Consensus on the definition of colorectal anastomotic leakage: A modified Delphi study

Table 3 Recommendations final round

Category	Recommendation
General definition	The ISREC definition of CAL is used by the majority of the participants (71%)
Clinical parameters	Tachycardia, clinical deterioration, abdominal pain other than wound pain, discharge from the abdominal drain, discharge from the rectum, rectovaginal fistula and anastomotic defect found by digital examination are clinical symptoms that contribute to the suspicion of CAL
Laboratory tests	CRP and the combination of CRP and leukocytosis are appropriate laboratory tests and should be tested if there is a suspicion of CAL. Albumin, urea and creatinine do not contribute to the suspicion of CAL and therefore should not be tested
Radiological findings	Extravasation of endoluminal administrated contrast, collection around the anastomosis, presacral abscess near the anastomosis, perianastomotic air and free intra-abdominal air should be defined as CAL on CT-scan. However, defining free intra-abdominal air as CAL depends on the amount of post-operative days
Findings during reoperation	Necrosis of the anastomosis, necrosis of the blind loop, signs of peritonitis and dehiscence of the anastomosis should all be defined as CAL when observed during reoperation
Grading systems	It is important to grade or classify CAL. Both the ISREC-classification and Clavien-Dindo classification are appropriate grading systems
Timing	Distinction between early and late anastomotic leakage should be made. There should not be a fixed range of days in which CAL can occur to define it as CAL
Colon/rectum	Colonic anastomotic leakage and rectal anastomotic leakage should be seen as two separate problems, based on different incidence rates, different anatomy, different surgical technique

CAL: Colorectal anastomotic leakage; CRP: C-reactive protein; CD: Clavien-Dindo; CT: Computed tomography.