Objective Anastomotic leakage (AL) is generally accepted as a major complication of rectal resection surgery. In our study, we aimed to validate its present definition and grading system which were proposed by International Study Group of Rectal Cancer (ISREC) in 2010. Methods Patients who underwent rectal anterior resection in two colorectal surgery centers from January 2012 to December 2014 were included and categorized into different groups according to the ISREC criteria, further, the rate, the severity and the clinical outcomes of their AL were analyzed and compared. Results During a median follow-up period of 38.9 months, 984 patients were included in total. The overall AL rate was 5.0% (49/984), including 7 (14.0%) grade A patients, 21 (43.0%) grade B patients and 21 (43.0%) grade C patients. The rate of grade C AL in protective diverting stoma group was significantly lower than the one in non-stoma group (0.6% vs 2.8%, P=0.029). Patients with grade B or grade C AL had much longer hospital stay than grade A AL patients (P=0.016). The overall 3-year survival rates of grade A, B and C group were 83.3%, 66.7% and 55.6% respectively, without statistical significance. Conclusions Patients who were divided into different groups according to the grading system proposed by the ISREC criteria had significantly different symptoms, clinical outcomes, management and duration of hospitalization. Our study supported that the ISREC criteria which was proved to be applicable to complete surgical outcome assessment and quality assurance of rectal resection surgery.

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