Anastomotic reinforcement in rectal surgery: a position statement from an expert panel of colorectal surgeons

Anastomotic leakage (AL) remains one of the most feared complications after rectal surgery for cancer, with stable incidence rates despite advances in surgical technique and perioperative care. Multiple anastomotic reinforcement strategies have been proposed, yet evidence remains heterogeneous and no clear consensus exists regarding their routine use. A structured expert position panel process was conducted. Eleven clinical scenarios based on AL risk factors and twenty thematic items addressing indications, devices, timing, contraindications, surgical approach, stoma use, costs, and expected outcomes were developed. A panel of experts evaluated each statement using a five-point Likert scale through a two-round process. Consensus was assessed using median scores and interquartile ranges (IQR). Consensus was not reached for most individual or combined preoperative risk factors. Most reinforcement techniques did not receive clear endorsement because of inconsistent and heterogeneous evidence. Strong agreement emerged regarding the central role of intraoperative assessment: tissue perfusion, mechanical tension, tissue quality, and unexpected technical difficulty were identified as key determinants. The panel agreed that reinforcement may still be appropriate in the presence of a diverting stoma, as diversion reduces clinical severity but does not prevent leakage or long-term sequelae. Surgical approach and material cost were not considered influent factors. This position statement highlights the lack of robust evidence supporting routine, indication-driven, or device-specific anastomotic reinforcement in rectal cancer surgery. The main shared recommendation was to base reinforcement on intraoperative surgical judgment, including tissue perfusion, tension, tissue quality, and unexpected technical difficulty. Keywords: anastomotic leakage, rectal cancer surgery, anastomotic reinforcement