Why use an anastomotic risk-stratifier
Objective 2: The purpose of stratifying patient risk of anastomotic leak
There is a small sub-group of patients who are at highest risk of anastomotic leak. In the ESCP audit data, this sub-group contributed a high proportion of the patients who suffered anastomotic leak overall.
A risk stratifier allows many of these patients to be identified before operation.
This highest risk group may benefit from interventions to modify underlying risk factors, or may in fact wish to avoid the risk of leak all together and consider a defunctioning stoma. Risk stratification can enhance informed consent as part of this decision making process.
The causes of anastomotic leak are multi-factorial, and so can be difficult to predict. Sophisticated computer algorithms have been developed that use big clinical data sets to help objectively predict the risk of anastomotic leak.
The ESCP Safe-anastomosis programme encourages surgeons to routinely use preoperative risk stratification before both elective and emergency right colectomy.
This hopes to improve patient outcomes in four ways:
- Two of these influence pre-operative care and decision making
- Two of these influence intra-operative or post-operative care.
In the pre-operative period, risk stratification can:
- Specific interventions can be used to modify risk factors in high-risk patients.
- Factors that can potentially be modified in the pre-operative setting including as smoking, body mass index, medications, and hypoalbuminaemia.
- Read more about a systematic review of risk factors.
- Objective assessment of risk is fundamental to patient consent.
- Risk stratification allows a personalised approach to the consent process, driven by individual patient’s characteristics.
- Better understanding of risk empowers shared decision making by patients and surgeons, and is recommended by international guidelines.
- Read more about risk stratification in patient consent.
If a patient is predicted to have a high risk of leak the options of either an end or loop stoma should be discussed at the time of consent.
In the intra-operative and post-operative period, pre-operative risk stratification can:
- The predicted risk of leak may inform the surgeon’s choice of anastomotic technique.
- For example, in the 2015 ESCP audit, data suggested that hand sewn anastomoses may be safer with diseased bowel or the presence of intra-abdominal infection.
- Additional measures to check the integrity of the anastomosis and its perfusion may also be possible.
- Related paper: Relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection
- High-risk patients should be considered for admission to post-operative wards that offer closer monitoring (e.g. critical care unit).
- High-risk patients may benefit from additional post operative tests, such as serial c-reactive protein (CRP) monitoring
- CRP monitoring is useful as a negative predictive test for the development of an anastomotic leak
- Related paper: Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery