Assessment of Various Prognostic Factors of Intestinal Anastomotic Leakage

Objectives: To determine the various prognostic factors of intestinal anastomosis leakage at tertiary care Hospital 
Material and Methods: This prospective cross-sectional study was conducted in Surgical Units of Liaquat University Hospital Jamshoro/Hyderabad. A total 100 patients were included those underwent intestinal anastomosis. After taking detailed history and clinical examination, in the patients’ relevant investigations i.e. Blood CP, X-ray abdomen, Methylene Blue Test (to confirm leaks) and ultrasound of the abdomen. If they remain free of any complication, they were discharged. After collection of data, the analyses were done using Statistical Package for Social Science (SPSS) program version 26.0 
Results: Mean age of the patients was recorded as 51.5+3.5 years and males were found in the majority (76.6%). In the clinical presentation, abdominal pain was the most common (63.6%). Typhoid 75(25.0%) was the most common diagnosis. The pathological sites were found as Ileocolic 180(60.0%). Poor nutritional status was in 60.0% cases. Anaemia was 40%, diabetes 20%, and hypertension 10%. A high steroid dose history was in 10% cases and 6.6% had a history of chemotherapy. Ischemia of the intestine at the suture line was seen in 6%, local sepsis was 20%, obstruction distal to the anastomosis was 6.6%, postoperative early adhesions was 6.6%. 
Conclusion: Male gender, poor nutritional status, diabetes, anemia, presence of local sepsis, chemotherapy and high dose steroid were observed highly prevalent and suspected as factors of anastomosis leakage. Furthermore, many efforts need to be made to reduce the mortality and morbidity rates associated with anastomotic leaks.


INTRODUCTION
Anastomotic leakage is the most feared complication of gastrointestinal surgery. However, anastomotic leakage in most patients presents in a dramatic fashion, early in the postoperative period, thus leaving little doubt in making an appropriate diagnosis. A considerable proportion present in a far more subtle fashion, late in the postoperative phase is common, consequently it's difficult to differentiate from other infectious postoperative complications. Even though a great advancement in gastrointestinal surgery has taken place but anastomotic leakage or dehiscence is still common in surgical practice, and greatly increases the morbidity and mortality associated with the surgery. Hence, doubles the hospital stay and increases the mortality up to a tenfold increase. 1 Patients with anastomotic leakage classically present with abdominal pain, rigid abdomen and tachycardia. The available literature suggests 10%-15% mortality rate after anastomotic leakage. [2][3][4][5] Though most cases having an Anastomotic leak develops more gradual but harmful outcomes. 6 The diagnosis appears to become much more challenging in these individuals, as the clinical history is typically identical to other postoperative infectious consequences. The cause of the leakage is often multifactorial, including patientrelated factors, additionally faulty technique contribution, at the line of suture intestinal ischemia, high pressure across the anastomosis and mesentery, local infection, and to the anastomosis obstruction distal, chronic obstructive pulmonary disease and multiple blood transfusions during the operation. The older age (>80 years), anaemic, malnutrition with numerous coexisting diseases, after chemoradiotherapy, getting heavy dosages of steroids are also the relatively higher risk to develop the Anastomotic leakage. 8 Available literature confirms the above factors, however it is not yet been established that which are the dependent factors and how they affect in combination. Therefore, this study was designed to analyze the various prognostic factors of intestinal anastomosis leakage at tertiary care Hospital.

MATERIALS AND METHODS
This prospective cross-sectional study was conducted in all surgical units of Liaquat University Hospital Jamshoro/ Hyderabad. All the patients who underwent gastrointestinal surgeries with intestinal anastomosis, aged > 12 years and of either gender, were included. All the patients who did not agree to participate in the study were excluded. The patient's or family member's written informed permission was obtained. Patients fulfilling the inclusion criteria and admitted to the Surgical Wards were selected. After taking a detailed history and clinical examination, all the required investigations, including abdominal ultrasound, were done. On a proforma created specifically for this study, the data of every participant was collected. Follow-up for ten weeks was carried out in all the cases. After the collection of data, the analysis was done by using the Statistical Package for Social Science (SPSS) programme version 26.
Poor nutritional status was found in the majority of the cases, 60.0%. As per co-morbidities, anaemia was found to be the most common 40%, diabetes 20%, and hypertension 10%. A history of high dose steroids was found in 10% of the cases, and a history of chemotherapy was noted in 6.6% of the cases. Suture line ischemia of the intestine was found in 6% of the cases, local sepsis was found in 20% of the cases, distal to the anastomosis was seen in 6.6% of the cases, 6.0% had postoperative early adhesions, 6.0% of the cases had developed postoperative internal herniation, and the hospital mortality rate was 8.0%. Table 2.

DISCUSSION
Anastomotic leaking is a potentially serious complication that can develop after colorectal surgery and result in increased morbidity and mortality, the establishment of a permanent stoma, and the recurrence of cancer. 9 Multiple risk factors for anastomotic leak have been found, and these can help to prevent and diagnose this serious complication earlier. 9 In this study male gender, poor nutritional status, diabetes, anemia, presence of local sepsis, chemotherapy and high dose steroid were suspected as factors of anastomosis leakage. These findings were almost similar to the study of Midura EF et al 10 the Male gender, steroid usage, smoking, open approach, operational time, and preoperative chemotherapy were all linked to an increased risk of anastomotic leaks, while divertion ileostomy was linked to a lower risk of leaks. In the study of Cheng S et al 11 demonstrated that the tumor differentiation medium degree, anastomotic method, chemoradiotherapy, intraoperative bleeding, diabetes and smoking were the causative factors of anastomosis leakage. While many writers believe that surgery time is a simple metric of difficulty, greater surgery time produces changes in inflammatory mediator activities, resulting in a large frequency of ischemic and septic sequelae. On other hand Lavanya NR et al 12 reported that the eight of the thirteen patients who experienced anastomotic leak were men. Anastomotic leak developed in one patient undergoing elective surgery. Four of the 13 cases with anastomotic leak were anaemic, four were hyponatremic, and five were hypoalbuminemia. Nine of the 13 patients with anastomotic leak had peritonitis at the time of presentation. In this study, the mean age of patients was 51.5+3.5 years and males were found in the majority (76.6%). Consistently, El-Badawy HA et al. reported that the average age of the study subjects was 44.23 years, and males were in the majority 63.64%. In another study, of Gutema Wako et al15 reported that 46.44 years was the average age of the cases, and males were 74.8%. In this study, anaemia and poor nutritional status were highly frequent. On the other hand, it is stated that anaemia has been linked to the development of leaks. Hemoglobin is linked to anastomotic margin perfusion and oxygenation, which are critical for anastomotic healing.15 Currently, this is a research topic, and various authors have found that haemoglobin levels less than 11 g/dL increase the risk of leak, as explained by a diminished capacity to transfer oxygen to the tissues and the danger of ischemia that follows.15,16

CONCLUSION
Male gender, poor nutritional status, diabetes, anemia, local sepsis, chemotherapy, and high dose steroids were found to be highly prevalent and suspected as factors in anastomosis leakage. Morbidity can be reduced by improving nutritional status and managing anaemia properly. many efforts need to be made to bring down the mortality and morbidity rates associated with anastomotic leaks.

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).