48 Chapter 2 Table 3. Continued Reporting Element Number of publications Grading terms N = 43/95, 45% ISREC classification Other classifications: Clavien-Dindo Hinchey Major vs minor leaks Radiological vs clinical leaks Clinical vs subclinical leaks Generalized vs localized leaks Early vs late leaks Significant vs non-significant leaks Complete vs partial leaks 21 (49%) 8 (19%) 1 (2%) 6 (14%) 4 (9%) 4 (9%) 1 (2%) 1 (2%) 1 (2%) 1 (2%) CRP, C-reactive protein; I-FABP, intestinal fatty acid binding protein; TNFRSF1A, TNF receptor superfamily member 1A; IL-6, interleukine-6; IL-8, interleukine-8; CCl2, C-C motif chemokine ligand 2; CT, Computerized tomography scan; MRI, Magnetic resonance imaging; PET, Positron emission tomography. DISCUSSION This systematic review aimed to evaluate the various elements and criteria used to report on the definition and grading colorectal AL following CRC resections. This current review of the literature reveals the lack of a widely accepted and applied definition of colorectal AL. Despite the increase in the number of high level of evidence publications (RCTs, SRs and MA’s) on this topic in recent years, 72% (n = 376) of publications screened for eligibility did not include a specific definition to assess the presence of AL, even though the incidence of AL served as a primary or secondary outcome. Based on our literature search, only 18% (n = 95) of eligible studies specified how AL was defined. In order to gain knowledge of general definitions of AL across eligible publications, specific elements contributing to the definition and grading of the severity of leaks were compared across studies when applicable (i.e., clinical-, biochemical-, radiological-, findings at reoperation, and severity grades). The latter led to another noteworthy finding; the extensive range of elements utilized, led to vast variations in the reported colorectal AL rates (based on the various categories or domains used), and ultimately resulted in difficulty comparing findings across studies. Overall, to support the diagnosis of an AL, clinical signs and symptoms were used in 68% of included studies, radiological modalities and radiological findings in 63% and 62% respectively, biochemical elements in 26% and findings at reoperation only in 13% of studies. In addition, 45% of studies reported grading the severity of AL, with 46% reporting a more detailed definition and 41% including a timeframe for AL reporting.
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