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

Table 1 List of panel members

Name	Institute
Dietmar Öfner	Medical University of Innsbruck, Austria
Robin McLeod	University of Toronto, Canada
Zhou-Qiao Wu	Peking University Cancer Hospital, China
Ismail Gögenur	Zealand University Hospital, Centre for surgical Science, Denmark
Lars Nannestad Jørgensen	Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Denmark
Yves Panis	Beaujon Hospital, Paris, France
Pablo Ortega-Deballon	University Hospital of Dijon, France
Markus Büchler	University of Heidelberg, Germany
Gianluca Pellino	Università degli Studi della Campania ''Luigi Vanvitelli'', Italy
Harry van Goor	Radboud University Medical Center, The Netherlands
Adam Dziki	Medical University of Lodz, Poland
Eduardo García-Granero	Hospital La Fe, University of Valencia, Spain
Martin Rutegård	Umea University, Sweden
Ignazio Tarantino	Kantonsspital St. Gallen, Switzerland
Steven D Wexner	Cleveland Clinic Florida, Weston, FL, United States
Michael Stamos	University of California, Irvine, CA, United States
John Alverdy	University of Chicago Medical Center, Chicago, IL, United States
James Kinross	Imperial college London, United Kingdom
Dermot Burke	Leeds Teaching Hospitals NHS Trust, United Kingdom

Table 2 Summary of the consensus on the definition of colorectal anastomotic leakage after two rounds

Category	Consensus
Clinical parameters	Tachycardia, clinical deterioration, abdominal pain, discharge from abdominal drain, discharge from rectum, rectovaginal fistula and anastomotic defect found by digital examination contribute to the suspicion of CAL
Laboratory tests	CRP and the combination of CRP and leukocytosis contribute to the suspicion of CAL; Albumin, urea and creatinine do not contribute to the suspicion of CAL
Radiological findings	Extravasation of endoluminal administrated contrast, collection around the anastomosis, presacral abscess near anastomosis, perianastomotic air and free intra-abdominal air are defined as CAL on CT-scan
Findings during reoperation	Necrosis of anastomosis, necrosis of blind loop, signs of peritonitis and dehiscence of anastomosis are defined as CAL during reoperation
Grading systems	Grading or classifying CAL is important; Both the ISREC-classification and Clavien-Dindo classification are suitable
Timing	Distinction between early and late anastomosis should be made; There should not be a fixed range of days in which CAL can occur to define it as CAL
Colon/rectum	Colon and rectum should be seen as separate entities

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

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.