324 Chapter 14 state among the remaining microbiota, potentially leading to anastomotic breakdown 10, 11. Selective antibiotics, also known as selective decontamination, may effectively suppress mucosal-associated flora in the gastro-intestinal tract and, thus, prevent the contamination of the anastomosis 13. Factors such as diet, antibiotic usage, surgical stress, and opioid consumption significantly influence the gut microbiome and may be adjustable at different stages of surgery 11. Despite extensive research, much remains unknown about the normal composition and behavior of the gut microbiome compared to altered states. Therefore, targeting the gut microbiome as a modifiable factor in anastomotic healing could present a new approach for preventing AL. Fast recognition and subsequent treatment of AL is necessary to minimize clinical consequences and chronic sequelae for these patients 14. Current diagnostic methods often lack the ability to detect AL early enough to facilitate prompt intervention and mitigate severe morbidity and mortality 15. Computerized tomography (CT) scanning and water-soluble contrast studies are currently the preferred techniques to diagnose AL 16. We acknowledge CT scanning exhibit variable sensitivity and specificity, and we believe it is therefore pivotal to appropriately report radiological findings. The lack of reporting radiological features was highlighted in our systematic review in chapter 2, but also in previous research 1, 5. Earlier, a panel of eight surgeons attempted to reach consensus not only on the definition of AL, but also on radiological criteria 17. Consensus could only be achieved when a leak was radiologically defined as extravasation of contrast outside the intestinal lumen near the anastomosis on postoperative day (POD) 12 following laparoscopic sigmoidectomy; on POD 35 following low anterior resection (LAR); or when air bubbles around the anastomosis were seen on POD 35 following laparoscopic LAR. Consensus was not achieved for signs on earlier days, or when a leak was defined as radiological collections treated with antibiotics or those requiring percutaneous drainage (i.e., ISREC grade B leaks). Currently no consensus is published on how to report and manage leaks based on radiological examination 18. Hence, the CoReAL group, comprising both surgeons and radiologists, acknowledged the necessity of establishing a method for radiological assessment and reporting of leaks. However, rather than attempting to reach a consensus on a specific radiological definition, the expert team proposed a scoring system for future reporting of AL. This concept was previously introduced by radiological colleagues as Reporting and Data Systems (RADS) of which the first published system was the breast RADS (BI-RADS) to assess breast cancer on mammography, magnetic resonance imaging (MRI), and ultrasound (US) 19. It enables radiologists to communicate results to the referring breast surgeon clearly and consistently, with a final assessment and specific management recommendations. Many additional malignancy RADS were developed afterwards like C-RADS (colon cancer; CT colonography), LI-RADS (liver cancer; MRI, CT, US, and contrast-enhanced US), Lung-RADS (lung cancer; low-dose CT), NI-RADS (head and neck cancers; PET, CT, and MRI), O-RADS (adnexal masses; US), PI-RADS (prostate cancer; MRI), and TI-RADS (thyroid cancer; US) 19. Additionally, systems to assess certain diseases instead of the likelihood of malignancy were developed as well like CAD-RADS (CT angiography) for coronary artery
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