217 The patient perspective on colorectal anastomotic leaks: A qualitative study our study corroborate findings from a cohort study (1,197 patients), where patients with colorectal AL experienced a clinically significant reduction in quality of life (QoL) at 6 months relative to baseline, while long-term QoL scores were similar to patients without an AL 3. This emphasizes the necessity for increased support for patients during the initial phase of AL and up to 6 months post-diagnosis. Additionally, our participants expressed concerns about adjusting to a stoma. Despite prior studies demonstrating good QoL scores in older patients living with a stoma 27, the stigma and disability of stomas are well documented28. The interviews highlighted the different ways participants coped with AL using their support network and developing resilience. Various studies indicated that interventions aimed at enhancing optimism, social support, and active coping strategies like acceptance and positive reappraisal, could foster positive changes in the aftermath and enhance QoL 29, 30. The identified coping mechanisms may explain why participants experienced minimal disruption in their daily lives in the longer-term period. The key aspects of AL care identified by our participants emphasized the importance of social support, patient- and family-centered care, including communication strategies and shared decision-making, and approaches such as nurse-led case management. These elements have all been shown to improve patient outcomes in general, particularly psychological well-being31-39. We developed five clinically applicable recommendations, displayed in Table 4, to apply the findings of this study in improving perioperative care for colorectal patients at risk of an AL. Table 4. Recommendations for perioperative care 1. Complete a preoperative risk assessment and provide clear and realistic information regarding AL (including associated signs and symptoms); 2. Apply a patient- and family-centered care approach (including clear communication, information provision, and shared-decision making); 3. Make timely referrals to supportive care (e.g. referrals to a stoma therapists, physio therapists, wound care specialists, and social work); 4. Emphasize the importance of streamlining information (not too many people involved in the treatment plan); 5. Optimize pain management, particularly as it relates to the need for further interventions like percutaneous drain management. The findings of this study were used to inform the ASCRS’ CoReAL project, which aims to create an evidence-, patient- and expert-informed standardized framework for reporting colorectal AL 40. The CoReAL framework includes the reporting of AL-related factors at different stages: preoperative, intraoperative, and postoperative short-term (<90 days) and long-term (> 90 days). Based on the current work, we integrated specific patient-identified reporting elements into the framework. In the preoperative phase, patients emphasized the importance of risk assessment and the need for clear information about the risk of AL. This is reflected in the CoReAL framework where all modifiable (obesity, smoking, albumin levels and alcohol consumption) and non-modifiable risk factors for AL (tumor characteristics and comorbidities) were compiled as preoperative reporting elements. We recommend assessing these factors preoperatively and providing a detailed individualized preoperative 10
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