87 International Consensus on Reporting colorectal Anastomotic Leaks (CoReAL) S3. Expert commentary on the statements • Statement 7: Although the statement on sarcopenia, experts believe sarcopenia may be associated with AL and future research needs to be performed to investigate the impact of sarcopenia and frailty to AL outcomes. • Statement 9: Splenic flexure mobilization represents a way to create a tension free anastomosis. The experts asked themselves ‘What is tension free?’ and concluded this cannot be measured objectively. They therefore decided to formulate the statement regarding flexure mobilization, with the expert note that if there is no tension free anastomosis, the risk of AL increases and flexure mobilization is a way to reduce this risk, but, as stated here, this is not necessary to perform routinely. • Statement 11: As conversion reflects intraoperative difficulty, it is not the conversion itself that increases AL rates, but reflects the fact that the operation was difficult, which is a risk factor for AL development. • Statement 15: The ‘severity’ of leaks is something difficult to measure, but the experts decided to use this phrasing as it’s more about the consequences of leaks instead of the rates. • Statement 27: The experts state that transanal or endoscopic management is possible when appropriate expertise is available. Besides, some experts stated that this should never be performed alone but always in combination with a lavage, although this opinion was not supported by everyone, nor was this specified in the evidence. 3
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