Crystalloids after primary colon resection and anastomosis at initial trauma laparotomy: excessive volumes are associated with anastomotic leakage.

BACKGROUND: Recognition of preventable risk factors for suture line failure after colon anastomosis is important for optimizing anastomotic healing. The purpose of this study was to investigate the impact of crystalloids on the occurrence of anastomotic leakage after traumatic colonic injuries.
METHODS: Retrospective review from January 2005 to August 2009 of severely injured patients who underwent primary colocolonic anastomosis and intensive care unit (ICU) admission for ≥72 hours. Demographics on hospital and ICU admission, amount of crystalloids, and blood component transfusions within the first 72 hours were assessed by multivariate analysis to explore independent associations with anastomotic leakage.
RESULTS: Of a total of 123 patients with primary colocolonic anastomosis, 7 died within 72 hour and 24 were discharged before 72 hour from the ICU. The remaining 92 patients required ICU admission for ≥72 hour. Their mean Injury Severity Score was 20.8 ± 10.7, and they were 29.9 years ± 13.0 years old. Twelve patients (13.0%) developed an anastomotic leak. Demographics on hospital and ICU admission, intraoperative blood loss, and the volume of intraoperative fluids given did not differ statistically between patients with or without anastomotic leakage. However, the cumulative amount of crystalloids given over the first 72 hours significantly predicted anastomotic leakage (area under the receiver operating characteristic curve: 0.758 [95% confidence interval 0.592-0.924], p=0.009). By multivariate analysis, ≥10.5 L of crystalloids given over the first 72 hours was independently associated with anastomotic breakdown (odds ratio [95% confidence interval]: 5.26 [1.14-24.39], p=0.033). In addition, increasing age, hemorrhagic shock on admission, and a concomitant stomach injury were independent risk factors for an anastomotic leak (R=0.396).
CONCLUSION: Increased use of crystalloids after primary colocolonic anastomosis at initial trauma laparotomy is associated with anastomotic leakage. A threshold of 10.5 L of crystalloid fluid infused over the first 72 hours is associated with a 5-fold increased risk for colocolonic suture line failure. The impact of crystalloid restriction on anastomotic failure in trauma patients warrants prospective investigation.