321 Summary, general discussion and future perspectives The outcomes underscored the pervasive issue of incomplete and inconsistent reporting of AL within the published CRC literature. To facilitate clearer communication regarding leaks, enable data comparison, and enhance clinical outcomes, there is an urgent need to develop and implement a consensus framework for defining, grading, and reporting AL. Chapter 3 represented the collaborative consensus project “Consensus on Reporting colorectal Anastomotic Leaks (CoReAL)”, which provided an evidence overview and reporting framework for AL after oncological colorectal surgery. The project consisted of a distinguished group of expert surgeons who were all members of international surgical societies. Firstly, the group analyzed all the available literature on AL. Based on an analysis of 477 high-level evidence (systematic reviews with or without meta-analysis, and RCTs) papers, a total of 33 evidence-based statements regarding AL after CRC surgery were formulated. In summary, we have identified pre-operative modifiable and non-modifiable risk factors associated with AL and acknowledged that preoperative oral antibiotics may reduce AL rates. Intraoperatively, we stated that factors such as the level of mesenteric artery ligation, conversion status, number of stapler firings, use of fluorescence angiography, anastomotic integrity tests, and prophylactic fecal diversion also impact AL occurrence. In the postoperative diagnostic phase, we found that serial C-reactive protein (CRP), CT-scan, or endoscopic examination are useful, and both minimally invasive and open re-interventions are feasible with proper patient selection to realize both earlier detection of AL and subsequent reduced morbidity. The evidence highlighted the long-term consequences of AL as increased mortality rates, overall complications, risk for permanent stoma, decreased overall survival and disease-free survival, higher local recurrence rates, and increased healthcare costs. All other formulated statements were on factors that did not influence AL rates based on the analyzed evidence. Secondly, the statements aimed to support the reporting framework presented in this paper, together with the input from an international group of experts as well as patients’ perspectives. The final core reporting elements represent pre-operative (risk factors, antibiotics, mechanical bowel preparation, and potential need of a stoma), intra-operative (stoma creation, intraoperative difficulty, integrity testing, stapler loads, conversion, pitfalls, splenic flexure mobilization, inferior mesenteric artery ligation, and perfusion assessment), and postoperative short-term and long-term factors (re-interventions, stoma creation, diagnostic modalities, CRP measurement, readmission, length of hospital stay, ICU admission, anastomotic complications, oncological outcomes, functional outcomes, QoL outcomes and mortality) that should be documented and reported once a patient develops AL. For the postoperative course, these reporting elements were subdivided as reporting elements that should be reported during index admission, within 30 days up to 90 days and after 90 days during the follow-up period. Increasing demand for healthcare escalating costs, resource constraints, and evidence of disparities in clinical practice have prompted a keen interest in assessing and enhancing the quality of healthcare delivery 2. To conduct a meaningful quality assessment, it is imperative 14
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