of AL and reoperations related to leakage, although the number
of randomized control trials included in both studies was small. It has been suggested that the use of
pelvic drainage after anterior resection may detect early AL, reducing the incidence of pelvic sepsis and
decreasing the need of reoperation. However, some studies have reported potential risks related to the
use of pelvic drains such as bowel perforation, vessel injury, infection around the site of its entrance, and
[15]
pain . Recently, a prospective randomized trial showed no benefit in reduction of pelvic sepsis or in the
[24]
time to diagnosis the AL among patients with suction pelvic drain after rectal excision for cancer . Some
groups support the use of laser fluorescence angiography intraoperatively in order to evaluate perfusion
[25]
of the proximal colon prior to creation of the anastomosis , but level 1 evidence is required before this
becomes universally accepted as a standard practice. There is consensus that a surgical anastomosis
should be tension-free with good blood supply, often necessitating splenic flexure mobilisation and inferior
[18]
mesenteric vein ligation under the inferior border of the pancreas .
[17]
Early diagnosis of AL is critical to managing the ensuing pelvic sepsis and treating high-risk patients .
Classically, an anastomotic leak is diagnosed between postoperative day 6 to 9, although the range is
[26]
wide . An abnormal abdominal examination, in addition to increased systemic inflammatory response