The REAL (REctal Anastomotic Leak) score for prediction of anastomotic leak after rectal cancer surgery
Anastomotic leak after rectal cancer surgery is a severe complication associated with poorer oncologic outcome and quality of life. Preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity to create a defunctioning stoma.
The purpose of this study was to identify and quantify the risk factors for anastomotic leak to minimize risk by either not restoring bowel continuity or protecting the anastomosis with a temporary diverting stoma.
Potentially relevant studies were identified from the following databases: PubMed, Embase and Cochrane Library. This meta-analysis included studies on transabdominal resection for rectal cancer that reported data about anastomotic leak. The risk for anastomotic leak after rectal cancer surgery was investigated. Preoperative, intraoperative, and postoperative factors were extracted and used to compare anastomotic leak rates. All variables demonstrating a p value < 0.1 in the univariate analysis were entered into a multivariate logistic regression model to determine the risk factors for anastomotic leak.
Twenty-six centers provided individual data on 9735 patients. Selected preoperative covariates (time before surgery, age, gender, smoking, previous abdominal surgery, BMI, diabetes, ASA, hemoglobin level, TNM classification stage, anastomotic distance) were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. With a threshold value of the receiver operating characteristics (ROC) curve corresponding to 0.0791 in the training set, the area under the ROC curve (AUC) was 0.585 (p < 0.0001). Sensitivity and specificity of the model’s probability > 0.0791 to identify anastomotic leak were 79.1% and 32.9%, respectively. Accuracy of the threshold value was confirmed in the validation set with 77.8% sensitivity and 35.2% specificity.
We trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. The score is now available online (http://www.real-score.org).
KeywordsRectal cancer Anastomotic leak Score
We wish to thank the study participants, without whose contribution this study would not have been possible. REAL Score Collaborators are: Takashi Akiyoshi, Department of Gastroenterological Surgery, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan. Sergio Eduardo Alonso Araujo, Division of Surgical Oncology V. Santa Catarina Teaching Hospital SBIB Albert Einstein, Sao Paulo, Brazil. Gian Luca Baiocchi, Surgical Clinic-Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy. Roberto Bergamaschi, Division of Colon & Rectal Surgery, State University of New York, Stony Brook, NY USA. Claus Anders Bertelsen, Department of Surgery, Hillerød University Hospital, Copenhagen, Denmark. Roberto Biffi, Dept. of General Surgery-European Institute of Oncology and University of Milan, Italy. Marco Augusto Bonino, PhD, Department of Surgical Sciences, University of Torino, Italy. Riccardo Brachet Contul, Department of Surgery, Aosta, Italy. Krzysztof Bujko, Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, Poland. Jasna But-Hadzic, Radiotherapy Department, Institute of Oncology, Ljubljana, Slovenia. Annemieke Cats, Department of Gastroenterology and Hepatology, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands. Miguel A. Cuesta, Department of Surgery, VU Medical Center, Amsterdam, The Netherlands. Jacopo Desiderio, Department of Digestive Surgery and Liver Unit, St. Maria Hospital, Terni, Italy. Morten Tandberg Eriksen, MD, Department of Surgery, Buskerud Hospital, Drammen, Norway. Serge Evrard, Institut Bergonié, Université de Bordeaux, France. Dominic CC Foo, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China. Hironori Fukuoka, Department of Gastroenterological Surgery, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan. Henrik Harling, Department of Surgery, Bispebjerg University Hospital, Copenhagen, Denmark. Eiji Hidaka, Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan. Kalpesh Jani, SIGMA Surgery, India. Julien Jarry, Institut Bergonié, Université de Bordeaux, France. Jin Cheon Kim, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea. Marilyne M. Lange, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands. Zaher Lakkis, Department of colorectal surgery, Beaujon Hospital and University Paris VII, France. Wai Lun Law, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China. Seok-Byung Lim, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea. Joseph E. Martz, Department of surgery, Beth Israel Medical Center, NY, USA. Elma Meershoek-Klein Kranenbarg, Leiden University Medical Center, The Netherlands. Roger Motson, The ICENI Center, Colchester General Hospital, Colchester, UK. Valero Navarro Graciela, Department of General Surgery, Virgen de la Arrixaca University Hospital, University of Murcia, Murcia, Spain. Chinnasamy Palanivelu, GEM Hospital, India. Yves Panis, Department of colorectal surgery, Beaujon Hospital and University Paris VII, France. Amilcare Parisi, Department of Digestive Surgery and Liver Unit, St. Maria Hospital, Terni, Italy. Roberto Passera, BioStat & PharmD, Division of Nuclear Medicine, University of Torino, Italy. Koen C.M.J. Peeters, Leiden University Medical Center, The Netherlands. Freddy Penninckx, MD, Department of Abdominal Surgery, Leuven, Belgium. Carlo Augusto Sartori, General Surgery Department, Castelfranco Veneto Hospital, Castelfranco Veneto, Italy. Kassem Shmaissany, Dept. of General Surgery-European Institute of Oncology and University of Milan, Italy. Matej Škrovina, Czech Republic, Oncological Center Novy Jicin, Czech Republic. Cornelis J.H. van de Velde, Leiden University Medical Center, The Netherlands. Vincent van der Noort, Biometrics Department, Netherlands Cancer Institute, Amsterdam, The Netherlands. Alexander A. F. A. Veenhof, Department of Surgery, VU Medical Center, Amsterdam, The Netherlands. Vaneja Velenik, Radiotherapy Department, Institute of Oncology, Ljubljana, Slovenia. Arne Wibe, MD, Institute of Cancer Research and Molecular Medicine, Trondheim University Hospital, Norway. Karen You, Division of Colon & Rectal Surgery, State University of New York, Stony Brook, NY, USA.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 27.Araújo SE, Seid VE, Bertoncini A et al (2011) Laparoscopic total mesorectal excision for rectal cancer after neoadjuvant treatment: targeting sphincter-preserving surgery. Hepatogastroenterology 58:1545–1554Google Scholar
- 38.Sammour T, Lewis M, Thomas ML, Lawrence MJ, Hunter A, Moore JW (2017) A simple web-based risk calculator (http://www.anastomoticleak.com) is superior to the surgeon’s estimate of anastomotic leak after colon cancer resection. Tech Coloproctol 21:35–41
- 46.Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos D (2012) Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2:CD003144Google Scholar
- 50.Marijnen CA, Kapiteijn E, van de Velde CJ et al (2002) Cooperative Investigators of the Dutch Colorectal Cancer Group. Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 20:817–825CrossRefGoogle Scholar
- 55.Smith ST, Seski JC, Copeland LJ, Gershenson DM, Edwards CL, Herson J (1985) Surgical management of irradiation-induced small bowel damage. Obstet Gynecol 65:563–567Google Scholar