IMARI: multi-Interventional program for prevention and early Management of Anastomotic leakage after low anterior resection in Rectal cancer patIents: rationale and study protocol
Authors: Slooter M. D. , Talboom K. , Sharabiany S. , van Helsdingen C. P. M. , van Dieren S. , Ponsioen C. Y. , Nio C. Y. , Consten E. C. J. , Wijsman J. H. , Boermeester M. A. , Derikx J. P. M. , Musters G. D. , Bemelman W. A. , Tanis P. J. , Hompes R. ,   on behalf of the IMARI-study group, van der Bilt J. D. W. , Burger J. W. A. , Crolla R. M. P. H. , Daams F. , Faneyte I. , Gerhards M. , de Graaf E. J. R. , de Jonge W. J. , van der Meij W. , Oosterling S. J. , Stassen L. P. S. , Tuynman J. B. , Verdaasdonk E. G. G. , van Westreenen H. L. , de Wilt J. H. W. 
Published: October 2020

Abstract
Background
Anastomotic leakage (AL) is still a common and feared complication after low anterior resection (LAR) for rectal cancer. The multifactorial pathophysiology of AL and lack of standardised treatment options requires a multi-modal approach to improve long-term anastomotic integrity. The objective of the IMARI-trial is to determine whether the one-year anastomotic integrity rate in patients undergoing LAR for rectal cancer can be improved using a multi-interventional program.

Methods
IMARI is a multicentre prospective clinical effectiveness trial, whereby current local practice (control cohort) will be evaluated, and subsequently compared to results after implementation of the multi-interventional program (intervention cohort). Patients undergoing LAR for rectal cancer will be included. The multi-interventional program includes three preventive interventions (mechanical bowel preparation with oral antibiotics, tailored full splenic flexure mobilization and intraoperative fluorescence angiography using indocyanine green) combined with a standardised pathway for early detection and active management of AL. The primary outcome is anastomotic integrity, confirmed by CT-scan at one year postoperatively. Secondary outcomes include incidence of AL, protocol compliance and association with AL, temporary and permanent stoma rate, reintervention rate, quality of life and functional outcome. Microbiome analysis will be conducted to investigate the role of the rectal microbiome in AL.
In a Dutch nationwide study, the AL rate was 20%, with anastomotic integrity of 90% after one year. Based on an expected reduction of AL due to the preventive approaches of 50%, and increase of anastomotic integrity by a standardised pathway for early detection and active management of AL, we hypothesised that the anastomotic integrity rate will increase from 90 to 97% at one year. An improvement of 7% in anastomotic integrity at one year was considered clinically relevant. A total number of 488 patients (244 per cohort) are needed to detect this difference, with 80% statistical power.

Discussion
The IMARI-trial is designed to evaluate whether a multi-interventional program can improve long-term anastomotic integrity after rectal cancer surgery. The uniqueness of IMARI lies in the multi-modal design that addresses the multifactorial pathophysiology for prevention, and a standardised pathway for early detection and active treatment of AL.

Trial registration
Trialregister.nl (NL8261), January 2020.