Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients
Authors: Greijdanus Nynke G , Wienholts Kiedo , Ubels Sander , Talboom Kevin , Hannink Gerjon , Wolthuis Albert , de Lacy F Borja , Lefevre Jérémie H , Solomon Michael , Frasson Matteo , Rotholtz Nicolas , Denost Quentin , Perez Rodrigo O , Konishi Tsuyoshi , Panis Yves , Rutegård Martin , Hompes Roel , Rosman Camiel , van Workum Frans , Tanis Pieter J , de Wilt Johannes H W ,   TENTACLE-Rectum Collaborative Group, Bremers Andreas J A , Ferenschild Floris T , de Vriendt Stefanie , D’Hoore André , Bislenghi Gabriele , Farguell Jordi , Lacy Antonio M , Atienza Paula González , van Kessel Charlotte S , Parc Yann , Voron Thibault , Collard Maxime K , Muriel Jorge Sancho , Cholewa Hannia , Mattioni Laura A , Frontali Alice , Polle Sebastiaan W , Polat Fatih , Obihara Ndidi J , Vailati Bruna B , Kusters Miranda , Tuynmann Jurriaan B , Hazen Sanne J A , Grüter Alexander A J , Amano Takahiro , Fujiwara Hajime , Salomon Mario , Ruiz Hernán , Gonzalez Ricardo , Estefanía Diego , Avellaneda Nicolas , Carrie Augusto , Santillan Mateo , Pachajoa Diana A Pantoja , Parodi Matias , Gielis Manuel , Binder Alf-Dorian , Gürtler Thomas , Riedl Peter , Badiani Sarit , Berney Christophe , Morgan Matthew , Hollington Paul , da Silva Nigel , Nair Gavin , Ho Yiu M , Lamparelli Michael , Kapadia Raj , Kroon Hidde M , Dudi-Venkata Nagendra N , Liu Jianliang , Sammour Tarik , Flamey Nicolas , Pattyn Paul , Chaoui Ahmed , Vansteenbrugge Louis , van den Broek Nathalie E J , Vanclooster Patrick , de Gheldere Charles , Pletinckx Pieter , Defoort Barbara , Dewulf Maxime , Slavchev Mihail , Belev Nikolay , Atanasov Boyko , Krastev Panche , Sokolov Manol , Maslyankov Svilen , Gribnev Petar , Pavlov Vasil , Ivanov Tsvetomir , Karamanliev Martin , Filipov Emil , Tonchev Pencho , Aigner Felix , Mitteregger Martin , Allmer Caterina , Seitinger Gerald , Colucci Nicola , Buchs Nicolas , Ris Frédéric , Toso Christian , Gialamas Eleftherios , Vuagniaux Aurélie , Chautems Roland , Sauvain Marc-Olivier , Daester Silvio , von Flüe Markus , Guenin Marc-Olivier , Taha-Mehlitz Stephanie , Hess Gabriel F , Martínek Lubomír , Skrovina Matej , Machackova Maria , Benčurik Vladimir , Uluk Deniz , Pratschke Johann , Dittrich Luca S , Guel-Klein Safak , Perez Daniel , Grass Julia-Kristin , Melling Nathaniel , Mueller Simone , Iversen Lene H , Eriksen Jacob D , Baatrup Gunnar , Al-Najami Issam , Bjørsum-Meyer Thomas , Teras Jüri , Teras Roland M , Monib Fatma A , Ahmed Nagm Eldin Abu Elnga , Alkady Eithar , Ali Ahmed K , Khedr Gehan Abd Elatti , Abdelaal Ahmed Samir , Ashoush Fouad M Bassyouni , Ewedah Moataz , Elshennawy Eslam M , Hussein Mohamed , Fernández-Martínez Daniel , García-Flórez Luis J , Fernández-Hevia María , Suárez-Sánchez Aida , del Hoyo Aretxabala Izaskun , Docampo Iria Losada , Zabala Jesús Gómez , Tejedor Patricia , de Quirós Javier T Morales Bernaldo , Quiroga Ignacio Bodega , Navarro-Sánchez Antonio , Darias Iván Soto , Fernández Cristina López , de La Cruz Cuadrado Cristina , Sánchez-Guillén Luis , López-Rodríguez-Arias Francisco , Soler-Silva Álvaro , Arroyo Antonio , Bernal-Sprekelsen Juan C , Gómez-Abril Segundo Á , Gonzálvez Paula , Torres María T , Sánchez Teresa Rubio , Antona Francisco Blanco , Lara Juan E Sánchez , Montero José A Alcázar , Mendoza-Moreno Fernando , Díez-Alonso Manuel , Matías-García Belén , Quiroga-Valcárcel Ana , Colás-Ruiz Enrique , Tasende-Presedo Marta M , Fernández-Hurtado Ignacio , Cifuentes-Ródenas José A , Suárez Marta Castro , Losada Manuel , Hernández Miguel , Alonso Alfredo , Diéguez Beatriz , Serralta Daniel , Quintana Rita E Medina , Lopez Jose M Gil , Pinto Francisca Lima , Nieto-Moreno Elena , Bonito Alba Correa , Santacruz Carlos Cerdán , Marcos Elena Bermejo , Septiem Javier García , Calero-Lillo Aránzazu , Alanez-Saavedra Javier , Muñoz-Collado Salvador , López-Lara Manuel , Martínez María Labalde , Herrero Eduardo Ferrero , Borda Francisco Javier García , Villar Óscar García , Escartín Jorge , Blas Juan L , Ferrer Rocío , Egea Jorge García , Rodríguez-Infante Antonio , Mínguez-Ruiz Germán , Carreño-Villarreal Guillermo , Pire-Abaitua Gerardo , Dziakova Jana , Rodríguez Carlos Sáez-Cazallas , Aranda María J Pizarro , Huguet José M Muguerza , Borda-Arrizabalaga Nerea , Enriquez-Navascués José M , Echaniz Garazi Elorza , Ansorena Yolanda Saralegui , Estaire-Gómez Mercedes , Martínez-Pinedo Carlos , Barbero-Valenzuela Alejandro , Ruíz-García Pablo , Kraft Miquel , Gómez-Jurado María J , Pellino Gianluca , Espín-Basany Eloy , Cotte Eddy , Panel Nathalie , Goutard Claire-Angéline , deÁngelis Nicola , Lauka Lelde , Shaikh Shafaque , Osborne Laura , Ramsay George , Nichita Vladimir-Ion , Bhandari Santosh , Sarmah Panchali , Bethune Rob M , Pringle Heather C M , Massey Lisa , Fowler George E , Hamid Hytham K S , de Simone Belinda D , Kynaston James , Bradley Nicholas , Stienstra Roxane M , Gurjar Shashank , Mukherjee Tanmoy , Chandio Ashfaq , Ahmed Safia , Singh Baljit , Runau Francois , Chaudhri Sanjay , Siaw Oliver , Sarveswaran Janahan , Miu Victor , Ashmore Daniel , Darwich Haitham , Singh-Ranger Deepak , Singh Nirbhaibir , Shaban Mohamed , Gareb Fahed , Petropolou Thalia , Polydorou Adreas , Dattani Mit , Afzal Asma , Bavikatte Akshay , Sebastian Boby , Ward Nicholas , Mishra Amitabh , Manatakis Dimitrios , Tasis Christos Agalianos,Nikolaos , Antonopoulou Maria-Ioanna , Karavokyros Ioannis , Charalabopoulos Alexandros , Schizas Dimitrios , Baili Efstratia , Syllaios Athanasios , Karydakis Lysandros , Vailas Michail , Balalis Dimitrios , Korkolis Dimitrios , Plastiras Aris , Rompou Aliki , Xenaki Sofia , Xynos Evangelos , Chrysos Emmanuel , Venianaki Maria , Christodoulidis Grigorios , Perivoliotis Konstantinos , Tzovaras George , Baloyiannis Ioannis , Ho Man-Fung , Ng Simon Siu-man , Mak Tony Wing-chung , Futaba Kaori , Šantak Goran , Šimleša Damir , Ćosić Jurica , Zukanović Goran , Kelly Michael E , Larkin John O , McCormick Paul H , Mehigan Brian J , Connelly Tara M , Neary Peter , Ryan Jessica , McCullough Peter , Al-Juaifari Maytham A , Hammoodi Hayder , Abbood Ali Hashim , Calabrò Marcello , Muratore Andrea , Terra Antonio La , Farnesi Francesca , Feo Carlo V , Fabbri Nicolò , Pesce Antonio , Fazzin Marta , Roscio Francesco , Clerici Federico , Lucchi Andrea , Vittori Laura , Agostinelli Laura , Ripoli Maria Cristina , Sambucci Daniele , Porta Andrea , Sinibaldi Giovanni , Crescentini Giacomo , larcinese Antonella , Picone Emanuele , Persiani Roberto , Biondi Alberto , Pezzuto Roberto , Lorenzon Laura , Rizzo Gianluca , Coco Claudio , D’Agostino Luca , Spinelli Antonino , Sacchi Matteo M , Carvello Michele , Foppa Caterina , Spinelli Antonino , Sacchi Matteo M , Carvello Michele , Foppa Caterina , Maroli Annalisa , Palini Gian M , Garulli Gianluca , Zanini Nicola , Delrio Paolo , Rega Daniela , Carbone Fabio , Aversano Alessia , Pirozzolo Giovanni , Recordare Alfonso , D’Alimonte Lucrezia , Vignotto Chiara , Corbellini Carlo , Sampietro Gianluca M , Lorusso Leonardo , Manzo Carlo A , Ghignone Federico , Ugolini Giampaolo , Montroni Isacco , Pasini Franceso , Pasini Francesco , Ballabio Michele , Bisagni Pietro , Armao Francesca T , Longhi Marco , Ghazouani Omar , Galleano Raffaele , Tamini Nicolò , Oldani Massimo , Nespoli Luca , Picciariello Arcangelo , Altomare Donato F , Tomasicchio Giovanni , Lantone Giuliano , Catena Fausto , Giuffrida Mario , Annicchiarico Alfredo , Perrone Gennaro , Grossi Ugo , Santoro Giulio A , Iacomino Giacomo Zanus ,Alessandro , Novello Simone , Passuello Nicola , Zucchella Martino , Puca Lucia , deGiuli Maurizio , Reddavid Rossella , Scabini Stefano , Aprile Alessandra , Soriero Domenico , Fioravanti Emanuela , Rottoli Matteo , Romano Angela , Tanzanu Marta , Belvedere Angela , Mariani Nicolò M , Ceretti Andrea P , Opocher Enrico , Gallo Gaetano , Sammarco Giuseppe , de Paola Gilda , Pucciarelli Salvatore , Marchegiani Francesco , Spolverato Gaya , Buzzi Gianluca , Di Saverio Salomone , Meroni Paola , Parise Cristiano , Bottazzoli Elisa I , Lapolla Pierfrancesco , Brachini Gioia , Cirillo Bruno , Mingoli Andrea , Sica Giuseppe , Siragusa Leandro , Bellato Vittoria , Cerbo Daniele , de Pasqual Carlo A , de Manzoni Giovanni , di Cosmo Maria A , Alrayes Bourhan M H , Qandeel Mahmoud W M , Hani Mohammad Bani , Rabadi Alexander , el Muhtaseb Mohammad S , Abdeen Basel , Karmi Fahed , Žilinskas Justas , Latkauskas Tadas , Tamelis Algimantas , Pikūnienė Ingrida , Šlenfuktas Vygintas , Poskus Tomas , Kryzauskas Marius , Jakubauskas Matas , Mikalauskas Saulius , Jakubauskiene Lina , Hassan Soha Y , Altrabulsi Amani , Abdulwahed Eman , Ghmagh Reem , Deeknah Abdulqudus , Alshareea Entisar , Elhadi Muhammed , Abujamra Saleh , Msherghi Ahmed A , Tababa Osama W E , Majbar Mohammed A , Souadka Amine , Benkabbou Amine , Mohsine Raouf , Echiguer Sabrillah , Moctezuma-Velázquez Paulina , Salgado-Nesme Noel , Vergara-Fernández Omar , Sainz-Hernández Juan C , Alvarez-Bautista Francisco E , Zakaria Andee D , Zakaria Zaidi , Wong Michael P K , Ismail Razif , Ibrahim Aini F , Abdullah Nik A N , Julaihi Rokayah , Bhat Sameer , O’Grady Greg , Bissett Ian , Lamme Bas , Musters Gijsbert D , Dinaux Anne M , Grotenhuis Brechtje A , Aalbers Ernst J Steller Arend G J , Leeuwenburgh Marjolein M , Rutten Harm J T , Burger Jacobus W A , Bloemen Johanne G , Ketelaers Stijn H J , Waqar Usama , Chawla Tabish , Rauf Hareem , Rani Pallavi , Talsma Aaldert K , Scheurink Lieke , van Praagh Jasper B , Segelman Josefin , Nygren Jonas , Anderin Kajsa , Tiefenthal Marit , de Andrés Beatriz , de Heredia Juan P Beltrán , Vázquez Andrea , Gómez Tania , Golshani Parisa , Kader Rawaz , Mohamed Abudi , Westerterp Marinke , Marinelli Andreas , Niemer Quirine , Doornebosch Pascal G , Shapiro Joël , Vermaas Maarten , de Graaf Eelco J R , van Westreenen Hendrik L , Zwakman Marije , van Dalsen Annette D , Vles Wouter J , Nonner Joost , Toorenvliet Boudewijn R , Janssen Paul T J , Verdaasdonk Emiel G G , Amelung Femke J , Bahadoer Koen C M J Peeters Renu R , Holman Fabian A , Heemskerk Jeroen , Vosbeek Noortje , Leijtens Jeroen W A , Taverne Sophie B M , Heijnen Bob H M , El-Massoudi Youssef , de Groot-van Veen Irene , Hoff Christiaan , Jou-Valencia Daniela , Burghgraef Esther C J Consten Thijs A , Geitenbeek Ritch , Hulshof Lorenzo G W L , Slooter Gerrit D , Reudink Muriël , Bouvy Nicole D , Wildeboer Aurelia C L , Verstappen Sonja , Pennings Alexander J , van den Hengel Berber , Wijma Allard G , de Haan Jael , de Nes Lindsey C F , Heesink Vera , Karsten Tom , Heidsma Charlotte M , Koemans Willem J , Dekker Jan-Willem T , van der Zijden Charlène J , Roos Daphne , Demirkiran Ahmet , van der Burg Sjirk , Oosterling Steven J , Hoogteijling Tijs J , Wiering Bastiaan , Smeeing Diederik P J , Havenga Klaas , Lutfi Hamid , Consten Esther C J , Tsimogiannis Konstantinos , Sköldberg Filip , Folkesson Joakim , den Boer Frank , van Schaik Ted G , van Gerven Pieter , Sietses Colin , Hol Jeroen C , Boerma Evert-Jan G , Creemers Davy M J , Schultz Johannes K , Frivold Tone , Riis Rolf , Gregussen Hilde , Busund Sondre , Sjo Ole H , Gaard Maria , Krohn Nina , Ersryd Amanda L , Leung Edmund , Waqar Usama , Chawla Tabish , Rauf Hareem , Rani Pallavi , Sultan Hytham , Hajjaj Baraa Nabil , Alhisi Ahmed Jehad , Khader Ahmed A E , Mendes Ana Filipa Dias , Semião Miguel , Faria Luis Queiroz , Azevedo Constança , da Costa Devesa Helena M , Martins Sónia Fortuna , Jarimba Aldo M Rodrigues , Marques Sónia M Ribeiro , Ferreira Rita Marques , Oliveira António , Ferreira Cátia , Pereira Ricardo , Surlin Valeriu M , Graure Giorgiana M , Ramboiu Stefan Patrascu Sandu D , Negoi Ionut , Ciubotaru Cezar , Stoica Bogdan , Tanase Ioan , Stoica Bogdan , Ciubotaru Cezar , Negoita Valentina M , Florea Sabrina , Macau Florin , Vasile Mihai , Stefanescu Victor , Dimofte Gabriel-Mihail , Luncă Sorinel , Roată Cristian-Ene , Mușină Ana-Maria , Garmanova Tatiana , Agapov Mikhail N , Markaryan Daniil G , Eduard Galliamov , Yanishev Alexey , Abelevich Alexander , Bazaev Andrey , Rodimov Sergey V , Filimonov Victor B , Melnikov Andrey A , Suchkov Igor A , Drozdov Evgeniy S , Kostromitskiy Dmitriy N , Sjöström Olle , Matthiessen Peter , Baban Bayar , Gadan Soran , Jadid Kaveh Dehlaghi , Staffan Maria , Park Jennifer M , Rydbeck Daniel , Lydrup Marie-Louise , Buchwald Pamela , Jutesten Henrik , Darlin Lotten , Lindqvist Ebba , Nilsson Karl , Larsson Per-Anders , Jangmalm Staffan , Košir Jurij A , Tomažič Aleš , Grosek Jan , Božič Tajda Košir , Zazo Aya , Zazo Rama , Fares Hala , Ayoub Kusay , Niazi Ammar , Mansour Ali , Abbas Ayman , Tantoura Mohammad , Hamdan Alaa , Hassan Naya , Hasan Bassam , Saad Ahmad , Sebai Amine , Haddad Anis , Maghrebi Houcine , Kacem Montasser , Yalkın Ömer , Samsa Mehmet Veysi , Atak İbrahim , Balci Bengi , Haberal Elifcan , Dogan Lütfi , Gecim Ibrahim E , Akyol Cihangir , Koc Mehmet A , Sivrikoz Emre , Piyadeoğlu Deniz , Larkin John O , avanagh Dara O , Sökmen Selman , Bişgin Tayfun , Günenç Erşan , Güzel Melek , Leventoğlu Sezai , Yüksel Osman , Kozan Ramazan , Göbüt Hüseyin , Cengiz Fevzi , Erdinc Kemal , Acar Nihan Coşgun , Kamer Erdinc , Özgür İlker , Aydın Oguzhan , Keskin Metin , Bulut Mehmet Türker , Kulle Cemil B , Kara Yasin , Sıbıç Osman , Özata İbrahim H , Buğra Dursun , Balık Emre , Kulle Cemil B , Çakır Murat , Alhardan Anas , Colak Elif , Aybar Ahmet B CiftciEngin , Sari Ahmet Can , Atici Semra Demirli , Kaya Tayfun , Dursun Ayberk , Calik Bulent , Özkan Ömer Faruk , Ülgür Hanife Şeyda , Düzgün Özgül , Monson John , George Sarah , Woods Kayla , Al-Eryani Fatima , Albakry Rudaina , Coetzee Emile , Boutall Adam , Herman Ayesiga , Warden Claire , Mugla Naser , Forgan Tim , Mia Imraan , Lambrechts Anton 
Published: October 2023

Abstract

Background
The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied.

Methods
Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1).

Results
Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of −1.1 (95 per cent c.i. −9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (−28 to 52) days).

Conclusion
Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding.