Risk Factors for and Oncologic Impact of Anastomotic Leakage After Sphincter-Preserving Proctectomy for Mid/Low Rectal Cancer: A Multi-institutional Cohort Study in Japan.

Background: Anastomotic leakage after sphincter-preserving proctectomy is a serious postoperative complication. It is unclear whether diverting ostomy prevents anastomotic leakage, and whether anastomotic leakage worsens long-term oncologic outcomes.

Patients and methods: Data from patients with stage II-III mid/low rectal cancer who underwent sphincter-preserving proctectomy between January 2010 and December 2011 were retrospectively analyzed using a multicenter database from 69 institutions. Factors associated with anastomotic leakage and its influence on oncologic outcomes were evaluated.

Results: A total of 922 patients were included. Anastomotic leakage was diagnosed in 125 patients (13.6%). Anastomotic leakage was associated with increased reoperations (29.6% vs. 1.0%, p < 0.0001), longer hospital stays (median 34 days vs. 15 days, p < 0.0001), and more frequent permanent ostomy (20.8% vs. 11.0%, p = 0.002). Multivariable analysis revealed that absence of diverting ostomy (odds ratio 2.46, 95% confidential interval 1.59-3.85, p = 0.0004) and male sex (odds ratio 2.54, 95% confidence interval 1.58-4.26, p = 0.001) were independently associated with an increased risk of anastomotic leakage. The risk reduction with diverting ostomy was observed in both sexes in interaction term analysis. Anastomotic leakage was associated with an increased risk of local recurrence in patients with pathologic stage III disease (hazard ratio 2.11, 95% confidence interval 1.08-4.14, p = 0.03) but was not associated with overall or recurrence-free survival.

Conclusions: Absence of diverting ostomy and male sex were risk factors for anastomotic leakage, and anastomotic leakage was associated with increased local recurrence in patients with stage III disease. These findings support the practice of protective diversion after sphincter-preserving proctectomy in patients with mid/low rectal cancer.