Risk factors associated with anastomotic leakage in colorectal surgery: a systematic review and synthesis of recent evidence
DOI:
https://doi.org/10.71112/agy1fk25Keywords:
Anastomotic leakage, Colorectal surgery, Risk factors, Colorectal anastomosis, Indocyanine green, Intestinal perfusion, Diabetes mellitus, Hypoalbuminemia, Predictive models, Systematic reviewAbstract
One of the most severe complications associated with colorectal surgery is anastomotic leakage, which is correlated with increased postoperative morbidity and mortality, the need for reoperation, prolonged hospital stay, and deterioration of clinical and oncological outcomes. The occurrence of this phenomenon is driven by a multifactorial mechanism involving patient-related clinical conditions, comorbidities, nutritional status, tumor characteristics, surgical factors, perioperative variables, and the quality of intestinal perfusion. In this context, the purpose of this systematic review was to identify and synthesize the most recent scientific evidence regarding risk factors associated with the development of anastomotic leakage in patients undergoing colorectal surgical procedures.
A systematic review was conducted in accordance with the PRISMA 2020 methodological recommendations. A systematic search was performed in PubMed/MEDLINE, Embase, Web of Science, Scopus, and the Cochrane Library using terms related to colorectal surgery, anastomotic leakage, risk factors, comorbidity, malnutrition, neoadjuvant therapy, indocyanine green, and perfusion assessment. Of the 500 records initially identified, 5 studies met the inclusion criteria and were incorporated into the qualitative synthesis. The included studies were heterogeneous in terms of design, population, type of surgery, definition of anastomotic leakage, variables assessed, and methods used for risk estimation.
The findings showed that the most important clinical and demographic factors were male sex, diabetes mellitus, smoking, elevated body mass index, and the patient’s general condition. From a nutritional perspective, hypoalbuminemia and malnutrition were associated with greater anastomotic vulnerability. The most prominent surgical and perioperative factors were low rectal surgery, distal anastomotic location, anastomotic tension, intraoperative bleeding, transfusion, technical complexity, and impaired intestinal perfusion. Likewise, fluorescence angiography with indocyanine green and predictive models based on clinical, surgical, and technological variables emerge as promising tools to improve risk stratification, although they require further external validation and standardization.
In summary, anastomotic leakage in colorectal surgery should be regarded as a multifactorial complication requiring a comprehensive prevention strategy that includes preoperative identification of high-risk patients, nutritional and metabolic optimization, control of comorbidities, appropriate surgical planning, intraoperative assessment of intestinal perfusion, and timely postoperative follow-up. Although current evidence allows the identification of relevant risk factors, prospective, multicenter, and methodologically robust studies are needed to establish definitive recommendations that can be applied in a standardized manner in colorectal surgery.
Downloads
References
Blumetti, J., Chaudhry, V., Prasad, L., & Abcarian, H. (2012). Delayed transanal repair of persistent coloanal anastomotic leak in diverted patients after resection for rectal cancer. Colorectal Disease, 14(10), 1238–1241. https://doi.org/10.1111/j.1463-1318.2012.02932.x
Burch, J. (2023). Stoma management: enhancing patient knowledge.
Chiarello, M. M., Fransvea, P., Cariati, M., Adams, N. J., Bianchi, V., & Brisinda, G. (2022). Anastomotic leakage in colorectal cancer surgery. In Surgical Oncology (Vol. 40). Elsevier Ltd. https://doi.org/10.1016/j.suronc.2022.101708
Depalma, N., D’Ugo, S., Manoochehri, F., Libia, A., Sergi, W., Marchese, T. R. L., Forciniti, S., del Mercato, L. L., Piscitelli, P., Garritano, S., Castellana, F., Zupo, R., & Spampinato, M. G. (2023). NIR ICG-Enhanced Fluorescence: A Quantitative Evaluation of Bowel Microperfusion and Its Relation to Central Perfusion in Colorectal Surgery. Cancers, 15(23). https://doi.org/10.3390/cancers15235528
Dias, A. C., Moreira, V. P., & Comba, J. L. D. (2024). RoBIn: A Transformer-Based Model For Risk Of Bias Inference With Machine Reading Comprehension. http://arxiv.org/abs/2410.21495
Gan, J., & Hamid, R. (2017). Literature Review: Double-Barrelled Wet Colostomy (One Stoma) versus Ileal Conduit with Colostomy (Two Stomas). In Urologia Internationalis (Vol. 98, Number 3, pp. 249–254). S. Karger AG. https://doi.org/10.1159/000450654
Grammoustianou, A., Saeidi, A., Longo, J., Risch, F., & Ionescu, A. M. (2024). Real-time detection of C-reactive protein in interstitial fluid using electrochemical impedance spectroscopy-towards wearable health monitoring.
Hain, E., Maggiori, L., Manceau, G., Zappa, M., Prost À La Denise, J., & Panis, Y. (2016). Persistent Asymptomatic Anastomotic Leakage after Laparoscopic Sphincter-Saving Surgery for Rectal Cancer: Can Diverting Stoma Be Reversed Safely at 6 Months? Diseases of the Colon and Rectum, 59(5), 369–376. https://doi.org/10.1097/DCR.0000000000000568
Inan, D., Beyaztas, U., Tekwe, C. D., Chen, X., & Zoh, R. S. (2025). Functional Linear Cox Regression Model with Frailty. http://arxiv.org/abs/2501.07450
Iourovitski, D. (2024). Grade Score: Quantifying LLM Performance in Option Selection. http://arxiv.org/abs/2406.12043
Khalifa, M., Magrabi, F., & Gallego, B. (2025). Developing an Evidence-Based Framework for Grading and Assessment of Predictive Tools for Clinical Decision Support.
Li, H.-Y., Zhou, J.-T., Wang, Y.-N., Zhang, N., & Wu, S.-F. (2023). Establishment and application of three predictive models of anastomotic leakage after rectal cancer sphincter-preserving surgery. World Journal of Gastrointestinal Surgery, 15(10), 2201–2210. https://doi.org/10.4240/wjgs.v15.i10.2201
Blumetti, J., Chaudhry, V., Prasad, L., & Abcarian, H. (2012). Delayed transanal repair of persistent coloanal anastomotic leak in diverted patients after resection for rectal cancer. Colorectal Disease, 14(10), 1238–1241. https://doi.org/10.1111/j.1463-1318.2012.02932.x
Burch, J. (2023). Stoma management: enhancing patient knowledge.
Chiarello, M. M., Fransvea, P., Cariati, M., Adams, N. J., Bianchi, V., & Brisinda, G. (2022). Anastomotic leakage in colorectal cancer surgery. In Surgical Oncology (Vol. 40). Elsevier Ltd. https://doi.org/10.1016/j.suronc.2022.101708
Depalma, N., D’Ugo, S., Manoochehri, F., Libia, A., Sergi, W., Marchese, T. R. L., Forciniti, S., del Mercato, L. L., Piscitelli, P., Garritano, S., Castellana, F., Zupo, R., & Spampinato, M. G. (2023). NIR ICG-Enhanced Fluorescence: A Quantitative Evaluation of Bowel Microperfusion and Its Relation to Central Perfusion in Colorectal Surgery. Cancers, 15(23). https://doi.org/10.3390/cancers15235528
Dias, A. C., Moreira, V. P., & Comba, J. L. D. (2024). RoBIn: A Transformer-Based Model For Risk Of Bias Inference With Machine Reading Comprehension. http://arxiv.org/abs/2410.21495
Gan, J., & Hamid, R. (2017). Literature Review: Double-Barrelled Wet Colostomy (One Stoma) versus Ileal Conduit with Colostomy (Two Stomas). In Urologia Internationalis (Vol. 98, Number 3, pp. 249–254). S. Karger AG. https://doi.org/10.1159/000450654
Grammoustianou, A., Saeidi, A., Longo, J., Risch, F., & Ionescu, A. M. (2024). Real-time detection of C-reactive protein in interstitial fluid using electrochemical impedance spectroscopy-towards wearable health monitoring.
Hain, E., Maggiori, L., Manceau, G., Zappa, M., Prost À La Denise, J., & Panis, Y. (2016). Persistent Asymptomatic Anastomotic Leakage after Laparoscopic Sphincter-Saving Surgery for Rectal Cancer: Can Diverting Stoma Be Reversed Safely at 6 Months? Diseases of the Colon and Rectum, 59(5), 369–376. https://doi.org/10.1097/DCR.0000000000000568
Inan, D., Beyaztas, U., Tekwe, C. D., Chen, X., & Zoh, R. S. (2025). Functional Linear Cox Regression Model with Frailty. http://arxiv.org/abs/2501.07450
Iourovitski, D. (2024). Grade Score: Quantifying LLM Performance in Option Selection. http://arxiv.org/abs/2406.12043
Khalifa, M., Magrabi, F., & Gallego, B. (2025). Developing an Evidence-Based Framework for Grading and Assessment of Predictive Tools for Clinical Decision Support.
Li, H.-Y., Zhou, J.-T., Wang, Y.-N., Zhang, N., & Wu, S.-F. (2023). Establishment and application of three predictive models of anastomotic leakage after rectal cancer sphincter-preserving surgery. World Journal of Gastrointestinal Surgery, 15(10), 2201–2210. https://doi.org/10.4240/wjgs.v15.i10.2201
Liu, Y., Zhao, M., Hu, G., & Zhang, Y. (2023). Association between nutritional factors, inflammatory biomarkers and cancer types: an analysis of NHANES data using machine learning.
Moradbeiki, P., Ghadiri, N., Zahabi, S. J., Wiil, U. K., Brockhattingen, K. K., & Ebrahimi, A. (2025). MedVQA-TREE: A Multimodal Reasoning and Retrieval Framework for Sarcopenia Prediction. http://arxiv.org/abs/2508.19319
Novák, V., Zelinka, I., Přibylová, L., Martínek, L., Benčurík, V., & Beseda, M. (2026). Quantum Machine Learning for Colorectal Cancer Data: Anastomotic Leak Classification and Risk Factors. http://arxiv.org/abs/2604.13951
Palmer, S. J. (2020). Overview of stoma care for community nurses. In British Journal of Community Nursing (Vol. 25, Number 7).
Papalas, J. A., Kulbacki, E. L., Kim Park, H., & Howell, E. R. (2012). Signet Ring Cell Primary Cutaneous CD30+ Lymphoproliferative Disorder Presenting as a Monomorphic T-Cell Posttransplant Lymphoproliferative Disease. www.amjdermatopathology.com
Ronsini, C., Solazzo, M. C., Di Donna, M. C., Cucinella, G., Scaffa, C., & Chiantera, V. (2026). Single-port robotic-assisted wet colostomy after total pelvic exenteration: a feasibility video report. Frontiers in Oncology, 15. https://doi.org/10.3389/fonc.2025.1698531
Sabbagh, C., Maggiori, L., & Panis, Y. (2013). Management of failed low colorectal and coloanal anastomosis. In Journal of visceral surgery (Vol. 150, Number 3, pp. 181–187). https://doi.org/10.1016/j.jviscsurg.2013.03.016
Salama, A., Calpin, G., Salama, M., Creavin, B., Maguire, P. J., Lonergan, P., Cho, J., Abu Saadeh, F., McLoughlin, L., Sammour, T., & Kelly, M. E. (2025). Double-Barrel Uro-Colostomy Versus Ileal Conduit for Urinary Diversion After Pelvic Exenteration: A Systematic Review and Meta-Analysis of Comparative Outcomes. In Cancers (Vol. 17, Number 21). Multidisciplinary Digital Publishing Institute (MDPI). https://doi.org/10.3390/cancers17213479
Salvo, G., Iniesta, M. D., Lasala, J. D., Meyer, L. A., Munsell, M. F., Sheth, N., & Ramirez, P. T. (2017). Bowel procedures during gynecologic surgery on an enhanced recovery program (ERP): Are perioperative outcomes compromised? Gynecologic Oncology, 145, 58–59. https://doi.org/10.1016/j.ygyno.2017.03.142
Sarno, G., Iacone, B., Tedesco, A., Gargiulo, A., Ranieri, A., Giordano, A., Tramontano, S., & Bracale, U. (2024). End-colostomy parastomal hernia repair: a systematic review on laparoscopic and robotic approaches. In Hernia (Vol. 28, Number 3, pp. 723–743). Springer-Verlag Italia s.r.l. https://doi.org/10.1007/s10029-024-03026-8
Soares, A. S., Bano, S., Clancy, N. T., Lovat, L. B., Stoyanov, D., & Chand, M. (2022). Fluorescence angiography classification in colorectal surgery -- A preliminary report. http://arxiv.org/abs/2206.05935
Stavropoulou, A., Vlamakis, D., Kaba, E., Kalemikerakis, I., Polikandrioti, M., Fasoi, G., Vasilopoulos, G., & Kelesi, M. (2021). “Living with a Stoma”: Exploring the Lived Experience of Patients with Permanent Colostomy. International Journal of Environmental Research and Public Health, 18(16). https://doi.org/10.3390/ijerph18168512
Liu, Y., Zhao, M., Hu, G., & Zhang, Y. (2023). Association between nutritional factors, inflammatory biomarkers and cancer types: an analysis of NHANES data using machine learning.
Moradbeiki, P., Ghadiri, N., Zahabi, S. J., Wiil, U. K., Brockhattingen, K. K., & Ebrahimi, A. (2025). MedVQA-TREE: A Multimodal Reasoning and Retrieval Framework for Sarcopenia Prediction. http://arxiv.org/abs/2508.19319
Novák, V., Zelinka, I., Přibylová, L., Martínek, L., Benčurík, V., & Beseda, M. (2026). Quantum Machine Learning for Colorectal Cancer Data: Anastomotic Leak Classification and Risk Factors. http://arxiv.org/abs/2604.13951
Palmer, S. J. (2020). Overview of stoma care for community nurses. In British Journal of Community Nursing (Vol. 25, Number 7).
Papalas, J. A., Kulbacki, E. L., Kim Park, H., & Howell, E. R. (2012). Signet Ring Cell Primary Cutaneous CD30+ Lymphoproliferative Disorder Presenting as a Monomorphic T-Cell Posttransplant Lymphoproliferative Disease. www.amjdermatopathology.com
Ronsini, C., Solazzo, M. C., Di Donna, M. C., Cucinella, G., Scaffa, C., & Chiantera, V. (2026). Single-port robotic-assisted wet colostomy after total pelvic exenteration: a feasibility video report. Frontiers in Oncology, 15. https://doi.org/10.3389/fonc.2025.1698531
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Fabián Andrés Veintimilla Paladines, Marilyn Denise Guevara Acurio, María José Macanchí Santín, Camila Zarahi Pardo Jaramillo, Xiomara Belen Ramos Morales, Amán Sánchez Carlos Daniel (Autor/a)
This work is licensed under a Creative Commons Attribution 4.0 International License.
