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Objective
Anastomotic leak is a potentially devastating complication of bowel surgery. Abnormal postoperative vital signs are often cited retrospectively and in medicolegal settings as evidence of negligence and failure to make an early diagnosis. The purpose of this study was to profile the postoperative course of patients who underwent bowel anastomosis and determine how reliably abnormal vital signs predicted anastomotic leaks.
Design
Case series utilizing a prospective complication tracking system
Setting
Academic medical center
Patients
Consecutive patients undergoing bowel resection with anastomosis between 7/1/09 and 6/30/11.
Main Outcome Measures
Abnormal vital signs defined as temperature >38°C, leukocytosis ≤4k or ≥12k, systolic blood pressure ≤80 mmHg or diastolic blood pressure ≤50 mmHg, pulse ≥100, and respiratory rate ≥20.
Results
452 patients underwent resection with anastomosis during the study period. 271 total complications were identified in 100 patients, 19 patients (4.2%) had an anastomotic leak. At most only 37.9% (±7.7%, p=0.05) of patients with diagnosed leak were ever febrile on any given day. Conversely, in patients with an entirely uncomplicated postoperative course, tachycardia, fever, tachypnea, and leukocytosis were extremely common (25%-68% -Figure 1), with a broad overlap between complicated and uncomplicated recovery. The positive predictive value of any aberrant vital sign or white count for leak was between 5% (tachycardia) and 17% (fever).
Conclusions
Abnormal vital signs are extremely common after bowel resection with anastomosis. Even sustained aberrant vital signs or leukocytosis in isolation cannot be taken as evidence of a leak or other surgical complication.