63 International Consensus on Reporting colorectal Anastomotic Leaks (CoReAL) INTRODUCTION Anastomotic leak (AL) represents a critical and challenging complication of colorectal cancer (CRC) resections with substantial impact on short and long-term outcomes. Despite advances in preoperative risk assessment, surgical technique and postoperative care, the prevalence of colorectal AL ranges from 1.5% to 23% with sequelae that range from minimal to severe morbidity, and mortality rates as high as 16%-29% 1-5. The lack of consensus on how AL is defined, graded and reported complicates our understanding of the true prevalence of AL and our ability to compare risk factors, interventions and outcomes of AL across studies 6,7. In recent years, there has been a growing recognition of the importance of standardizing the reporting of colorectal ALs. While previous endeavors have been undertaken to achieve consensus on definitions and severity grading of colorectal AL, widespread adoption and reporting have remained limited 8-12. A recent systematic review of the literature to assess the quality of reporting of AL in CRC trials, highlighted significant heterogeneity across trials. Among studies where colorectal AL following CRC resection was a primary or secondary endpoint, only 20% provided clear reporting of how AL was defined, with even fewer describing diagnostic modalities and/or re-interventions for AL in the short and long-term study follow-up 13. This lack of reporting undermines the validity of clinical trials, complicates the comparison of any given interventions on outcomes of AL across studies, ultimately hindering the assessment of the effectiveness of strategies to mitigate AL 14-17. We hypothesized that the lack of an acceptable standardized reporting system leads to widespread underreporting of colorectal AL and subsequent anastomotic complications. This inconsistency in reporting of AL represents a clinical and scientific gap that prompted the development of a consensus framework aimed at enhancing the quality of reporting of AL in both clinical practice and clinical trials. The aim of this Consensus on Reporting colorectal Anastomotic Leaks (CoReAL) project was to create a framework to standardize the reporting of AL following left-sided colorectal cancer resections with a colorectal anastomosis based on expert consensus, informed by high-level published evidence and patient perspectives. MATERIALS AND METHODS The CoReAL project consisted of two phases (Figure 1). First, all available evidence regarding key questions related to factors that may or may not contribute to the development, severity and short and long-term outcomes after AL, was analyzed and used to develop evidencebased statements. Second, the evidence statements were complemented with expert opinions and patients’ perspectives to develop a reporting framework. The topic of colorectal AL was divided into four phases along the AL episode of care, including preoperative, 3
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