Paper of the Month for January looks at how benchmarking colorectal surgery outcomes informs quality improvement. ESCP's CORREA 2022 snapshot audit aimed to assess contemporary colorectal resection practices and short-term outcomes across European countries and beyond.
Towards safer colorectal surgery worldwide: Outcomes and benchmarks from the ESCP CORREA 2022 audit
2022 European Society of Coloproctology (ESCP) CORREA Collaborating Group. Colorectal Dis. 2025 Nov;27(11):e70281. doi: 10.1111/codi.70281. PMID: 41286435; PMCID: PMC12644303.
What is known about the subject
Colorectal resection remains associated with considerable postoperative morbidity, with anastomotic leak persisting as one of the most severe complications, carrying an incidence of approximately 8.10% in recent series [1, 2]. The 2015 ESCP audit of right colectomies highlighted the significant clinical impact of leaks, with 30-day mortality rates rising sharply from 1.6% in patients without leaks to 10.7% when an anastomotic leak occurred [3, 4]. In recent years, improvements in surgical methods, like minimally invasive surgery, enhanced recovery protocols, better imaging, and intensive care, have led to better results. However, their effect on anastomotic leak rates remains unclear.
What the study adds
The ESCP CORREA 2022 audit included 3,521 patients from 216 hospitals in 53 countries over six weeks (January-April 2022), providing updated real-world benchmarks for contemporary colorectal resection practices [5].
A minimally invasive approach was used in 55.2% of cases, comprising 48.7% laparoscopic and 6.5% robotic procedures. The conversion rates were 14.6% for laparoscopic and 4.3% for robotic surgery. Emergency procedures were more common in open surgery (44.4%) compared to laparoscopic (13.6%) and robotic surgeries (7.1%).
The 30-day anastomotic leak rate among patients who underwent primary anastomosis was 7.96% (214 out of 2689 patients). Leak rates varied by procedure: right-sided resections 6.9%, left-sided resections 7.7%, anterior rectal resections 9.7%, pouch procedures 16.0%, and subtotal colectomies 11.8%.
Multivariable analysis identified independent risk factors for anastomotic leakage: male sex (9.3% versus 6.3%, OR having male as reference = 0.69, 95% CI 0.51 to 0.95, p = 0.023) and emergency surgery (11.4% versus 7.1%, OR having elective as reference = 1.58, 95% CI 1.10 to 2.27, p = 0.013). Operations performed by colorectal consultant surgeons were protective factors.
The 30-day mortality rate was 2.38% overall, with significant variation by surgical approach: open surgery 5.3% (66/1246) compared with laparoscopic 0.5% (9/1680) and robotic 0.4% (1/224) (p < 0.001). Nevertheless, this difference highlights variations in cohort composition, with open cases tending to involve older, more ill, and frequently urgent patients.
Patients had a reduced length of hospital stay when treated with minimally invasive methods: the median stay was 5 days (IQR 4.0–7.0) for the robotic approach and 6 days (4.0–8.0) for the laparoscopic approach, in contrast to 8 days (6.0–14.0) for the open approach (p < 0.001).
Notably, when accounting for case mix, the rates of anastomotic leaks were similar between open and minimally invasive techniques. This suggests that although minimally invasive surgery provides distinct short-term benefits, it does not fundamentally alter the biological process of anastomotic healing.
Implications for colorectal practice
This large international audit confirms that minimally invasive techniques have become the most frequent practice for planned colorectal surgeries by 2022, with their widespread adoption across diverse healthcare settings. These findings support the continued expansion of minimally invasive surgery training and infrastructure.
Despite numerous technical advances in surgical devices, tissue sealants, and perfusion assessment tools, the anastomotic leak rate remains persistently high, at approximately 1 in 12 patients with anastomosis. This plateau underscores the urgent need for intensified research on predictive biomarkers, novel preventive strategies, and improved management protocols for anastomotic leakage. The ESCP EAGLE trial represents an important step in systematically evaluating the quality improvement interventions to reduce these complications [6].
The identification of risk factors for anastomotic leakage, including male sex, emergency surgery, and anterior rectal resections, can aid clinicians in preoperative risk stratification and patient counseling. This approach facilitates more personalized surgical planning and enhances vigilance for individuals identified as high-risk.
Quality-improvement initiatives, such as adherence to enhanced recovery protocols, mechanical bowel preparation with oral antibiotics, and meticulous surgical technique (ensuring adequate blood supply, avoiding tension, wide mobilization, and considering protective stomas for high-risk distal anastomoses), remain essential strategies for reducing anastomotic complications. Technical factors, such as anastomotic configuration and staple selection, warrant consideration in high-risk procedures [7].
The current results provide up-to-date real-world data that can guide both national and international policies, support efforts to improve quality, and set priorities for future research focused on advancing patient care in colorectal surgery worldwide.
References
- 2015 European Society of Coloproctology collaborating group. The relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit. Colorectal Dis. 2017 Mar 6;19(8):e296–311.
- Chiarello MM, Fransvea P, Cariati M, Adams NJ, Bianchi V, Brisinda G. Anastomotic leakage in colorectal cancer surgery. Surg Oncol. 2022 Mar;40(101708):101708.
- 2015 European Society of Coloproctology Collaborating Group. Predictors for anastomotic leak, postoperative complications, and mortality after right colectomy for cancer: Results from an international snapshot audit. Dis Colon Rectum. 2020 May;63(5):606–18.
- 2015 European Society of Coloproctology Collaborating Group. The impact of stapling technique and surgeon specialism on anastomotic failure after right-sided colorectal resection: an international multicentre, prospective audit. Colorectal Dis. 2018 Nov;20(11):1028–40.
- 2022 European Society of Coloproctology (ESCP) CORREA Collaborating Group. Towards safer colorectal surgery worldwide: Outcomes and benchmarks from the ESCP CORREA 2022 audit. Colorectal Dis. 2025 Nov;27(11):e70281.
- ESCP EAGLE Safe Anastomosis Collaborative and NIHR Global Health Research Unit in Surgery. Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries. Br J Surg [Internet]. 2024 Jan 3;111(1). Available from: http://dx.doi.org/10.1093/bjs/znad370
- European Society of Coloproctology (ESCP) Circular Stapled Anastomosis Working Group and 2017 European Society of Coloproctology (ESCP) Collaborating Group. Anastomotic leak after manual circular stapled left-sided bowel surgery: analysis of technology-, disease-, and patient-related factors. BJS Open [Internet]. 2024 Sept 3;8(5). Available from: http://dx.doi.org/10.1093/bjsopen/zrae089