320 Chapter 14 This thesis aimed to improve post-operative outcomes for colorectal cancer (CRC) patients by focusing on two key areas: increasing awareness on reporting and reducing anastomotic leakage (AL) and preventing the occurrence of metachronous peritoneal metastases (PM). More specifically the aims were to increase (I) insight in how AL is reported in high level evidence literature, and subsequently create an evidence-based reporting framework and radiological scoring system that can be used to standardize complication reporting of AL in the future, (II) investigate the feasibility and quantification of intestinal perfusion with innovative image-guided surgery techniques (both indocyanine green (ICG) and methylene blue (MB) and with Laser Speckle Contrast Imaging (LSCI), and (III) create an overview of the current knowledge of the impact on the Quality of Life (QoL) of patients after colorectal AL and obtain a more in-depth understanding of their experiences. Since there is increasing evidence suggesting that AL is also influencing oncological outcomes, this thesis additionally aimed to identify predictive biomarkers in primary colorectal tumors for metachronous PM and evaluate the safety of an intraperitoneal cytostatic-loaded supramolecular hydrogel as potential preventive strategy (part IV). The introduction (Chapter 1) provided an overview of the available evidence and current status with regard to the aims of thesis. PART I: INCREASING INTERNATIONAL CONSENSUS ON CURRENT EVIDENCE AND REPORTING OF ANASTOMOTIC LEAKS AFTER COLORECTAL CANCER SURGERY Reporting of AL has been challenging as the precise definition of what constitutes a leakage subsequent to colorectal anastomotic surgery has remained a subject of ongoing debate 1. Yet, reporting complications is essential for promoting transparency, accountability, and continuous improvement in healthcare delivery, ultimately enhancing patients’ outcomes and quality of care 2. In the first section of the thesis, our focus was to enhance understanding of the diverse ways of reporting colorectal AL and subsequently develop a system to improve its reporting. Chapter 2 comprised an overview in the form of a systematic review on how AL is currently reported in high-level evidence literature (randomized controlled trials (RCTs), systematic reviews, and meta-analyses). Among the 471 articles addressing AL as either a primary or secondary outcome, only 95 studies (comprising 45 randomized controlled trials, 13 systematic reviews, and 37 meta-analyses) provided a clear definition. This collective involved a total of 346,140 patients. Within these 95 articles, 68% provided a description of the clinical signs and symptoms of AL, 26% utilized biochemical criteria, 63% relied on radiological modalities, 62% considered radiological findings, and 13% described the findings during re-intervention. Notably, only 45% (n = 43) of the studies included in the analysis, reported the grading of AL severity or leak classification, and 41% (n = 39) specified a timeframe for AL diagnosis. A high degree of heterogeneity among the included studies was highlighted.
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