Anastomotic leak after colorectal surgery is a severe complication which can lead to a catastrophic outcome. Leak typically presents on the 5th to 7th postoperative days, but occasionally an early anastomotic dehiscence can occur. All surgeons fear its occurrence. Many discussions exist about how to prevent them or how to reduce its negative impact in patients' recovery. The main discussion is to do or not to do a protection stoma. There is no consensus yet.
Another question needs answer. How to predict anastomotic leaks after colorectal surgery?
According to Liron Berkovich et al., surgeons from the University of Tel Aviv, Israel, CEA may be of good help. In September 2016 these authors published in "The American Journal of Surgery" a brief report on the utility of determination of CEA levels in abdominal drains' fluid to predict early anastomotic leaks.
A total of 105 patients submitted to elective colorectal surgery from May 2012 to August 2015 were included, 67 for cancer and 38 for benign colonic conditions. The authors included patients with cancer and benign conditions because they have recently demonstrated that CEA levels are elevated in peritoneal fluid after colorectal surgery for both malignant and benign aetiologies. In all 105 patients CEA level from abdominal drain's fluid (near anastomosis) was measure: 6-8 h after surgery, once a day for the first 3 days.
Data presented are interesting!
Liron Berkovich et al. report three cases (3/105 - 2,86%) of early anastomotic dehiscence (day 2), and all occurred in patients with benign conditions (1 with inflammatory bowel disease, 2 with non-inflamatory bowel disease). In all the three cases, CEA levels in postoperative peritoneal drain fluid were extremely elevated (above 1000 ng/mL) compared to all the other patients (p < 0,001). These high CEA levels were noticed in the first analysis at 6-8 h after surgery, and throughout the first two postoperative days. Preoperative and postoperative serum CEA levels of the three patients with early anastomotic leak were normal.
The reason Berkovich et al. present to justify these data, is that early and later leaks have different pathophysiology. Later leaks are due to impaired healing, but early leaks occur because of "mechanical anastomotic dehiscence". When this mechanical disruption takes place enterocytes can fracture and spill their cytoplasm content, including CEA, in the peritoneal fluid near the anastomosis. That is why there are high levels of CEA in the abdominal drain fluid.
The authors conclude that hight CEA levels from abdominal drain's fluid soon after colorectal surgery (for cancer or benign conditions) may predict early anastomotic leak before it has clinical significance. CEA levels in the first 3 postoperative days can not predict later leaks or other complications. They also conclude that more studies are necessary to confirm the data presented.
Well... I think one question emerges immediately after reading this interesting paper, which I recommend. If more studies confirm that CEA levels in abdominal drain fluid predict early leak after colorectal surgery before it has clinical significance, which will be its impact in clinical practice? Will surgeons need to act before clinical presentation? Will a stoma be indicated only because CEA is higher than 1000 ng/mL? Will clinical presentation loose its major importance in this setting? Or will it just be an alarming sign meaning more intense surveillance or an early CT scan?
I believe clinical presentation will always be surgeons' best friend, and the major factor for diagnosis and therapeutic decision. Biochemical and radiological findings will only help in those decisions.
Link to PubMed:
Carlos Eduardo Costa Almeida
General Surgeon