Anastomotic leakage stands as one of the most frequently encountered complications following intestinal surgery. Despite advancements in surgical techniques, it has persisted as a daunting complication throughout the past century. Managing these leaks can prove challenging and often leads to considerable frustration among surgeons [1]. Anastomotic leaks are frequently linked to prolonged hospital stays, elevated mortality and morbidity rates, and a heightened likelihood of readmission. Research has demonstrated that the mortality rate associated with anastomotic leaks ranges from 9% to 40%, often resulting in a 10% to 100% increase in the need for a permanent stoma. Among gastrointestinal cancer patients who experience anastomotic leaks, there is a greater risk of recurrence. Furthermore, these patients often face significant delays in receiving post-surgery chemotherapy [2].

Typically, anastomotic leakage tends to manifest between the 4th and 6th days following surgery. Clinical symptoms can range from mild, including low-grade fever and abdominal pain, to more severe presentations like prolonged ileus or failure to thrive [3]. The occurrence of anastomotic leakage is influenced by multiple factors. While suboptimal surgical techniques can certainly contribute to such leaks, there are instances when anastomotic leakage becomes unavoidable even with technically sound procedures. Numerous research studies have sought to uncover the risk factors associated with anastomotic leakage. These factors include the presence of local sepsis, insufficient blood supply to the sutured area (intestinal ischemia), excessive tension at the anastomotic site, and the presence of an obstruction downstream from the anastomosis [4, 5].

This prospective study aims to assess a range of risk factors linked to anastomotic leakage following elective or emergency open intestinal resection. Furthermore, the study seeks to identify independent predictive factors associated with anastomotic leakage, with the intention of using these predictive values to enhance the management of such occurrences in the future [6, 7].

This study was conducted within the Department of Surgery over a one-year period, focusing on patients who underwent intestinal anastomosis involving both the small and large intestine. All patients who received intestinal anastomosis, whether in emergency or routine operating room settings, were included in the study. Comprehensive patient data was collected, encompassing details such as age, gender, occupation, socioeconomic background, as well as histories of smoking and alcohol consumption. Additionally, a thorough clinical assessment included the presence of any concurrent medical conditions like diabetes, hypertension, or renal failure, along with the identification of risk factors that may contribute to these conditions. The study also documented any prior instances of intestinal pathologies, tuberculosis, or abdominal surgeries in the patients’ medical histories. Following the inclusion of patients in the study, a comprehensive general examination was carried out. This examination encompassed the assessment of various vital signs, including pulse, blood pressure, and temperature.

Additionally, observations were made regarding the presence of physical indicators such as cyanosis, jaundice, edema, and generalized lymphadenopathy. Respiratory parameters, including the rate and type of respiration (abdominothoracic/thoracoabdominal), were also noted. Other aspects evaluated included the degree of pallor, signs of dehydration (assessed by dryness of the tongue, skin turgor, and sunken eyeballs), and any notable skin tumors. All this gathered data was accurately recorded for each patient. A comprehensive clinical examination of the abdomen was performed, involving the assessment of various aspects. This included measuring abdominal distension, observing peristalsis and its pattern, checking for the presence or absence of previous operation scars or hernial orifices, and noting bowel sounds. Additionally, detailed clinical examinations were conducted for the cardiovascular system, respiratory system, central nervous system (CNS), and genitourinary system.

Routine laboratory investigations were conducted for all patients, comprising assessments such as hemoglobin (Hb%) levels, total leukocyte count (TLC), differential leukocyte count (DLC), serum electrolyte levels, urea and creatinine levels, serum albumin levels, liver function tests, random blood sugar levels, and a complete urine examination. The data collected from all the variables were subjected to analysis using the Chi-square test with continuity correction, which helps in reducing the number of independent variables considered for analysis [8]. Variables that reached a significance level, typically set at \(p=0.05\), were then subjected to further examination through multivariate analysis. This was accomplished using the forward stepwise logistic regression test, allowing for a more comprehensive evaluation of their significance and potential predictive power.

Regarding gender differences, males exhibited a slightly higher rate of anastomotic leakage at 16.65% compared to females at 14.72%. However, it’s worth mentioning that this difference did not reach statistical significance. Importantly, the study found a significantly higher survival rate among patients who did not experience a leak \((p<0.001)\). Relationship of associated systemic chronic diseases with the incidence of anastomotic leaks is presented in Table 2 and the association of preoperative ASA grading with leak incidence is given in Table 3.

The study demonstrated an increase in the rate of anastomotic leaks as the ASA (American Society of Anesthesiologists) grading increased. Patients with ASA grade I had an 11.11% incidence of leaks, while in grade IV patients, the leak rate escalated to 50% \((p<0.01)\).

Furthermore, the presence of radiological findings suggestive of intestinal obstruction (66.66%), pleural effusion (41.66%), and pneumonitic patches (30%) were associated with higher rates of leaks. Additionally, a higher incidence of anastomotic leakage was observed in cases of emergency surgeries (17.59%) and when parenteral nutrition was not administered (18.75%). Colorectal anastomosis (26.66%) performed using a double-layer technique (16.66%) and cases involving a blood loss of more than one liter, either preoperatively or postoperatively, were also linked to an increased leak rate (36.36%).

Even with the advancements in surgical techniques, anastomotic disruption remains a dreaded and severe complication of intestinal surgery. Extensive research has been conducted to pinpoint factors that promote the successful healing of anastomosis, as well as those that increase the risk of anastomotic disruption. In our study, we assessed a total of 150 patients over a one-year study period to contribute to this understanding. In our study, we observed a relatively higher incidence of anastomotic leakage, reaching 16%. The highest incidence rate was found in the 50-60 years age group at 23.08%, followed by the 0-10 years age group at 18.17%. Interestingly, our findings differ from those of Makela et al. [6] who reported that age does not significantly affect the incidence of anastomotic leakage in patients.

Furthermore, our study indicated that patients suffering from anastomotic leakage experienced approximately three times longer hospital stays and increased morbidity. While we noted a slightly higher incidence of leaks in males, this result did not reach statistical significance (p>0.05).[7, 8] This contrasts with some studies that suggest male gender as an independent risk factor for colonic anastomotic leaks. However, it’s important to note that our study may have seen different results due to the presence of multiple risk factors and a higher number of male patients in our sample. Prior research has consistently demonstrated that individuals with a lower socioeconomic status face adverse implications on their prognosis and surgical outcomes. Patients from lower socioeconomic backgrounds tend to experience malnutrition, anemia, immunosuppression, and a higher susceptibility to infections and inflammatory conditions. All of these factors can significantly impede the process of wound healing [9]. In our current study, approximately two-thirds of the study population came from a low socioeconomic status, with a substantial portion having hemoglobin levels below 10 gm/dL (29.41%) \((p<0.05)\). Choudhuri et al. [10] also reported that a hemoglobin level less than 8 gm/dL is independently associated with a greater incidence of anastomotic leakage [10].

A notably elevated rate of anastomotic leakage was observed in patients undergoing corticosteroid therapy, reaching 66.66% \((p<0.001)\). This finding aligns with the stud[11], which also reported an increased anastomotic leak rate among patients receiving corticosteroid therapy.

Furthermore, our study revealed a relatively high but statistically nonsignificant association between chronic diseases and anastomotic complications. Approximately half of the cases with leaks had underlying chronic diseases, including chronic obstructive pulmonary disease (30%) and malignancy. However, no significant association was identified between diabetes and anastomotic leakage [12].

In our study, a consistent rise in the leak rate was observed with the duration of the surgery. However, we did not identify a significant association between excessive blood loss and the occurrence of leaks \((p>0.05)\) [13].

The authors declare no conflicts of interest.

All authors contributed equally to this paper. They have all read and approved the final version.

1. Phillips, B. (2016). Reducing gastrointestinal anastomotic leak rates: Review of challenges and solutions. Open Access Surgery, 9, 5-14
2. Krarup, P. M., Nordholm-Carstensen, A., Jorgensen, L. N., & Harling, H. (2014). Anastomotic leak increases distant recurrence and long-term mortality after curative resection for colonic cancer: A nationwide cohort study. Annals of Surgery, 259, 930-938.
3. Pickleman, J., Watson, W., Cunningham, J., Fisher, S. G., & Gamelli, R. (1999). The failed gastrointestinal anastomosis: An inevitable catastrophe? Journal of the American College of Surgeons, 188, 473-482.
4. Rahbari, N. N. (2010). Definition and grading of anastomotic leakage following anterior resection of the rectum: A proposal by the International Study Group of Rectal Cancer. Surgery, 147, 339-351.
5. Bruce, J., Krukowski, Z. H., Al-Khairy, G., Russell, E. M., & Park, K. G. (2001). Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. British Journal of Surgery, 88, 1157-1168.
6. Makela, J. T., Kiviniemi, H., & Laitinen, S. (2003). Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastomosis. Diseases of the Colon & Rectum, 46, 653-660.
7. Zhou, C., Wu, X. R., Liu, X. H., Chen, Y. F., Ke, J., He, X. W., ... & Lan, P. (2018). Male gender is associated with an increased risk of anastomotic leak in rectal cancer patients after total mesorectal excision. Gastroenterology Report, 6(2), 137-143.
8. Park, J. S., Huh, J. W., Park, Y. A., Cho, Y. B., Yun, S. H., & Kim, H. C. (2016). Risk factors of anastomotic leakage and long-term survival after colorectal surgery. Medicine (Baltimore), 95(8), e2890}.
9. Daams, F., Luyer, M., & Lange, J. F. (2013). Colorectal anastomotic leakage: Aspects of prevention, detection, and treatment. World Journal of Gastroenterology, 19, 2293-2297.
10. Choudhuri, A. H., Uppal, R., & Kumar, M. (2013). Influence of non-surgical risk factors on anastomotic leakage after major gastrointestinal surgery: Audit from a tertiary care teaching institute. International Journal of Critical Illness and Injury Science, 3, 246-249.
11. Golub, R., Golub, R. W., Cantu, J. R., & Stein, H. D. (1997). A multivariate analysis of factors contributing to leakage of intestinal anastomoses. Journal of the American College of Surgeons, 184, 364-372.
12. }Kim, S. H., Son, S. Y., Park, Y. S., Ahn, S. H., Park, D. J., & Kim, H. H. (2015). Risk factors for anastomotic leakage: A retrospective cohort study in a single gastric surgical unit. Journal of Gastric Cancer, 15, 167-175.
13. Jannasch, O., Klinge, T., Otto, R., Chiapponi, C., Udelnow, A., Lippert, H., ... & Mroczkowski, P. (2015). Risk factors, short and long term outcome of anastomotic leaks in rectal cancer. Oncotarget, 6(34), 36884-36893.