Balancing Risk in Rectal Cancer Surgery: A Retrospective Cohort Study Examining the Consequences of Anastomotic Leaks and Diversion

Aim: This study aimed to aid decision-making concerning selective diversion in rectal cancer surgery by examining the complications and management of anastomotic leaks in diverted and undiverted patients, as well as ileostomy complications and permanence.Method: A review of all anterior resections performed at our United Kingdom tertiary referral center between 2012 and 2018 was conducted to assess anastomotic leaks and their management and ileostomy-related complications and closure rate.Results: Of 578 total anterior resections, 223 (38.5%) were diverted.Leaks occurred in 40 (6.9%), of which 25 (62.5%) were diverted and 15 (37.5%) were undiverted; 89% of diverted patients did not leak.There was one death, which was not leak-related.Of the 40 leaks, 24 (60%) were managed transanally and percutaneously with antibiotics or were incidental; these were mostly in the diverted patients.Undiverted patients underwent operative management more frequently, mostly with laparoscopic washout and ileostomy formation (47%).Ileostomy morbidity was common at both creation (27%) and closure (25%), with a leak rate of 3%.Diversion permanence occurred in 16% overall and 10% in ileostomies created at rescue, the most common reason being disease progression (38%) as opposed to leakage (11%). Conclusion:The anastomotic leak rate is low, with one-third of all patients being "overprotected" and thus unlikely to derive any benefit from index diversion.Although diverted patients are more likely to have non-operative management of a leak, significant ileostomy complication rates and permanence should be taken into account when deciding which patients to divert.