A 62-year-old man undergoes low anterior resection for rectal cancer with total mesorectal excision and a diverting loop ileostomy. On postoperative day 5, he develops fever, pelvic pain, and purulent discharge from the drain. CT shows a pelvic collection with extraluminal contrast at the anastomosis. Which factor is the most significant independent risk factor for anastomotic leak in this patient?
- A Tumor location in the upper rectum (10-15 cm)
- B Low anastomotic height (within 5 cm from anal verge) ✓
- C Use of preoperative short-course radiotherapy
- D Female sex
Correct answer: B. Low anastomotic height (within 5 cm from anal verge)
Explanation
The strongest independent risk factor for anastomotic leak after anterior resection is low anastomotic height, particularly within 5 cm of the anal verge. Other risk factors include male sex, preoperative long-course chemoradiotherapy, and intraoperative complications. Upper rectal anastomoses have lower leak rates. Female sex is protective due to a wider pelvis. Diverting ileostomy reduces clinical severity but does not prevent leak.
Reference: Bailey and Love's Short Practice of Surgery, 28th ed.
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