Anastomotic leakage in colorectal cancer surgery in Syria: risk factors and improvements following guideline implementation - a retrospective cohort study.

[BACKGROUND] Anastomotic leakage (AL) is a serious complication following colorectal cancer surgery, associated with increased morbidity, mortality, and impaired oncologic outcomes. Evidence from resource-limited, conflict-affected settings such as Syria is scarce. This study aimed to identify risk factors for AL and evaluate outcomes after implementation of revised institutional preoperative guidelines.

[MATERIALS AND METHODS] A retrospective cohort study was conducted at Damascus Hospital, Syria. The first cohort (January 2016-February 2024) included patients undergoing elective sigmoid colon or rectal resection. Based on the findings, preoperative preparation guidelines were updated, and a follow-up cohort (April 2024-October 2025) was evaluated. AL was defined according to the International Study Group of Rectal Cancer criteria. Patient-, tumor-, and procedure-related factors were analyzed, and outcomes before and after guideline implementation were compared.

[RESULTS] The first cohort ( = 100) had an AL incidence of 15% and postoperative mortality of 19%. Significant risk factors included hypoalbuminemia, anemia, perioperative blood transfusion, prolonged corticosteroid use, extra-peritoneal anastomosis, and poor tumor differentiation. Following guideline implementation ( = 19), hypoalbuminemia decreased from 61.3% to 10.5%, perioperative transfusions from 60% to 42.1%, AL incidence from 15% to 10.5%, and mortality from 19% to 15.8%. Comparison with international studies highlighted the high baseline prevalence of hypoalbuminemia and AL, emphasizing the importance of nutritional optimization.

[CONCLUSION] AL is strongly associated with modifiable factors, particularly hypoalbuminemia and anemia. Evidence-based guideline implementation targeting these factors significantly improved postoperative outcomes, demonstrating the value of context-specific interventions in resource-limited settings.