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Objective: To characterize the rate and time course of clinical leak in diverted colorectal anastomoses.
Design: Cohort analysis.
Setting: Subspecialty practice at a tertiary care facility.
Patients: Consecutive subjects undergoing colorectal anastomosis and proximal fecal diversion between 7/16/2007-5/31/2012.
Interventions: None
Main Outcome Measures: Clinical leak.
Results: From a cohort of 6239 operative encounters, 238 patients underwent a colorectal anastomosis with proximal fecal diversion. A total of 33(14%) clinical leaks were identified at a median of 47-days. Clinical leaks were identified in 12(5%) patients within 30-days of surgery (early leaks) and in 21(9%) patients after 30-days (late leaks) (p<0.05). Age, sex, neoadjuvant chemoradiotherapy, and method of anastomotic construction were similar in patients with clinical leaks as compared to those with no leak. However, clinical leaks were more likely to develop in patients with a diagnosis of inflammatory bowel disease (IBD) or other diagnoses, i.e. radiation enteritis, fistula, and prior anastomotic leak (Table). We noted no significant associations between time of presentation (early vs. late) and sex, diagnosis, neoadjuvant chemoradiotherapy, or method of anastomotic construction (hand-sewn vs. stapled).
Conclusions: Clinical leaks in patients with a diverted anastomosis occur more commonly in those patients with a preoperative history of radiation enteritis, fistula, prior anastomotic leak, or IBD. In addition, most clinical leaks in patients with colorectal anastomoses and proximal fecal diversion manifest beyond 30-days of surgery. The standard practice of censoring further evaluation of outcomes at 30-days postoperatively will fail to identify a substantial fraction of leaks in patients with diverted colorectal anastomoses.

Risk Of Clinical Leak

Variable	No Leak	Clinical Leak	p Value
n	205	33
Age	54+/-17	52+/-22	0.3
Female Sex	96 (47%)	18 (55%)	0.5
Diagnosis			0.002
Neoplasm	93 (46%)	12 (37%)
IBD	50 (24%)	10 (30%)
Diverticulitis	50 (24%)	3 (9%)
Other	12 (6%)	8 (24%)
Radiation	58 (28%)	15 (46%)	0.1
Chemotherapy	54 (26%)	10 (30%)	0.8
Anastomosis			0.2
Hand-sewn	27 (13%)	8 (24%)
Stapled	178 (87%)	25 (76%)