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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.

A defunctioning stoma is used to alleviate the consequences of anastomotic leakage after low anterior resection for rectal cancer. A loop ileostomy is often preferred but may lead to dehydration and kidney injury. Here, we present a case series for an alternative: the left-sided loop colostomy. A convenience sample of four patients underwent robotic low anterior resection for rectal cancer. A complete splenic flexure mobilization and a total mesorectal excision were performed. To defunction the anastomosis, the redundant left colon was brought up to a stoma site in the left iliac fossa and matured as a loop colostomy. Two patients experienced minor stoma leaks and one also had a small prolapse, while all patients had their colostomies reversed on average 7 months after surgery without complications. There were no dehydration episodes and creatinine levels remained within baseline levels at end of follow-up (on average 18 months).

Purpose: Even though anastomotic leakage after colorectal surgery is a major clinical problem in need of a timely diagnosis, early indicators of leakage have been insufficiently studied. We therefore conducted a population-based observational study to determine whether the patient’s early postoperative pain is an independent marker of anastomotic leakage.

Methods: By combining the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry, we retrieved prospectively collected data on 3084 patients who underwent anastomotic colorectal surgery for cancer in 2014–2017. Postoperative pain, measured with the numerical rating scale (NRS), was considered exposure, while anastomotic leakage and reoperation due to leakage were outcomes. We performed logistic regression to evaluate associations, estimating odds ratios (ORs) and 95% confidence intervals (CIs), while multiple imputation was used to handle missing data.

Results: In total, 189 patients suffered from anastomotic leakage, of whom 121 patients also needed a reoperation due to leakage. Moderate or severe postoperative pain (NRS 4–10) was associated with an increased risk of anastomotic leakage (OR 1.69, 95% CI 1.21–2.38), as well as reoperation (OR 2.17, 95% CI 1.41–3.32). Severe pain (NRS 8–10) was more strongly related to leakage (OR 2.38, 95% CI 1.44–3.93). These associations were confirmed in multivariable analyses and when reoperation due to leakage was used as an outcome.

Conclusion: In this population-based retrospective study on prospectively collected data, increased pain in the post-anaesthesia care unit is an independent marker of anastomotic leakage, possibly indicating a need for further diagnostic measures.

Objective: The purpose of this study was to investigate the impact of tie level on oncological outcomes in rectal cancer surgery.

Summary background data: Theoretically, a high tie of the inferior mesenteric artery could facilitate removal of apical node metastases and improve tumor staging accuracy. However, no appropriately sized randomized controlled trial exists and results from observational studies are not consistent.

Methods: All stage I–III rectal cancer patients who underwent abdominal surgery with curative intention in 2007 to 2014 were identified and followed, using the Swedish Colorectal Cancer Registry. Primary outcome was cancer-specific survival, whereas overall and relative survival, locoregional and distant recurrence, and lymph node harvest were secondary outcomes, with high tie as exposure. We used propensity score matching to emulate a randomized controlled trial, and then performed Cox regression analyses to estimate hazard ratios (HRs) with confidence intervals (CIs).

Results: Some 8287 patients remained for analysis, of which 37% had high tie surgery. After propensity score matching, the 5-year cancer-specific survival rate was overall 86% and we found no association between the level of tie and cancer-specific (HR 0.92, 95% CI 0.79–1.07) or overall (HR 0.98, 95% CI 0.89–1.08) survival, nor to locoregional (HR 0.85, 95% CI 0.59–1.23) or distant (HR 1.01, 95% CI 0.88–1.15) recurrence, nor to relative survival (HR 1.05, 95% CI 0.85–1.28). Stratification and sensitivity analyses were similarly insignificant, after adjustment for confounding. Total lymph node harvest was, however, increased after high tie surgery (P < 0.01), but no differences were seen regarding positive nodes (P = 0.72).

Conclusion: In this nationwide cohort study, the level of tie did not influence any patient-oriented oncological outcome, neither overall nor in node-positive patients. This would allow the patient's anatomical configuration and the surgeon's preferences to determine the level of tie.

Surgery is still the most common treatment for rectal cancer, being the most effective and cost-efficient modality. However, it is not without risk, nor without controversies. This dissertation is an evaluation of the pros and cons of high versus low ligation, whether anastomotic leakage is still prevalent after surgery and associated with increased mortality, and if the risk of leakage could be predicted by early postoperative pain.

Study I relied upon case records and registry data to evaluate the causal effect of high ligation on the risk of anastomotic leakage after anterior resection in 722 patients with increased cardiovascular risk. When controlling for confounders, no association was found overall. However, an increased risk for leakage after high ligation was noted for the few patients who suffered from both manifest cardiovascular disease and ASA III–IV (OR 3.66, 95% CI 1.04–12.85) and when performed in a low volume hospital (OR 3.89, 95% 1.58– 9.59). Study II estimated the risk of anastomotic leakage and death after anterior resection today. Among the 6,948 patients, 10.0% suffered from leakage, in whom mortality was 3.9% versus 1.5% for patients without a leak. However, this increased mortality was driven entirely by patients in need of reintervention, who exhibited a 7.5% 90-day mortality, resulting in a significantly increased risk (OR 5.57, 95% CI 3.29–9.44), when controlling for confounders, while conservatively treated leakage was not associated with mortality. Age acted as an effect modifier, as postoperative mortality after leakage was increased in the elderly.

Study III returned to high versus low ligation as exposure, to evaluate the long-term oncological benefits of either ligation level, with cancer-specific survival as primary outcome. The final cohort of 8,287 patients who underwent abdominal surgery for rectal cancer, with curative intent, was followed for a minimum of 3.5 years. After propensity score matching, no significant differences were found between high and low ligation for any survival or recurrence analysis, nor in the unmatched cohort, when controlling for confounders. A statistically significant difference was found for lymph node harvest, which was slightly greater in high ligation (17.7 vs 16.7 lymph nodes). Finally, study IV estimated the independent predictive ability of postoperative pain, measured on the numerical rating scale (NRS), on the risk for anastomotic leakage after colorectal cancer surgery. It seems as if increased early pain is an independent predictor for leakage (OR 1.73, 95% CI 1.22– 2.46 for NRS 4–10), with increasing risk of leakage with increasing pain (OR 2.42 for NRS 8–10). In addition, increased pain was more strongly associated with more severe leakage.

In summary, the level of ligation seems to be of importance only in a select group of high-risk patients, but offers no obvious oncological advantages. The high incidence and serious sequelae of anastomotic leakage makes it one of the most important clinical challenges in colorectal surgery, with especially detrimental effects in the elderly. A better understanding of the causal pathways behind leakage, and the overall harm and benefit of ligation level and diverting stomas, might allow a better selection of treatment for future patients.

Background: Anastomotic leakage following anterior resection for rectal cancer may result in death. The aim of this study was to yield an updated, population‐based estimate of postoperative mortality and evaluate possible interacting factors.

Methods: This was a retrospective national cohort study of patients who underwent anterior resection between 2007 and 2016. Data were retrieved from a prospectively developed database. Anastomotic leakage constituted exposure, whereas outcome was defined as death within 90 days of surgery. Logistic regression analyses, using directed acyclic graphs to evaluate possible confounders, were performed, including interaction analyses.

Results: Of 6948 patients, 693 (10·0 per cent) experienced anastomotic leakage and 294 (4·2 per cent) underwent reintervention due to leakage. The mortality rate was 1·5 per cent in patients without leakage and 3·9 per cent in those with leakage. In multivariable analysis, leakage was associated with increased mortality only when a reintervention was performed (odds ratio (OR) 5·57, 95 per cent c.i. 3·29 to 9·44). Leaks not necessitating reintervention did not result in increased mortality (OR 0·70, 0·25 to 1·96). There was evidence of interaction between leakage and age on a multiplicative scale (P = 0·007), leading to a substantial mortality increase in elderly patients with leakage.

Conclusion: Anastomotic leakage, in particular severe leakage, led to a significant increase in 90‐day mortality, with a more pronounced risk of death in the elderly.

Purpose A diverting stoma is commonly used to reduce the risk of anastomotic leakage when performing total mesorectal excision (TME) in anterior resection for rectal cancer. The purpose of this study was to evaluate the impact of fecal diversion in relation to partial mesorectal excision (PME).

Methods A retrospective analysis was undertaken on a national cohort, originally created to study the impact of central arterial ligation on patients with increased cardiovascular risk. Some 741 patients operated with anterior resection for rectal cancer during the years 2007 through 2010 were followed up for 53 months. Multivariate logistic regression was used to evaluate the impact of diverting stoma on the risk of anastomotic leakage and permanent stoma, expressed as odds ratios (ORs) and 95 % confidence intervals (CIs).

Results The risk of anastomotic leakage was increased in TME surgery when not using a diverting stoma (OR 5.1; 95 % CI 2.2-11.6), while the corresponding risk increase in PME patients was modest (OR 1.8; 95 % CI 0.8-4.0). At study completion or death, 26 and 13 % of TME and PME patients, respectively, had a permanent stoma. A diverting stoma was a statistically significant risk factor for a permanent stoma in PME patients (OR 4.7; 95 % CI 2.5-9.0), while less important in TME patients (OR 1.8; 95 % CI 0.6-5.5).

Conclusion The benefit of a diverting stoma concerning anastomotic leakage in this patient group seems doubtful. Moreover, the diverting stoma itself may contribute to the high rate of permanent stomas.

Aim: Controversy still exists as to whether division of the inferior mesenteric artery close to the aorta influences the risk of anastomotic leakage after anterior resection for rectal cancer. This population-based study was carried out to evaluate the independent association between high arterial ligation and anastomotic leakage in patients with increased cardiovascular risk.

Method: All 2673 cases of registered anterior resection for rectal cancer from 2007 to 2010 were identified from the Swedish Colorectal Cancer Registry and cross-referenced with the Prescribed Drugs Registry, rendering a cohort of all patients with increased cardiovascular risk. Operative charts and registered data were reviewed for 722 patients. The association between high tie and anastomotic leakage, as quantified by ORs and 95% CIs, was evaluated in a logistic regression model, with adjustment for confounding, including assessment of interaction.

Results: Symptomatic anastomotic leakage occurred in 12.3% (41/334) of patients in the high tie group and in 10.6% (41/388) in the low tie group. The use of high tie was not independently associated with a higher risk of anastomotic leakage (OR = 1.05; 95% CI: 0.61–1.84). In a post-hoc analysis, patients with a history of manifest cardiovascular disease and American Society of Anesthesiologists (ASA) score III–IV seemed to be at greater risk (OR = 3.66; 95% CI: 1.04–12.85).

Conclusion: In the present population-based, observational setting, high tie was not independently associated with an increased risk of symptomatic anastomotic leakage after anterior resection for rectal cancer. However, this conclusion may not hold for patients with severe cardiovascular disease.