Risk and protective factors for postoperative anastomotic leakage in esophageal and gastrointestinal surgery: an umbrella review of meta-analyses and systematic reviews

BACKGROUND AND OBJECTIVE: Anastomotic leakage (AL) is a common and serious complication in gastrointestinal surgery, which significantly affects patient recovery and long-term prognosis. This umbrella review aims to summarize the risk and protective factors for AL after gastric, esophageal, and colorectal cancer surgeries, and to provide a comprehensive evaluation of the quality of existing literature, offering guidance for clinical practice. METHODS: A systematic search was conducted to identify eligible meta-analyses. For each included study, we recalculated and assessed the risk estimates, heterogeneity, small-study effects, excess significance testing, and publication bias. Additionally, we considered the quality of the studies and graded the evidence. RESULTS: A total of 173 potential associations were included. The analysis revealed that ASA scores (3-4), male gender, diabetes, hypertension, and chronic kidney disease were significantly associated with an increased risk of AL. Preoperative mechanical bowel preparation combined with oral antibiotics significantly reduced the incidence of AL. Intraoperative use of collagen or fibrin-based sealants, indocyanine green (ICG) fluorescence imaging, flexible endoscopic examination, and leak tests were all significantly associated with reduced AL risk. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) was linked to an increased risk of AL. In rectal cancer surgeries, low-anterior resection was associated with a significantly higher risk of AL. In esophageal cancer surgeries, the incidence of AL was higher after transthoracic anastomosis than after cervical anastomosis, although the severity of complications associated with cervical anastomoses was lower. CONCLUSION: AL remains a major challenge in gastrointestinal surgery, and involves multiple risk factors. Optimizing perioperative management, refining intraoperative techniques, and judicious use of antibiotics and NSAIDs can significantly reduce the risk of AL. Future research should focus on high-quality, large-sample, multicenter studies to explore more effective prevention and treatment strategies.