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Aim: Palliative rectal cancer patients typically retain their primary tumour, as trials have concluded no survival benefit of tumour resection in non-curative patients. This patient group is understudied regarding the natural course of the remaining tumour, particularly concerning the need of surgical management.

Method: This was a retrospective study on rectal cancer patients diagnosed between 2007 and 2020 in Region Västerbotten, Sweden. Data were obtained from the Swedish Colorectal Cancer Registry and chart review. Patients were excluded if treated with curative intent, underwent primary tumour resection, had a synchronous colorectal cancer, had locally recurrent colorectal cancer, or refused treatment. Patients were followed from diagnosis until death or end of follow-up. Indications for palliative treatment, tumour-related complications and surgical and oncological management were investigated, with a stratified analysis for study period and patient age.

Results: Some 156 patients remained after applying exclusion criteria. The majority had metastasized and incurable disease (76%). Almost half suffered local complications (44%) and 48% underwent surgical intervention, due to the unremoved primary tumour. Tumour perforation occurred in 7% with a significantly higher risk in patients aged ≤75 years (p = 0.009). Bowel obstruction afflicted 23%, while 40% underwent stoma diversion. Almost half received chemotherapy (48%) and radiotherapy (42%), respectively.

Conclusion: Rectal cancer patients with an unremoved primary tumour face a substantial risk of local complications, often necessitating surgical intervention. Therefore, the benefits of surgical resection should be carefully considered, especially for patients with a longer estimated survival. Further research is needed to accurately identify patients where tumour removal might be beneficial.

Background: Large bowel obstruction is a possible complication in patients undergoing neoadjuvant treatment for rectal cancer; however, it may be prevented by placing a pretreatment defunctioning stoma. The aim of this retrospective study was to investigate complication rates in patients with rectal cancer undergoing long-course neoadjuvant therapy, comparing those with and without a prophylactic stoma.

Methods: All patients with rectal cancer undergoing neoadjuvant therapy between 2007 and 2022 in Region Västerbotten, Sweden, were identified using the Swedish Colorectal Cancer Registry. Patients not planned for curative long-course neoadjuvant therapy and those requiring a stoma due to urgent bowel-related issues before treatment were excluded. The primary outcome was the incidence of complications between diagnosis and resection surgery or end of follow-up. The secondary outcomes were 30-day complications following resection, time to treatment (neoadjuvant therapy and surgery), and overall survival. Multivariable regression analysis was used, with adjustment for age, sex, American Society of Anesthesiologists fitness grade, and clinical tumour stage.

Results: Of 482 identified patients, 105 were analysed after exclusion. Among these, 22.9% (24 of 105) received a pretreatment stoma, whereas 77.1% (81 of 105) received upfront neoadjuvant therapy. The complication incidence before resection in the group with a defunctioning stoma and in the group without a defunctioning stoma was 75.0% (18 of 24) and 29.6% (24 of 81) respectively. A considerable number of complications were directly caused by the stoma surgery. Patients in the stoma group had an adjusted OR of 6.71 (95% c.i. 2.17 to 20.76) for any complication. However, for 30-day complications following resection, an adjusted non-significant OR of 2.05 (95% c.i. 0.62 to 6.81) was documented for the stoma group, in comparison with the control group. Neoadjuvant treatment was also delayed for the stoma group (adjusted mean time difference: 21 (95% c.i. 14 to 27) days), whereas the difference was not significant for the time to resection surgery. The median survival after diagnosis was 4.7 years in the stoma group and 12.2 years in the control group (P = 0.015); however, adjustment in the multivariable analysis rendered the estimate non-significant (HR 1.71 (95% c.i. 0.93 to 3.14)).

Conclusion: Patients with rectal cancer who receive a stoma before long-course neoadjuvant therapy, in the absence of urgent symptoms, experience more complications than those without a stoma and a delay with regard to the start of neoadjuvant treatment.

Aim: To investigate short- and long-term kidney injury incidence in patients undergoing low anterior resection for rectal cancer, comparing those with and without a defunctioning ileostomy.

Method: We identified all Swedish rectal cancer patients ≤80 years old, with ASA fitness grade ≤III and tumour height ≤12 cm from the anal verge, who underwent anterior resection between 2007 and 2021 using CRCBaSe, a nationwide registry linkage. Patients who received a defunctioning ileostomy during surgery were compared with those who did not. Outcomes included chronic kidney failure, chronic kidney disease, acute kidney injury, and dehydration. Cox proportional hazards models were fitted for each outcome, using overlap weights derived from propensity scores for receiving a defunctioning ileostomy. Stoma reversal impact and mediation by anastomotic leakage were also examined.

Results: Among 5286 patients, 4623 (87%) received a defunctioning ileostomy and 663 (13%) did not. A defunctioning ileostomy was not significantly associated with chronic kidney failure (HR 1.68, 95% CI: 0.19–15.16) or chronic kidney disease (HR 1.65, 95% CI: 0.91–2.98) but increased risks of acute kidney injury (HR 3.01, 95% CI: 1.61–5.64) and dehydration (HR 4.02, 95% CI: 2.33–6.94). Risks declined after stoma reversal. Stomas reduced anastomotic leakage with negligible mediation effects on short-term kidney damage.

Conclusion: A defunctioning ileostomy after low anterior resection increases the risks of acute kidney injury and dehydration but not chronic kidney failure or chronic kidney disease. These risks decrease following stoma reversal, highlighting the need for careful perioperative management.

Aim: To investigate whether patients with endoscopically untraversable rectal cancer may benefit from a defunctioning stoma created before neoadjuvant therapy or resectional surgery.

Methods: This retrospective study comprise patients diagnosed with rectal cancer during 2007–2020 in Region Västerbotten, Sweden. The primary outcome was time between diagnosis and any treatment, while survival and the incidence of complications were secondary outcomes. Excluded were patients without endoscopic obstruction, patients already having a stoma, patients with recurrent disease, palliative patients, and patients receiving a stoma shortly after diagnosis due to any urgent bowel-related complication. Data were obtained from the Swedish Colorectal Cancer Registry and medical records. Kaplan–Meier failure curves were drawn, and a multivariable Cox regression model was employed for confounding adjustment.

Results: Out of 843 patients, 57 remained after applying exclusion criteria. Some 12/57 (21%) patients received a planned stoma before treatment, and the remainder received upfront neoadjuvant therapy or surgery. Median time to any treatment was 51 days for the planned stoma group and 36 days for the control group, with an adjusted hazard ratio of 0.28 (95% confidence interval: 0.12–0.64). Complications occurred at a rate of 5/12 (42%) and 7/45 (16%) in the planned stoma group and control group, respectively. Survival was similar between groups.

Conclusion: A planned stoma results in treatment delay, but it remains unclear whether this is clinically relevant. Complications were more common in the planned stoma group, although the data are limited. While larger studies are needed, it seems feasible to avoid defunctioning stomas even in endoscopically obstructing rectal cancers.