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Increased Local Recurrence and Reduced Survival From Colorectal Cancer Following Anastomotic Leak: Systematic Review and Meta-Analysis

Mirnezami, Alexander PhD, FRCS*; Mirnezami, Reza MRCS; Chandrakumaran, Kandiah PhD, FRCS; Sasapu, Kishore FRCS§; Sagar, Peter MD, FRCS§; Finan, Paul MD, FRCS§

doi: 10.1097/SLA.0b013e3182128929
Meta Analyses

Objective: To examine the long-term oncological impact of anastomotic leakage (AL) after restorative surgery for colorectal cancer using meta-analytical methods. Outcomes evaluated were local recurrence, distant recurrence, and survival.

Background: Recurrence after potentially curative surgery for colorectal cancer remains a significant clinical problem and has a poor prognosis. AL may be a risk factor for disease recurrence, however available studies have been conflicting. A meta-analysis was conducted to investigate the impact of AL on disease recurrence and long-term survival.

Methods: Studies published between 1965 and 2009 evaluating the long-term oncological impact of AL were identified by an electronic literature search. Outcomes evaluated included local recurrence, distant recurrence, and cancer specific survival. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute odds ratio and 95% confidence intervals. Study heterogeneity was evaluated using Q statistics and I2 and publication bias assessed with funnel plots and Egger's test.

Results: Twenty-one studies comprising 13 prospective nonrandomized studies, 1 prospective randomized, and 7 retrospective studies met the inclusion criteria, yielding a total of 21,902 patients. For rectal anastomoses, the odd ratios (OR) of developing a local recurrence when there was AL was 2.05 (95% CI = 1.51–2.8; P = 0.0001). For studies describing both colon and rectal anastomoses, the OR of local recurrence when there was an AL was 2.9 (95% CI = 1.78–4.71; P < 0.001). The OR of developing a distant recurrence after AL was 1.38 (95% CI = 0.96–1.99; P = 0.083). Long term cancer specific mortality was significantly higher after AL with an OR of 1.75 (95% CI = 1.47–2.1; P = 0.0001).

Conclusions: AL has a negative prognostic impact on local recurrence after restorative resection of rectal cancer. A significant association between colorectal AL and reduced long-term cancer specific survival was also noted. No association between AL and distant recurrence was found.

Anastomotic leakage (AL) following surgery for colorectal cancer may be a risk factor for disease recurrence. However, available studies are conflicting. A meta-analysis was conducted to investigate the impact of AL on recurrence and late survival. AL was noted to have a negative impact on local recurrence and survival.

*Somers Cancer Research Building, University of Southampton Cancer Sciences Division, Southampton University Hospital NHS Trust, Tremona road, Southampton, United Kingdom

Department of Surgery, Hammersmith Hospital, London, United Kingdom

Department of Surgery, Basingstoke and North Hampshire Hospital NHS Trust, Hampshire, United Kingdom

§John Goligher Colorectal Unit, Leeds General Infirmary, Leeds, United Kingdom

Reprints: Mr. A.H. Mirnezami, Cancer Research UK and Royal College of Surgeons of England Clinician Scientist, Somers Cancer Research Building, University of Southampton Cancer Sciences Division, Southampton University Hospital NHS Trust, Tremona Road, SO166YD, Southampton, United Kingdom. E-mail: ahm@soton.ac.uk.

The authors A.H.M. and R.M. have contributed equally to this study.

Funded by the Cancer Research, UK.

A.H.M. is supported by grant funding from Wessex Medical Research and Cancer Research UK (C28503/A10013).

© 2011 Lippincott Williams & Wilkins, Inc.