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. 2023 Jul 18;13(7):e073085.
doi: 10.1136/bmjopen-2023-073085.

Systematic review of preoperative and intraoperative colorectal Anastomotic Leak Prediction Scores (ALPS)

Mary L Venn  1 , Richard L Hooper  2 , Tom Pampiglione  3 , Dion G Morton  4 , Dmitri Nepogodiev  4 , Charles H Knowles  3
Affiliations

Systematic review of preoperative and intraoperative colorectal Anastomotic Leak Prediction Scores (ALPS)

Mary L Venn et al. BMJ Open. .

Abstract

Objective: To systematically review preoperative and intraoperative Anastomotic Leak Prediction Scores (ALPS) and validation studies to evaluate performance and utility in surgical decision-making. Anastomotic leak (AL) is the most feared complication of colorectal surgery. Individualised leak risk could guide anastomosis and/or diverting stoma.

Methods: Systematic search of Ovid MEDLINE and Embase databases, 30 October 2020, identified existing ALPS and validation studies. All records including >1 risk factor, used to develop new, or to validate existing models for preoperative or intraoperative use to predict colorectal AL, were selected. Data extraction followed CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies guidelines. Models were assessed for applicability for surgical decision-making and risk of bias using Prediction model Risk Of Bias ASsessment Tool.

Results: 34 studies were identified containing 31 individual ALPS (12 colonic/colorectal, 19 rectal) and 6 papers with validation studies only. Development dataset patient populations were heterogeneous in terms of numbers, indication for surgery, urgency and stoma inclusion. Heterogeneity precluded meta-analysis. Definitions and timeframe for AL were available in only 22 and 11 ALPS, respectively. 26/31 studies used some form of multivariable logistic regression in their modelling. Models included 3-33 individual predictors. 27/31 studies reported model discrimination performance but just 18/31 reported calibration. 15/31 ALPS were reported with external validation, 9/31 with internal validation alone and 4 published without any validation. 27/31 ALPS and every validation study were scored high risk of bias in model analysis.

Conclusions: Poor reporting practices and methodological shortcomings limit wider adoption of published ALPS. Several models appear to perform well in discriminating patients at highest AL risk but all raise concerns over risk of bias, and nearly all over wider applicability. Large-scale, precisely reported external validation studies are required.

Prospero registration number: CRD42020164804.

Keywords: adult surgery; adverse events; colorectal surgery; prognosis; systematic review.

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Conflict of interest statement

Competing interests: Conflicts of Interest and Source of Funding: DM is chief investigator of the EAGLE study (ESCP Safe-anastomosis Programme in Colorectal Surgery) that uses a patient risk stratification tool as part of its intervention to reduce anastomotic leak. We thank the European Society of Coloproctology (ESCP) for the overall funding for EAGLE study conduct. RH, CHK, MLV and DN are members of the EAGLE steering and operations committees. This EAGLE study has in no way impacted the selection or assessment of the studies in this review. For the remaining authors no conflicts were declared. This study was unfunded.

Figures

Figure 1
Figure 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. AL, anastomotic leak.
See this image and copyright information in PMC

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