Colorectal surgeons' perspectives and emotional responses to anastomotic leakage following rectal cancer resection.

Abstract

Anastomotic leak (AL) following rectal cancer resection is a devastating complication. This study describes Irish colorectal surgeons' approaches towards AL prevention, diagnosis and management and their emotional response to its occurrence. A qualitative study was conducted using semi-structured interviews with senior colorectal trainees, fellows and consultants in Irish rectal cancer centres. Descriptive statistics summarised clinical approaches and thematic analysis (using NVivo software) explored emotional responses. Fifteen colorectal surgeons (13 male) from six Irish rectal cancer centres participated. Anastomotic height, tension and perfusion were rated the most important risk factors for AL. All surgeons routinely bowel-prepped patients though regimes varied significantly. Only 33.3% of surgeons routinely place intraoperative drains. 100% conduct routine air leak tests whereas 40.0% routinely use ICG perfusion testing. For AL management, only 6.7% use a fixed protocol approach with the majority individualising their decisions on clinical status, defunctioning stoma presence and defect size. Thematic analysis regarding emotional impact identified (1) profound psychological impact (especially among consultants) including guilt and self-blame following AL modulated by professional experience; (2) impact on professional confidence including doubt in surgical judgement and changed decision-making following a case of AL and (3) reliance on peers and mentors for emotional support and recognition of the multifactorial nature of AL as a coping mechanism. There is notable variability in surgeons' approach to AL following rectal cancer resection with a general instinctive emotional response of 'disappointment' both for the patient and in themselves when AL occurs.