Does hydrocortisone (Cortisol) cause abdominal anastomotic leak?

From the Guidelines

Hydrocortisone may increase the risk of abdominal anastomotic leaks, particularly in patients on high-dose or long-term therapy, due to its potential impact on wound healing. The evidence suggests that corticosteroids like hydrocortisone can impair wound healing by suppressing inflammatory responses and collagen synthesis, which are essential for proper tissue repair and anastomotic healing 1. This effect is dose-dependent and more significant with higher doses and longer durations of treatment. For example, a study found that patients on chronic steroid therapy had a higher rate of anastomotic leak (6.2%) compared to those undergoing elective colonic surgery (3.3%) 1. Another study found that patients who received oral steroid taper after surgery had a higher rate of anastomotic leak (34%) compared to those who did not (14%) 1.

Key Considerations

• The risk of anastomotic leak appears to be modest in most patients on physiologic replacement doses, but increases with higher anti-inflammatory dosing 1.
• Minimizing the dose or temporarily discontinuing hydrocortisone around the time of surgery may be considered, though this must be balanced against the risk of adrenal insufficiency in patients on chronic therapy 1.
• Surgeons may also consider additional technical precautions such as reinforcing anastomoses or more frequent monitoring for complications in patients requiring perioperative corticosteroids 1.
• The use of diverting ileostomy in patients taking high-dose steroids preoperatively is broadly accepted, particularly in patients with ulcerative colitis undergoing complex reconstructive procedures 1.

Clinical Implications

• Clinicians should be aware of the potential risks of hydrocortisone on wound healing and anastomotic integrity, particularly in patients on high-dose or long-term therapy 1.
• Patients with adrenal insufficiency who develop complications of surgery should be managed in the critical care environment 1.
• The importance of maintaining peri-operative fluid balance and glycaemic control is increasingly accepted, and thus sodium and water retention secondary to supplementation is a potential concern 1.

From the FDA Drug Label

Gastrointestinal: Steroids should be used with caution in active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and non-specific ulcerative colitis, since they may increase the risk of a perforation.

Hydrocortisone may cause abdominal anastomotic leak due to the increased risk of perforation associated with steroid use in patients with fresh intestinal anastomoses 2.

• Key points:
  • Steroids should be used with caution in patients with fresh intestinal anastomoses
  • Increased risk of perforation associated with steroid use in these patients
  • Abdominal anastomotic leak is a potential complication of steroid use in this context

From the Research

Hydrocortisone and Abdominal Anastomotic Leak

• Hydrocortisone, also known as cortisol, is a corticosteroid that has been studied in relation to its effects on wound healing and anastomotic leakage in surgical patients.
• A study published in 2014 3 found that the use of corticosteroids, including hydrocortisone, may increase the risk of anastomotic leakage in patients undergoing lower gastrointestinal surgery.
• The study reported an anastomotic leakage rate of 6.77% in patients who received corticosteroids, compared to 3.26% in those who did not receive corticosteroids.
• Another study published in 2022 4 noted that the concurrent use of corticosteroids, including hydrocortisone, increases the risk of anastomotic leaks in patients with inflammatory bowel disease.

Risk Factors for Anastomotic Leakage

• Several studies have identified corticosteroid use, including hydrocortisone, as a risk factor for anastomotic leakage in surgical patients 3, 5, 6.
• A study published in 2012 6 found that patients taking long-term corticosteroids or perioperative corticosteroids had a significantly higher incidence of anastomotic leakage.
• The study recommended that patients taking corticosteroids be considered for a diverting stoma or a Hartmann procedure to avoid anastomotic leakage.

Management of Anastomotic Leakage

• A study published in 2014 7 reviewed the management of anastomotic leakage in patients undergoing colon and rectal surgery.
• The study found that nonoperative management was successful in 57% of cases, while operative management was successful in 54% of cases.
• The study noted that the management of anastomotic leakage should be tailored to the individual patient, taking into account factors such as the location and severity of the leak.