197 Impact of anastomotic leakage after colorectal cancer surgery on quality of life: A systematic review to AL 20, 31. Di Re et al. additionally analysed oncological outcomes as disease free survival at one, three and five years after surgery 21, which were not significantly different between AL and non-AL patients. Overall, there was a lack of comparing type if (re-)interventions. DISCUSSION This systematic review appraised and synthesized the evidence on the impact of AL on QoL following oncological colorectal resections. In total, the studies comprised 4596 individual patients, with an overall incidence of AL of 12.4% (N=572). QoL was assessed using ten validated questionnaires administered at postoperative time points ranging from one month to 14 years. Overall, AL was found to negatively impact QoL at 6 and even 12 months postoperatively, with variable degree of subsequent improvement. The heterogeneity in questionnaires administered and variable times of assessment hindered our data analysis and may account for some of the conflicting results across studies. In a comprehensive systematic review of research studies on QOL and HRQOL, Haraldstad et al. concluded that the majority suffered from conceptual and methodological challenges with no clear consensus on how QoL should be measured. The use of various assessment tools and questionnaires in different studies hinders meaningful comparisons between similar study populations 34. Adoption of standard set of outcomes for colorectal cancer proposed by the International Consortium for Health Outcomes Measurements (ICHOM) may avoid some of these issues 35. In this consortium, it was recommended to use the EORTC QLQ-C30 tool to capture overall QoL and the -CR29 to capture colorectal cancer specific outcomes. The optimal time for QoL assessment was also addressed, with recommendations to administer questionnaires at baseline (prior to surgery), 6 months after surgery, and then annually up to 10 years. Our research team suggests following the ICHOM recommendations. Other patient and treatment variables such as the American Society of Anesthesiology (ASA) score, body mass index, anastomotic height, adjuvant radiotherapy and others that may impact QoL after colorectal cancer resections 36-39. Only two out of the 13 included studies performed multivariate logistic regression analyses to investigate whether differences in QoL scores observed between AL and non-AL groups were due to the leak, or driven by other factors like neo-adjuvant treatment, surgical procedure, or re-intervention 22, 23. Ideally, all studies should have performed such an analysis verify if AL is an independent factor that influences QoL. Besides, not all studies comparing outcomes relative to baseline function, which weakens the interpretation of the functional scores at subsequent postoperative time points. As a result, it was difficult to draw valid conclusions comparing the included studies. The observed decline in QoL scores reported among AL patients in the first six, and even 12 months, may be due to several reasons. AL delays recovery, result in additional postoperative 9
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