Development of a warning score for early detection of colorectal anastomotic leakage: Hype or hope?

Abstract

Background: Colorectal anastomotic leakage (CAL), a severe postoperative complication, is associated with high morbidity, hospital readmission, and overall healthcare costs. Early detection of CAL remains a challenge in clinical practice. However, some decision models have been developed to increase the diagnostic accuracy of this event.

Aim: To develop a score based on easily accessible variables to detect CAL early.

Methods: Based on the least absolute shrinkage and selection operator method, a predictive classification system was developed [Early ColoRectAL Leakage (E-CRALL) score] from a prospective observational, single center cohort, carried out in a colorectal division from a non-academic hospital. The score performance and CAL threshold from postoperative day (POD) 3 to POD5 were estimated. Based on a precise analytical decision model, the standard clinical practice was compared with the E-CRALL adoption on POD3, POD4, or POD5. A cost-minimization analysis was conducted, on the assumption that all alternatives delivered similar health-related effects.

Results: In this study, 396 patients who underwent colorectal resection surgery with anastomosis, and 6.3% (n = 25) developed CAL. Most of the patients who developed CAL (n = 23; 92%) were diagnosed during the first hospital admission, with a median time of diagnosis of 9.0 ± 6.8 d. From POD3 to POD5, the area under the receiver operating characteristic curve of the E-CRALL score was 0.82, 0.84, and 0.95, respectively. On POD5, if a threshold of 8.29 was chosen, 87.4% of anastomotic failures were identified with E-CRALL adoption. Additionally, score usage could anticipate CAL diagnosis in an average of 5.2 d and 4.1 d, if used on POD3 and POD5, respectively. Regardless of score adoption, episode comprehensive costs were markedly greater (up to four times) in patients who developed CAL in comparison with patients who did not develop CAL. Nonetheless, the use of the E-CRALL warning score was associated with cost savings of €421442.20, with most (92.9%) of the savings from patients who did not develop CAL.

Conclusion: The E-CRALL score is an accessible tool to predict CAL at an early timepoint. Additionally, E-CRALL can reduce overall healthcare costs, mainly in the reduction of hospital costs, independent of whether a patient developed CAL.

Keywords: Anastomotic leakage; Biomarkers; Colorectal; Costs; Score; Surgery.

Figure 1

Early ColoRectAL Leakage score logotype.

Figure 2

The decision tree model scenario with adoption of the Early ColoRectAL Leakage score, considering postoperative days 3, 4, or 5 independently). CAL: Colorectal anastomotic leakage; CT: Computed tomography; Diagn: Diagnosis; E-CRALL: Early ColoRectAL Leakage score; LPS: Laparoscopy; LPT: Laparotomy (open surgery).

Figure 3

Area under the receiver operating characteristic curve of colorectal anastomotic leakage for the Early ColoRectAL Leakage score for postoperative day 3 to postoperative day 5. AUC: Area under the curve; CAL: Colorectal anastomotic leakage; E-CRALL: Early ColoRectAL Leakage score; POD: Postoperative day.