Impact of safe-anastomosis digital training on 30-day anastomotic leak after right colectomy: international prospective cohort study (EAGLE-2).

Abstract

Anastomotic leak (AL) is the leading cause of major morbidity after right colectomy, affecting 5-10% of patients and accounting for up to one-third of postoperative deaths. The multicentre EAGLE randomized trial demonstrated reductions in AL when surgeons completed a digital safe-anastomosis training package, but its effectiveness outside a trial setting remains untested. EAGLE-2 was an international prospective cohort study conducted across participating centres over an 8-week intervals (June-September 2024). Consecutive adults undergoing right colectomy surgery with primary anastomosis were included. The EAGLE safe-anastomosis training platform was made open access and surgeons were categorized according to whether they had completed the modules before surgery. The primary outcome was 30-day AL, defined as a defect of intestinal wall integrity at the anastomotic site leading to frank AL and/or intra-abdominal collection. Secondary outcomes included collection alone, training uptake, and implementation of the recommended checklist. Mixed-effects logistic regression adjusting for ASA grade, urgency, and intraoperative contamination was performed with hospital as a random effect. A total of 2875 patients were recruited across 332 hospitals in 60 countries. Of these, 2242 (78.0%) operations were performed by trained surgeons and 633 (22.0%) by untrained surgeons. AL/collection occurred in 16.4% of the non-trained group versus 9.1% of the trained group, giving a difference of 7.3% (P < 0.001). Adjusted analysis found training was associated with almost a halving of the OR for AL (adjusted OR (aOR) 0.56 (95% c.i. 0.41 to 0.78)), as well as lower reoperation (aOR 0.64) and readmission (aOR 0.65) rates. Completion of a brief digital training programme was associated with a clinically and statistically significant lower rate of AL after right colectomy, alongside lower rates of reoperation, readmission, and death. Scalable digital education should be embedded into colorectal quality improvement programmes worldwide.