11 General introduction surgery, interpreting the findings remains challenging due to significant heterogeneity in AL reporting 13. This variation not only impacts reported incidence rates in clinical registries but also undermines the reliability of reported outcomes among colorectal surgery patients. Examination of an extensive colorectal dataset in the Netherlands has suggested a potential underestimation of AL rates following colorectal cancer resections in international literature 9. The audit suggests that AL may intricately be involved in up to 23% of low anterior resections, especially when considering both acute and delayed leaks, as well as leaks that may manifest asymptomatically in patients with fecal diversion. This underscores the imperative need for a standardized and widely acknowledged definition of AL in colorectal surgery, as the absence of such a consensus limits the meaningfulness of comparing outcomes across wordwide medical centers. The lack of uniformity in AL definitions also hampers efforts to identify and categorize risk factors, standardize treatment protocols, and implement quality improvement initiatives with the objective to reduce AL occurrences. Furthermore, the lack of consensus also influences surgical trials investigating AL rates, particularly when AL is specified as the primary endpoint. In 2010, the International Study Group of Rectal Cancer (ISREC) published a consensus on definition and grading AL, particularly in the context of anterior resection for rectal cancer, which stands out as the most frequently referenced and has garnered support through validation 14. However, despite its acknowledgment, this definition has not garnered widespread endorsement from surgical societies or widespread adoption among practicing surgeons. Although several consensus guidelines and position statements aiming to establish standardized definitions of AL 8, 13-15, a universally accepted definition remains elusive. Yet, consensus on the radiologic definition or standardized assessment of CT-scans is also still lacking 13, 15. Risk factors for AL Although the creation of an anastomosis is a surgical technique, numerous patient related risk factors linked to a higher risk of the development of AL have been identified, offering opportunities for improved prevention and early detection of this significant complication. Nonmodifiable factors, including male gender, comorbidities, and the tumor’s proximity to the anal verge, are among these contributors that can be assessed before surgery. Modifiable risk factors encompass smoking, alcohol consumption, obesity, neoadjuvant treatment, and the use of certain drugs 16. Beside preoperative patients factors, intraoperative factors may also play a rol. The most important one is adequate blood perfusion, which is widely recognized as a crucial factor for the successful healing of the anastomosis and thereby reducing the risk of AL 17. Bowel perfusion assessment Adequate anastomotic perfusion is important for anastomotic healing, as good blood flow promotes tissue viability, cellular metabolism, and collagen synthesis, all of which are critical 1
RkJQdWJsaXNoZXIy MTk4NDMw