46 Chapter 2 AL Severity Grading systems Grading or classification of AL severity was reported in 45% of included studies (n = 43) 12, 20, 21, 23, 26, 28, 29, 33-36, 38, 39, 41-43, 47, 49, 50, 56, 57, 60, 64, 66, 69, 70, 73, 74, 78, 80, 84, 85, 89, 93-96, 98, 100, 102, 113-115. Nearly half of publications used the ISREC grading system. This classification ranks AL into three grades (grade A, B, or C) based clinical management 10. The Clavien-Dindo grading was used in 19% (n = 8) of publications 28, 29, 36, 42, 43, 57, 78, 95. Leaks were classified as major vs minor leaks in 14% of the papers (n = 6), while radiological vs clinical and clinical vs subclinical leaks were reported in four papers 21, 49, 64, 66, 70, 73, 74, 80, 93, 95, 97, 100, 105, 113. Table 3. Overview of reported elements subdivided in clinical, biochemical, imaging, reinterventions and grading terms. Reporting Element Number of publications Clinical signs and/or symptoms N = 65/95, 68% Discharge from the drain Peritonitis Fever Fistula formation (e.g., rectovaginal fistula etc.) Discharge from the wound Local physical examination (e.g., bowel obstruction, gastric retention, facial dehiscence and/or abdominal pain) Anastomotic dehiscence/defect Discharge of pus per rectum Sepsis Cardiac complications (e.g., atrial fibrillation and/or tachycardia) Deterioration of clinical condition Tachypnea Decreased urine production Mental status change (e.g., agitation or lethargy) Nutritional status (e.g., tube feeding or total parental nutrition) Diarrhea Organ failure Abdominal distension 51 (78%) 42 (65%) 25 (38%) 23 (35%) 17 (26%) 14 (22%) 11 (17%) 8 (12%) 8 (12%) 5 (8%) 3 (5%) 3 (5%) 3 (5%) 3 (5%) 3 (5%) 1 (2%) 1 (2%) 1 (2%) Biochemical elements N = 25/95, 26% Leukocytosis / White cell count CRP elevation Worsening of renal function (e.g., creatinine or urea) Increase of pro-calcitonin Leukopenia pH changes Lactate (increase) Pyruvate (increase) Cytokines (increase) Lysozymes (increase) Matrix metalloproteinases (increase) Culture of intra-abdominal bacteria Other postoperative inflammatory markers (i.e., I-FABP, TNFRSF1A, IL-6, IL-8, CCL2) 22 (88%) 7 (28%) 3 (12%) 2 (8%) 1 (4%) 1 (4%) 1 (4%) 1 (4%) 1 (4%) 1 (4%) 1 (4%) 1 (4%) 1 (4%)
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