50 Chapter 2 towards classifying leaks based on degree of clinical severity (i.e., significant vs. non-significant leaks, clinical vs. radiological leaks, etc.), however the specific terminology used was ill-defined and non-standardized. One important attribute that may play an important role in reporting and managing ALs is the timeframe in which AL is identified, with clear distinction between early vs late or delayed leaks. Our review found that the timeframe of leak diagnosis, i.e. early and late or delayed, was only reported in one article,41 and most other studies described a 30 day postoperative timeframe for reporting. Including early and late timeframes as an element in the standardized reporting of AL may prevent under-reporting of late/delayed leaks and their sequelae, facilitate earlier management and improve long-term outcomes. The stigma associated with leaks and the use of institutional AL rates as a measure of surgical quality may contribute to the generalized reluctance to investigate leaks early and consistently, as reflected in the wide range of reported diagnostic elements in our review. This stigma must be balanced against the potential benefits of adopting a standardized reporting framework that facilitates earlier diagnosis, management, and resolution of leaks. Also within current reporting systems like The National Surgical Quality Improvement Program (NSQIP), the reporting of an AL is presently contingent upon the specific intervention undertaken and does lack background information (this encompasses a spectrum of scenarios: instances where no documented treatment intervention is recorded, cases managed through interventional methods, situations addressed with non-interventional or nonoperative approaches, instances necessitating reoperation, situations where there is no definitive diagnosis of a leak or a leak-related abscess, and cases categorized as unknown). The need for standardized, well-accepted terminology for reporting of AL remains an important issue especially when evaluating the effectiveness of targeted interventions and/or comparing procedural outcomes. Before formulating a novel framework for reporting and grading colorectal AL, that will gain wide acceptance, several issues need to be addressed. Consensus agreement needs to be reached with respect to which clinical and/or radiologic or endoscopic, and/or biochemical elements are most suggestive of AL, as reporting rates of these elements vary widely. Secondly, agreement is also needed with respect to grading the severity of leaks, that may not only take into account the type of intervention(s) required, but also short and longterm sequelae and impact on patients. Thirdly, additional elements relevant to the timeframe of diagnosis and management of leaks should be routinely incorporated in reporting, with clear distinction between early vs late/delayed AL diagnosis. Lastly, additional features of AL with potential implications on outcomes and interventions, may need to be included such as anastomotic height and protective fecal diversion. There are some limitations of the current work. The heterogeneity between the included studies and varying presentations of data prohibited a more detailed analysis. Also, not all papers solely reported on oncological cases. Furthermore, a deliberate choice was made to only include high-level evidence publications (i.e., RCTs and SRs with or without MAs). However, based on the findings of these studies, the urgency of achieving uniformity in the
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