Management of anastomotic leak after elective anterior resection for rectal cancer: A systematic review and pooled analysis.

[BACKGROUND] Anastomotic leak (AL) following rectal cancer resection significantly increases the clinical care, risks morbidity and mortality and impairs oncological outcomes. AL management is not standardised. This systematic review and pooled analysis evaluated the comparative efficacy of the various reported strategies.

[METHOD] After protocol generation with AMSTAR2, a systematic search was conducted in EMBASE, PubMed and SCOPUS. Primary and secondary outcome measures were pooled using the DerSimonian-Laird method with 95% confidence intervals, I statistics for heterogeneity and Egger and Begg's testing for bias, defining success as resolution of pelvic sepsis and/or healing of AL.

[RESULTS] Sixteen studies published between 2010 and 2024 comprising 7236 patients, 850 with AL, met eligibility criteria albeit with significant heterogeneity (I > 50%), reporting variability and moderate bias. Overall, success rates with conservative management (CM) was 44.4%, drainage procedures (DP) 73.7% (78.7% for passive drainage and 73.5% for active drainage), anastomosis conserving surgery (ACS) 69.7% and anastomotic takedown (SAT) 77.0%. Short-term mortality was CM: 0%, DP: 0.97%, ACS: 2.92% and SAT: 1.49%. Mean length of stay was CM: 28.7 days, DP: 59.9 days, ACS: 19.8 days and SAT: 14.7 days. Further intervention occurred in CM: 55.6%, DP: 29.1%, ACS: 53.3% and SAT: 41.1%. Long-term stoma rates were CM: 33.3%, DP: 22.5%, ACS: 27.6% and SAT: 46.0%.

[CONCLUSION] Drainage techniques demonstrate high success with low mortality and further intervention rate albeit with lengthened hospital stay. Surgical approaches also achieve success although mortality and long-term stoma rates are higher. Future studies need a core outcome set.