198 Chapter 9 complications, higher rates of re-intervention, and increase mortality within the first 30 days after surgery 4, 40. This often prolongs length of hospital stay and adversely impacts mobility and the ability for patients to care for themselves 41-43. Furthermore, some patients require stoma construction which impairs role and social functioning scores 44. In the current study, there was a lack of correlation of stoma status and QoL outcomes. One study excluded patients who had a stoma 26, while others did include them but did not draw strong conclusion on any association between stoma formation and QoL scores. AL has also been associated with higher rates of local recurrence and distant metastases in CRC patients 45, 46. Although smaller cohort studies have not found the same association between AL and colon cancer outcomes, the fear of (local) recurrence as well as additional treatments required to mitigate higher risk of recurrence, may further negatively impact QoL 47, 48. Moreover, AL has been shown to be an independent risk factor for worse defecatory function (LARS), sexual function after CRC resections 49-52. Although these functional outcomes were not specifically assessed in the current study, it is crucial to consider their impact on overall QoL 53. To our knowledge, this is the first systematic review on the effects of AL on QoL in patients undergoing oncological colon and rectal resections. This study has limitations. A high heterogeneity in AL reporting was found in the included articles. It was often unclear what type of intervention and re-operation was performed to manage leaks. Since these elements are important when comparing outcomes, standardizing the reporting and management of leaks would be helpful. Subsequently, some studies only included rectal cancer patients, while other included all types of colorectal surgeries. Secondly, a wide range of QoL questionnaires and timeframes for assessment was used across the different studies. Although only studies using validated instruments were included, the heterogeneity of questionnaires used creates challenges when comparing outcomes across studies and interpreting results. The use of patient-centred methods, like patient-reported outcome measures (PROMS) may be even more informative to gain more insight in overall changes 54. Due to the heterogeneity of the included studies, comparisons across studies are limited and a meta-analysis was not possible to perform. Lastly, all included studies demonstrated a moderate to serious risk of bias, which results in a low level of evidence and caution is warranted by the presented findings.
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