• Nynke G Greijdanus, Kiedo Wienholts, Sander Ubels, Kevin Talboom, Gerjon Hannink, Albert Wolthuis, F Borja de Lacy, Jérémie H Lefevre, Michael Solomon, Matteo Frasson, Nicolas Rotholtz, Quentin Denost, Rodrigo O Perez, Tsuyoshi Konishi, Yves Panis, Martin Rutegård, Roel Hompes, Camiel Rosman, Frans van Workum, Pieter J Tanis, de WiltJohannes H WJHW0000-0001-6773-9668Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands., and TENTACLE-Rectum Collaborative Group.
• Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
• Br J Surg. 2023 Nov 9; 110 (12): 186318761863-1876.

BackgroundThe optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied.MethodsPatients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1).ResultsOf 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days).ConclusionPrimary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding.© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.

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