93 Proposal of a Reporting and Data System for Colorectal Anastomotic Leakage: CAL-RADS surgery. This CT classification proposal, presented in Table 1, was developed based on findings from 30 patients who suffered from an AL after colorectal surgery, together with an extensive literature search that gathered all reported elements on imaging and radiological findings 6. The system underwent iterative refinement based on feedback from the included radiological experts. Table 1. Overview of CAL-RADS categories and the corresponding level of suspicion for AL after colorectal surgery Likelihood of AL Findings Management 0 (Technical) Inadequate CT Consider repeating the CT 1 Leakage unlikely • Expected amount of postoperative air and no localized peritoneal fluid No recommended intervention 2 Probable no leak • Ileus with an expected amount of postoperative air and no localized peritoneal fluid Follow-up based on clinical parameters 3 Possible a leak • Excessive and/or increasing post operative extraluminal gas; • With/without anastomotic abnormal bowel wall thickening; • Without peri-anastomotic fluid Suggest close observation and a low threshold for additional examination 4 Highly suggestive of a leak • Excessive and/or increasing postoperative extraluminal gas, with peri-anastomotic fluid and/or; • Presence of a peri-anastomotic abscess; • Disruption of the anastomotic integrity Appropriate intervention suggested 5 Known leak The designation of the CAL-RADS 0 category indicates that the scan lacks the diagnostic quality necessary for the reporting radiologist to definitively attribute or exclude one of the other CAL-RADS categories. This deficiency may arise from severe artifacts or incomplete abdominal coverage. It is important not to interpret this as a conclusive assessment, and if feasible, a repeat scan should be considered. The CAL-RADS 1 category encompasses cases with an abdominal CT scan that is either normal or exhibits expected amount of postoperative air. There are no signs of localized peritoneal fluid. The CAL-RADS 2 category comprises cases featuring radiological findings consistent with an ileus and an expected amount of post-operative air. Again, there are no signs of localized peritoneal fluid. The third category includes findings that, while some may be typical for AL, have still some overlaps with a normal postoperative image. Therefore, CAL-RADS 3 indicates a possible leak. Inclusion in this category is warranted by findings such as excessive and/or increasing post operative extraluminal gas with or without anastomotic abnormal bowel wall thickening, but still without peri-anastomotic fluid. This category implies suspicion for AL and therefore low threshold for additional examination. The fourth category reflects the image is highly suggestive of a leak. Features of the CAL-RADS 4 are excessive and/or increasing postoperative extraluminal gas 4
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