Changes in Clinical Practice Reduce the Rate of Anastomotic Leakage After Colorectal Resections

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Colorectal resections with primary anastomosis (n=894). Intervention: Changes in clinical practice (exclusion of perioperative NSAIDs, goal-directed fluid therapy, avoidance of primary anastomoses in emergency resections) vs. Standard clinical practice (before 2010). Primary outcome: Cumulative incidence of anastomotic leakage (RR 0.45, 95% CI 0.27-0.75, p=0.002).

Q: What does this research mean for the field?

A structured change in clinical practice—including excluding perioperative NSAIDs, utilizing goal-directed fluid therapy, and avoiding primary anastomoses in emergency resections—reduces the rate of anastomotic leakage after colorectal resections. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Henrik Iversen; Madelene Ahlberg; M. Lindqvist; Christian Buchli

doi:10.1007/s00268-017-4423-7

December 27, 2017World Journal of SurgeryOpen Access

Changes in Clinical Practice Reduce the Rate of Anastomotic Leakage After Colorectal Resections

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Key result

Structured practice changes linked to a ~55% reduction in anastomotic leakage after colorectal resection.

RR 0.45
95% CI 0.27-0.75
P=0.002
n=894

Figures

Why the study?

Anastomotic leakage is a serious complication after colorectal resections associated with increased length of stay, morbidity, and mortality, prompting evaluation of whether changes in clinical practice reduce leakage rates.

Does a structured change in clinical practice reduce the rate of anastomotic leakage in patients undergoing colorectal resections?

Key Points

To evaluate the effect of structured changes in clinical practice on anastomotic leakage rates following colorectal resections.
Analyzed 894 consecutive patients (N=894) receiving a primary anastomosis following colorectal resection at a single tertiary referral center between 2006 and 2013.
Compared outcomes before and after January 2010 practice changes, which eliminated perioperative nonsteroidal anti-inflammatory drugs, introduced intra-operative goal-directed fluid therapy, and avoided primary anastomoses in emergency resections.
The cumulative incidence of anastomotic leakage decreased from 10.0% (41 of 409) before the protocol change to 4.5% (22 of 485) afterward (relative risk 0.45, 95% CI 0.27–0.75, p = 0.002; adjusted odds ratio 0.45, 95% CI 0.26–0.78, p = 0.004).
Leakage rates fell significantly after colon resections from 9.1% (23 of 252) to 4.5% (14 of 310) (RR 0.49, 95% CI 0.26–0.94, p = 0.039) and after rectal resections from 11.5% (18 of 157) to 4.6% (8 of 175) (RR 0.40, 95% CI 0.18–0.89, p = 0.024).

Study Design

Type

Cohort (n=894)

Multicenter

No

Structured PICO

Does a structured change in clinical practice reduce the rate of anastomotic leakage in patients undergoing colorectal resections?

P

Population

894 consecutive patients undergoing colon or rectal resection with primary anastomosis at a Swedish tertiary referral center, evaluated for 30-day anastomotic leakage before and after a clinical practice change.

E

Exposure

Changes in clinical practice introduced in January 2010 (exclusion of perioperative nonsteroidal anti-inflammatory drugs, introduction of intra-operative goal-directed fluid therapy, and avoidance of primary anastomoses in emergency resections)

C

Comparator

Clinical practice before January 2010

O

Outcome

Incidence of anastomotic leakagesafety

Main Result

Relative Risk: 0.45 (95% CI 0.27–0.75)

Absolute Event Rate: 4.5% vs 10%

p-value: p=0.002

Implementing structured changes in clinical practice, including NSAID exclusion and goal-directed fluid therapy, significantly reduces anastomotic leakage rates after colorectal resections.

Limitations

The retrospective cohort design cannot determine to what extent each individual component contributed to the reduction in anastomotic leakage.
An overestimation of NSAID use during the control period and goal-directed fluid therapy during the intervention period cannot be excluded.
The local quality database lacked information about neo-adjuvant treatment (preoperative irradiation).
Asymptomatic grade A leakages were not registered in the trial.
External validity may be restricted due to a higher proportion of multivisceral resections and a very small proportion of minimally invasive procedures compared to the general population.

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Implication

Structured changes were associated with lower leakage rates; hypothesis-generating and requires randomized confirmation before practice change.

Abstract

BACKGROUND: Anastomotic leakage is a serious clinical problem after colorectal resections and is associated with a significantly increased length of stay, morbidity and mortality. The aim of the present study was to evaluate the effect of changes in clinical practice on anastomotic leakage rate after colorectal resections. METHODS: Retrospective cohort study based on prospectively collected data. All 894 patients with primary anastomosis after colorectal resection at a tertiary referral center between 2006 and 2013 were analyzed. Changes in clinical practice aiming at reducing the rate of anastomotic leakages were introduced in January 2010 and were characterized by exclusion of perioperative nonsteroidal anti-inflammatory drugs, introduction of intra-operative goal-directed fluid therapy and avoidance of primary anastomoses in emergency resections. The study population was divided into two groups, one treated before and one after the introduction of changes in clinical practice. Groups were compared regarding patient characteristics and incidence of anastomotic leakage. RESULTS: The cumulative incidence of anastomotic leakage after colorectal resections decreased from 10.0% (41 of 409) to 4.5% (22 of 485) after changing clinical practice, relative risk 0.45 (95% CI 0.27-0.75, p = 0.002). The adjusted odds ratio was 0.45 (0.26-0.78, p = 0.004). A separate analysis showed a decrease after colon resections from 9.1% (23 of 252) to 4.5% (14 of 310), relative risk 0.49 (0.26-0.94, p = 0.039), and from 11.5% (18 of 157) to 4.6% (8 of 175) after rectal resections, relative risk 0.40 (0.18-0.89, p = 0.024). CONCLUSION: Implementing a structured change of clinical practice can significantly reduce the anastomotic leakage rate after colorectal resections. TRIAL REGISTRATION: Clinical trial registration number: ACTRN12617001497392.

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Cite This Study

Iversen et al. (2017) conducted a cohort in Colorectal resections with primary anastomosis (n=894). Changes in clinical practice (exclusion of perioperative NSAIDs, goal-directed fluid therapy, avoidance of primary anastomoses in emergency resections) vs. Standard clinical practice (before 2010) was evaluated on Cumulative incidence of anastomotic leakage (RR 0.45, 95% CI 0.27-0.75, p=0.002). A structured change in clinical practice, including exclusion of perioperative NSAIDs and goal-directed fluid therapy, reduced the rate of anastomotic leakage after colorectal resections from 10.0% to 4.5% (RR 0.45).

synapsesocial.com/papers/6aa7fd9ed35154b47a31119a https://doi.org/10.1007/s00268-017-4423-7

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Changes in Clinical Practice Reduce the Rate of Anastomotic Leakage After Colorectal Resections

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Changes in Clinical Practice Reduce the Rate of Anastomotic Leakage After Colorectal Resections

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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