13 General introduction contrast, some studies did not find these significantly higher recurrence rates 28, 29. For colonic resections, a systematic review including 69,047 patients in which 2,555 patients developed AL, found that AL was significantly associated with impaired overall survival, disease free survival and cancer specific survival, but not with higher recurrence rates 30. These similar findings were also published later on by a study including both colon and rectal cancer patients 31. They showed that long-term oncological outcomes were negatively influenced by the occurrence of AL after rectal cancer surgery, but not for colon cancer; although the authors stated this was probably due to low power of this study. A recent large retrospective Dutch population-based study including 65,299 colon cancer patients and 22,855 rectal cancer patients stated that AL had a stage-dependent negative impact on survival, but no independent association with disease recurrence after CRC resection 32. Although oncological outcomes are not always significantly influenced by the occurrence of a leak, we know that survival rates are impaired for CRC patients after AL. Yet, it is necessary to avoid any further risk of poorer oncological and survival outcomes, which can be achieved by risk reduction of recurrence/metastatic spread after curative CRC surgery. PERITONEAL METASTASES Background Peritoneal metastases (PM), commonly referred to as peritoneal carcinomatosis, signify the dissemination of metastatic lesions across the peritoneal surface within the abdominal cavity. These deposits possess the capability to infiltrate abdominal organs and structures, frequently leading to complications such as bowel obstruction, ureteral obstruction, and malignant ascites 33. They may be identified either during the initial treatment of the primary tumor (referred to as synchronous PM) but also through follow-up assessments after primary surgery (referred to as metachronous PM) 34. The incidence of metachronous PM is estimated in 4–12% of patients who undergo curative resection for colon cancer and in 2–19% of patients who undergo curative resection for rectal cancer 35, with an estimated average of 5% in all colorectal patients 33. Although recurrence as PM seems to be a rare event in CRC patients after curative resection, consequences are notably significant. It is generally considered as a palliative situation when extensive spread is present as the typical life expectancy following diagnosis of PM spans from six to twelve months if no intervention takes place 36-38. The limited efficacy of routine imaging techniques often leads to a failure in detecting PM, attributed to their small size and the inherently low contrast resolution of soft tissue in which they manifest. Consequently, their true incidence is probably underestimated, which is also reflected by autopsy reports 5, 33, 35, 39. 1
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