Preoperative risk factors associated with anastomotic leakage after colectomy for colorectal cancer: a systematic review and meta-analysis

DIAS, VINÍCIUS EVANGELISTA; CASTRO, PEDRO ALVES SOARES VAZ DE; PADILHA, HOMERO TERRA; PILLAR, LARA VICENTE; GODINHO, LAURA BOTELHO RAMOS; TINOCO, AUGUSTO CLAUDIO DE ALMEIDA; AMIL, RODRIGO DA COSTA; SOARES, ALEIDA NAZARETH; CRUZ, GERALDO MAGELA GOMES DA; BEZERRA, JULIANA MARIA TRINDADE; SILVA, THAIS ALMEIDA MARQUES DA

doi:10.1590/0100-6991e-20223363-en

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Original article • Rev. Col. Bras. Cir. 49 • 2022 • https://doi.org/10.1590/0100-6991e-20223363-en copy

Preoperative risk factors associated with anastomotic leakage after colectomy for colorectal cancer: a systematic review and meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Introduction:

anastomotic leak (AL) after colectomy for colorectal cancer (CRC) is a life-threatening complication. This systematic review and meta-analysis aimed to evaluate the preoperative risk factors for AL in patients submitted to colectomy.

Methods:

the bibliographic search covered 15 years and 9 months, from 1st January 2005 to 19th October 2020 and was performed using PubMed, Cochrane Library, Scopus, Biblioteca Virtual em Saúde, Europe PMC and Web of Science databases. The inclusion criteria were cross-sectional, cohort and case-control studies on preoperative risk factors for AL (outcome). The Newcastle-Ottawa scale was used for bias assessment within studies. Meta-analysis involved the calculation of treatment effects for each individual study including odds ratio (OR), relative risk (RR) and 95% confidence intervals (95% CI) with construction of a random-effects model to evaluate the impact of each variable on the outcome. Statistical significance was set at p<0.05.

Results:

cross-sectional studies were represented by 39 articles, cohort studies by 21 articles and case-control by 4 articles. Meta-analysis identified 14 main risk factors for AL in CRC patients after colectomy, namely male sex (RR=1.56; 95% CI=1.40-1.75), smoking (RR=1.48; 95% CI=1.30-1.69), alcohol consumption (RR=1.35; 95% CI=1.21-1.52), diabetes mellitus (RR=1.97; 95% CI=1.44-2.70), lung diseases (RR=2.14; 95% CI=1.21-3.78), chronic obstructive pulmonary disease (RR=1.10; 95% IC=1.04-1.16), coronary artery disease (RR=1.61; 95% CI=1.07-2.41), chronic kidney disease (RR=1.34; 95% CI=1.22-1.47), high ASA grades (RR=1.70; 95% CI=1.37-2.09), previous abdominal surgery (RR=1.30; 95% CI=1.04-1.64), CRC-related emergency surgery (RR=1.61; 95% CI=1.26-2.07), neoadjuvant chemotherapy (RR=2.16; 95% CI=1.17-4.02), radiotherapy (RR=2.36; 95% CI=1.33-4.19) and chemoradiotherapy (RR=1.58; 95% CI=1.06-2.35).

Conclusions:

important preoperative risk factors for colorectal AL in CRC patients have been identified based on best evidence-based research, and such knowledge should influence decisions regarding treatment.

Keywords:
Risk Factors; Anastomotic Leaks; Colon Surgery; Colon Diseases

Articles	Location	Total sample population	NOS score	Reference
Cross sectional studies
Kinugasa et al., 2020	Kurume, Japan	97	6	[1]
Zhou et al., 2019	Beijing, China	288	5	[2]
Bakker et al., 2014	Leiden, Netherlands	15,667	6	[6]
Chen et al., 2011	Shantou, China	750	5	[7]
Choi et al., 2006	Hong Kong, China	1417	3	[8]
Frasson et al., 2015	Valencia, Spain	3139	6	[9]
Articles	Location	Total sample population	NOS score	Reference
Fukada et al., 2019	Gifu, Japan	101	3	[10]
Gong et al., 2014	Nanjing, China	460	5	[11]
Hayden et al., 2015	Maywood, EUA	123	7	[12]
Iancu et al., 2008	Cluj-Napoca, Romania	993	5	[13]
Jung et al., 2008	Seoul, South Korea	1391	5	[14]
Kang et al., 2013	Irvine, EUA	72055	5	[15]
Kato et al., 2019	Tokyo, Japan	447	4	[16]
Kawada et al., 2014	Tokyo, Japan	154	5	[17]
Kim et al., 2009	Seul, South Korea	270	5	[18]
Krarup et al., 2012	Copenhagen, Denmark	9333	8	[19]
Kruschewski et al., 2007	Berlin, Germany	276	3	[20]
Kryzauskas et al., 2020	Vilnius, Lithuania	900	9	[21]
Kumar et al., 2011	Nothern, India	108	5	[22]
Kwak et al., 2017	Seul, South Korea	423	5	[23]
Lai et al., 2013	Guangzhou, China	1312	5	[24]
Lee et al., 2020	Seul, South Korea	4282	7	[25]
Lee et al., 2018	Hwasun, South Korea	1063	4	[26]
Lee et al., 2008	Seul, South Korea	1278	4	[27]
Liu et al., 2016	Chengdu, China	306	6	[28]
Maeda et al., 2015	Osaka Japan	201	5	[29]
Majbar et al., 2014	Rabat, Morocco	130	4	[30]
Martel et al., 2008	Ottawa, Canada	220	5	[31]
Nickelsen et al., 2005	Nordre Ringvej, Denmark	5181	6	[32]
Peeters et al., 2005	Leiden, Netherlands	924	6	[33]
Piecuch et al., 2015	Zabrze, Poland	222	3	[34]
Rudinskaite et al., 2005	Kaunas, Lithuania	269	3	[35]
Shen et al., 2019	Beijing, China	423	6	[36]
Suzuki et al., 2021	Ube, Japan	136	7	[37]
Tian et al., 2017	Beijing, China	11397	5	[38]
Vermeer et al., 2014	Netherlands	517	6	[39]
Wang & Liu, 2020	Beijing, China	496	5	[40]
Xu & Kong, 2020	Shenyang, China	382	5	[41]
Yang et al., 2013	Nanjing, China	753	5	[42]
Cohort studies
Zhou et al., 2018	Guangzhou, China	956	8	[3]
Akasu et al., 2010	Tokyo, Japan	120	8	[43]
Akiyoshi et al., 2011	Tokyo, Japan	1,146	7	[44]
Bisgård et al., 2013	Herlev, Denmark	2755	8	[45]
Ciorogar et al., 2017	Cluj-Napoca, Romania	378	6	[46]
Articles	Location	Total sample population	NOS score	Reference
Eriksen et al., 2005	Oslo, Norway	1958	8	[47]
Gustafsson et al., 2015	Visby, Sweden	3428	8	[48]
Hu & Cheng, 2015	Chongqing, China	1968	5	[49]
Ionescu et al., 2013	Cluj-Napoca, Romania	252	8	[50]
Jannasch et al., 2015	Magdeburg, Germany	17867	8	[51]
Liu et al., 2018	Guangzhou, China	646	7	[52]
Matsuda et al., 2016	Tokyo, Japan	179	4	[53]
Nisar et al., 2012	Cleveland, EUA	1862	6	[54]
Nordholm-Carstensen et al., 2019	Roskild, Denmark	1414	7	[55]
Park et al., 2016	Seul, South Korea	10477	7	[56]
Reilly et al., 2014	Dublin, Ireland	129	3	[57]
2015 European Society of Coloproctology Collaborating Group, 2020	Valência, Spain	2444	6	[58]
Tanaka et al., 2017	Osaka, Japan	395	6	[59]
Voron et al., 2019	Paris, France	1025	7	[60]
Warschkow et al., 2011	St. Gallen, Switzerland	527	6	[61]
Yamamoto et al., 2012	Tokyo, Japan	111	6	[62]
Case-control studies
Altin & Alkan, 2019	Istambul, Turkey	302	4	[63]
Asteria et al., 2008	Florence, Italy	520	6	[64]
Jestin et al., 2008	Uppsala, Sweden	372	5	[65]
Nishigori et al., 2014	Chiba, Japan	176	6	[66]

Risk factor	Type of study	Number of studies	Number of participants	RR (95%CI)	References	Heterogeneity
Sex	Cohort	15	36,284	1.42 (1.07 - 1.89)	[43,44,46-49, 54-62]	I² = 83%
Sex	Case-control	4	1,346	1.28 (1.02 -1.60)	[63-66]	I² = 0%
Sex	Cross-sectional	34	145,509	1.56 (1.40 - 1.75)	[2,6-24,26, 27,29-31, 33-35,37-42]	I² = 66%
Smoking habits	Cohort	5	21,180	1.48 (1.30 - 1.69)	[43,51,55,57,58]	I² = 0%
Alcohol consumption	Cross-sectional	9	77,567	1.35 (1.21 - 1.52)	[8,13,15,20,23, 24,31,40,41]	I² = 0%
Diabetes mellitus	Cross-sectional	16	11,871	1.97 (1.44 - 2.70)	[2,8-11,13, 16,20,21, 23,24,29, 34,40-42]	I² = 69%
Lung diseases	Cross-sectional	5	5,260	2.14 (1.21 - 3.78)	[9,13,16, 23,31]	I² = 42%
COPD	Cross-sectional	6	74,459	1.10 (1.04 - 1.16)	[2,8,15, 20,29,34]	I² = 0%
CAD	Cross-sectional	6	3,065	1.61 (1.07 - 2.41)	[2,7,8,20, 34,41]	I² = 27%
CKD	Cross-sectional	4	74,819	1.34 (1.22 - 1.47)	[8,15, 16,21]	I² = 0%
ASA grades	Cross-sectional	16	35,727	1.70 (1.37 - 2.09)	[2,6,8,9,18,19, 21,23,24,26, 27,31,35,39-4]	I² = 60%
Previous abdominal surgery	Cohort	4	13,417	1.30 (1.04 - 1.64)	[56,58,59,62]	I² = 0%
CRC-related emergency surgery	Cross-sectional	5	29,546	1.61 (1.26 - 2.07)	[6,8,9,13,19]	I² = 58%
Neoadjuvant chemotherapy	Cohort	5	15,610	2.16 (1.17 - 4.02)	[44,55-58]	I² = 42%
Neoadjuvant radiotherapy	Cohort	4	14,426	2.36 (1.33 - 4.19)	[47,54,56,57]	I² = 68%
Neoadjuvant chemoradiotherapy	Cross-sectional	10	6,902	1.58 (1.06 - 2.35)	[2,12,14,24, 26,27,31, 37,41,42]	I² = 41%

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