Purpose: Anastomotic leaks are a dreaded complication of intestinal resection and have been associated with a high mortality rate. However, it is uncertain whether the leaks are typically the actual cause of death. We sought to assess the impact of surgeon on leak rates and determine the relationship of a leak to postoperative mortality.
Methods: All adult pts having a small or large bowel resection with anastomosis at a university hospital from 7/03-6/06 were entered into a prospectively maintained quality database; data was entered by a specially trained nurse practitioner who rounded daily with housestaff. Pts with a postop leak based on standardized criteria were identified. Pt characteristics, surgical procedure and operating surgeon were noted. Overall complication and leak rate by surgeon were compared using Fisher's exact test. Individual case review by a group of peers was performed for all pts with a leak who died to determine the relationship to mortality.
Results: 556 pts underwent resection with anastomosis during the study period. There were 27 leaks (4.9%), 6 of whom died. Leak rate for the highest volume surgeons ranged from 2.1 to 9.9 % (p<.01; Figure 1) and overall complication rate varied from 30.5 to 44% (p=.04). In 4/6 deaths, leaks occurred in very ill pts undergoing emergency procedures and appeared to be premorbid events. In only one case did the leak appear to be the primary cause of death.
Conclusions: The variability in leak rate by surgeons doing similar cases suggests that many may be preventable. However, death after a leak is most often a surrogate for a critically ill patient and infrequently is the actual cause of death.