Swedish Colorectal Cancer Registry Research Articles

Oncological outcome following Hartmann's procedure compared with anterior resection and abdominoperineal resection for rectal cancer-The type of procedure does not influence local recurrence or distant metastasis: A population-based study.

The type of surgical procedure used in rectal cancer treatment may affect cancer recurrence. The aim of this study was to determine whether the type of procedure influences oncological outcomes in rectal cancer surgery. We gathered data from the Swedish Colorectal Cancer Registry regarding patients with TNM Stage I-III rectal cancer who underwent R0/R1 surgery from 2013 to 2017. The outcomes after Hartmann's procedure (HP), anterior resection (AR) and abdominoperineal resection (APR) were compared, and a multivariable Cox regression analysis was performed. The primary outcome of the study was the local recurrence rate. The secondary outcomes were distant metastasis, disease-free survival and overall survival at 5 years as well as risk factors for local recurrence. A total of 4741 patients were included in the study: 614 underwent HP, 3075 underwent AR and 1052 underwent APR. Multivariable Cox regression revealed no difference in local recurrence, distant metastasis or disease-free survival. Overall survival was higher following AR (OR 0.62, CI 0.54-0.72). Risk factors for local recurrence were intraoperative bowel perforation (OR 2.41, CI 1.33-4.40), a pT4 tumour (OR 1.93, CI 1.11-3.4) and a positive circumferential resection margin (OR 5.62, CI 3.28-9.61). This nationwide study showed that the type of procedure did not affect the local recurrence rate or distant metastasis. In patients who are unfit for restorative surgery, HP is a viable alternative with oncological outcomes similar to those of APR.

The risk for rectal cancer recurrence and overall mortality is not increased in men previously diagnosed with prostate cancer: a report from the Swedish colorectal cancer registry

IntroductionLimited data exists on oncological outcomes following rectal cancer surgery in men who have previously been diagnosed with prostate cancer (PC). This study aimed to assess overall mortality and rectal cancer recurrence in men previously diagnosed with PC who underwent bowel resection.MethodsData from the Swedish Colorectal Cancer Registry identified men who had rectal cancer surgery between 2000 and 2016, and the National Prostate Cancer Registry was used to identify those with a prior PC diagnosis. Cox regression analysis with propensity score matching was employed for data analysis. The primary outcome was overall mortality. Secondary outcome was recurrence for rectal cancer.ResultsOut of 13,299 men undergoing bowel resection for rectal cancer between 2000 and 2016, 1130 had a history of PC. Overall mortality did not significantly differ between men with and without a prior PC diagnosis. Cox regression analyses with propensity score matching revealed that men with previously diagnosed low- or intermediate-risk (HR, 0.79; 95% CI, 0.70–0.90) and high-risk PC (HR, 0.85; 95% CI, 0.74–0.98) had lower overall mortality after rectal cancer surgery compared with men without a PC. There was no significant difference in rectal cancer recurrence between men with a previous low or intermediate-risk PC (HR, 0.92; 95% CI, 0.74–1.14) or high-risk PC (HR, 0.73; 95% CI, 0.52–1.01) compared with those without PC history.ConclusionMen undergoing rectal cancer surgery with a previous diagnosis of prostate cancer do not experience an increased risk of rectal cancer recurrence or overall mortality compared with men without a previous history of prostate cancer.

Earnings and work loss after colon and rectal cancer: a Swedish nationwide matched cohort study

Colorectal cancer is common and prognosis is improving. The conditions of survivors of treatment, including financial consequences, are thus important. The aim of this study was to quantify loss of earnings and work loss in working-age patients with colon and rectal cancer relative to matched comparators. The study utilised data from the CRCBaSe database that is generated from the nationwide Swedish ColoRectal Cancer Register and includes data from several Swedish nationwide registers. The study period was 1995-2020 for rectal cancer patients and 2007-2020 for colon cancer patients. A retrospective population-based nationwide cohort study on earnings, disposable income, and work loss, in survivors of stage I-III colorectal cancer treatment was undertaken. Median regression was used to analyse earnings and disposable income, and logistic regression to analyse the probability of work loss. A cohort of 8863 colorectal cancer survivors diagnosed before 2017 and 52,514 comparators matched on birth year, legal sex, and county of residence, was analysed. There was a clear reduction in earnings between the calendar year prior to and the calendar year after diagnosis, from € 31,319 to € 23,924 for colon cancer patients and from € 32,636 to € 22,647 for rectal cancer patients, and earnings never fully recovered during the 5-year follow-up. Disposable income was practically unaltered. The probability of work loss increased in the calendar year of diagnosis, from 29.8% to 25.3% the previous year to 83.3% and 84.4% for colon and rectal cancer patients respectively, and never fully recovered. The probability of work loss was similar between colon and rectal cancer survivors, but was higher among patients with rectal cancer who had received neoadjuvant therapy. This study shows that despite an extensive welfare system providing maintained disposable income, there is a financial burden in the form of increased risk of work loss and a reduction in earnings among survivors of colorectal cancer. The study was supported by the Swedish Cancer Society, the Swedish Cancer and Allergy Foundation, and the Stockholm Cancer Society, and supported by grants provided by the Regional Agreement on Medical Training and Clinical Research (ALF) between the Stockholm County Council and Karolinska Institutet.

72321 - Validation of the reporting of local recurrence of rectal cancer in the Swedish ColoRectal Cancer Registry (SCRCR)

72321 - Validation of the reporting of local recurrence of rectal cancer in the Swedish ColoRectal Cancer Registry (SCRCR)

Total mesorectal excision quality in rectal cancer surgery affects local recurrence rate but not distant recurrence and survival: population-based cohort study.

The quality of the total mesorectal excision specimen in rectal cancer surgery is assessed with a three-tier grade (mesorectal, intramesorectal and muscularis propria). This study aimed to analyse the prognostic impact of the total mesorectal excision grade on survival, and to identify risk factors for intramesorectal and muscularis propria resection in a population-based setting. All patients in the Swedish Colorectal Cancer Registry with rectal cancer stage I-III ≤ 10 cm from the anal verge, diagnosed 2015-2019, undergoing total mesorectal excision were analysed. Clinical, surgical and pathological data were retrieved and analysed for the following primary outcomes: local and distant recurrence and overall and relative survival; secondary outcomes were risk factors for total mesorectal excision grading (intramesorectal or muscularis propria resection). Of note, postoperative death < 30 days or recurrence within 90 days were exclusion criteria for survival and recurrence analysis. Recurrence-free patients with less than 3 years follow-up, and patients lacking data regarding recurrence, were also excluded from recurrence analyses. Overall, of 7979 patients treated during the study interval, 1499 patients were eligible for recurrence, 2441 patients for survival and 2476 patients for risk-factor analyses, of which 75% were graded mesorectal, 17% intramesorectal and 8% muscularis propria. Median follow-up for survival was 42 (1-77) months. The worst total mesorectal excision grading (muscularis propria resection) was an independent risk factor for local recurrence in multivariable analysis (HR 2.73, 95% c.i. 1.07 to 7.0, P = 0.036). Total mesorectal excision grade had no impact on distant recurrence or survival. Female sex, tumour level <5 cm, abdominoperineal resection, minimally invasive surgery (laparoscopic and robotic), high blood loss, long duration of surgery and intraoperative perforation were independent risk factors for worse total mesorectal excision grading (intramesorectal and/or muscularis propria resection) in multivariable analyses. Muscularis propria resection increases the risk of local recurrence but does not seem to affect distant recurrence or survival.

ACBC Study Protocol – Acute Colon Resection Versus Bridge to Colon Surgery with Stent Placement or Stoma Diversion: A Prospective Cohort Study

Abstract Background: Approximately 70% of all colon cancer emergencies result from colonic obstruction. Data from the Swedish Colorectal Cancer Registry indicate that patients undergoing emergency surgical resections for colon cancer face higher overall 30-day morbidity and increased mortality rates—5.8% at 30 days and 11.2% at 90 days—compared to those undergoing elective procedures, which have mortality rates of 1.1% and 2.0%, respectively. Other concerns about acute colon cancer resections are oncological outcomes. Long-term outcomes are significantly worse, with higher rates of recurrence and cancer-related death, regardless of the cancer stage or the use of adjuvant chemotherapy. Objectives: To evaluate the short- and long-term outcomes of primary resection for malignant colonic obstruction compared to only decompression using a self-expandable endoscopic metallic stent or diverting stomas as the first intervention (bridge to surgery) followed by later oncological resection. Design: This is a prospective observational study with data collected through the Swedish Colorectal Cancer Registry with an additional electronic case report form. Settings: Swedish multicenter study at both university and regional hospitals. Patients and Methods: Patients with suspected acute malignant large bowel obstruction due to colonic adenocarcinoma will be identified and followed. Analysis will be performed on an intention-to-treat basis. Descriptive statistics of the study cohort will be presented. Primary endpoints will be subjected to multivariate analyses adjusted for confounders. Main Outcome Measures: 30-day severe morbidity (Clavien–Dindo &gt; 3a), 30- and 90-day mortality rates, and overall survival after three and five years. Sample Size: We aim to include 1000 patients, with an interim analysis after the recruitment of 500 patients. Results: The study is ongoing. Conclusions: Acute colon obstruction is associated with substantial morbidity and mortality. We hypothesize that patients with malignant obstruction benefit from avoidance of emergency cancer resection and that bridge to surgery leads to decreased short-term morbidity and mortality and improved long-term oncological outcomes. Limitations: The main limitation is the risk of selection bias when the study is not a randomized controlled trial, which would be a standard process. A prospective observational study is, nevertheless, considered a pragmatic compromise between feasibility and ability to answer the research question. Conflicts of Interest: None.

Implications of pretreatment extramural venous invasion in rectal cancer patients: A population-based study.

Extramural venous invasion detected by MRI (mrEMVI) has in several expert centre studies been identified as an important prognostic factor in rectal cancer, and in guiding neoadjuvant therapy. However, population-based evidence for mrEMVI as a predictor for recurrent disease is lacking. This was a multicentre retrospective study based on the Swedish Colorectal Cancer Registry. The study period encompassed patients operated with abdominal resection for rectal cancer 2017-2021, with follow-up until January 2023. Patients diagnosed at hospitals with radiological registry data coverage <90% or with metastatic disease were excluded. Pretreatment mrEMVI constituted exposure, while recurrence-free survival was the main outcome. Distant and local recurrence, and overall survival were secondary outcomes, and pretreatment and postoperative scenarios were explored using multivariable Cox regression with multiple imputation. Hazard ratios (HRs) with 95% confidence intervals (CIs) were reported. A total of 2737 patients from 13 hospitals were eligible for analysis. Pretreatment mrEMVI was reported in 14.5% of patients, while 71.9% had negative findings and 13.6% had missing data. In the pretreatment scenario, mrEMVI was an independent predictor for worse recurrence-free survival with an adjusted HR of 1.64 (95% CI: 1.31-2.06). In the postoperative MDT setting, the influence of mrEMVI on recurrence-free survival decreased with an adjusted HR of 1.27 (95% CI: 1.00-1.61). mrEMVI at diagnosis is an independent predictor of recurrence-free survival in an unselected population of rectal cancer patients undergoing abdominal resection.

Postoperative complications and emergency surgeries in colorectal cancer patients

The incidence of colorectal cancer (CRC) in Sweden is increasing in individuals <50 years. This study aimed to examine differences in postoperative 30-day complications and rate of emergency surgeries in CRC patients <50 years at diagnosis compared to older age groups since population-based research on this topic is scarce. This population-based study included data from the Swedish Colorectal Cancer Registry for patients undergoing CRC resection between 2010 and 2018. Bivariate analysis and logistic regression were used to analyse the relationship between age groups (<50, 50-79 and ≥80 years) and probability of postoperative 30-day complications adjusted for gender, tumour localization, neoadjuvant (chemo)radiotherapy and American Society of Anesthesiologists score. In total 33 320 patients were included. Patients <50 years had a lower American Society of Anesthesiologists score, more advanced tumours and received more neoadjuvant treatment. Emergency surgeries were less common in the youngest age group (P < 0.001) as well as overall postoperative 30-day complications: ORadj 0.84 (95% CI 0.74-0.96) compared to those ≥80 years. Surgical complications were more common in age groups <50 and 50-79 years (16.5% and 16.9% respectively) compared to patients ≥80 years (14.1%) (P < 0.001). Anastomotic leakage and intra-abdominal infections were more frequent in patients <50 years (5.7% and 3.5% respectively) compared to age groups 50-79 years (5.1% and 2.8% respectively) and ≥80 years (3.5% and 2.1% respectively) (P < 0.001). Wound infections were more common in the two youngest age groups compared to patients ≥80 years (5.3% vs. 3.7% respectively) (P < 0.001). Colorectal cancer patients <50 years and 50-79 years had a higher proportion of surgical complications regarding anastomotic leakage, intra-abdominal infections and wound infections but lower overall postoperative complications. The incidence of surgical emergencies was highest amongst patients ≥80 years. Postoperative diagnostic workup in symptomatic individuals <50 years is warranted.

Risk Factors for Recurrence After Surgery for Rectal Cancer in a Modern, Nationwide Population-Based Cohort

BackgroundThe success of modern multimodal treatment in rectal cancer is dependent on risk prediction. Better knowledge of the risk of locoregional and distant recurrence, in relation to preoperative treatment, pathological stage, and commonly used risk factors, is needed when deciding on adjuvant therapy and surveillance.MethodsThe Swedish ColoRectal Cancer Registry was used to identify patients diagnosed with rectal adenocarcinoma between 2011 and 2018. Readily available variables, including patient, tumor, and treatment factors were exposures. Cox proportional hazard models were used to identify important risk factors for recurrence and calculate recurrence risks.ResultsA total of 9428 curatively resected patients were included and followed for a median of 72 months. Eighteen percent had distal recurrence and 3% had locoregional recurrence at 5 years. Risk factors with major impact on distal recurrence were pT4a (hazard ratio [HR] 5.1, 95% confidence interval [CI] 3.3–8.0), pN2b (HR 3.4, 95% CI 2.7–4.2), tumor deposit (HR 1.7, 95% CI 1.5–1.9), lymph node yield (HR 1.5, 95% CI 1.3–1.8), and tumor level 0–5 cm (HR 1.5, 95% CI 1.3–1.8). Pathologic stage and number of risk factors identified groups with markedly different recurrence risks in all neoadjuvant treatment groups.ConclusionsReadily available risk factors, as a complement to stage, are still valid and robust in all neoadjuvant treatment groups. Tumor deposit is important, while circumferential resection margin might no longer be important with improved oncological treatments and high-quality TME surgery. Tailored surveillance is possible in selected groups using risk stratification based on stage and risk factors.

Postoperative morbidity following Hartmann's procedure in comparison to anterior resection and abdominoperineal resection for rectal cancer-a population-based study.

There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry. All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry. A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality. For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.

Assessment by a multidisciplinary team conference affects treatment strategy and overall survival in patients with synchronous colorectal liver metastases

BackgroundThe aim of this retrospective observational study was to investigate the geographical or sex differences in patients with synchronous colorectal liver metastases (sCRLM) in terms of assessment by a multidisciplinary team conference (MDT), curative treatment, and overall survival. MethodAll sCRLM patients in the South-East Health Care Region of Sweden from 2009 to 2015 were included (n = 615). Data were derived from the Swedish Colorectal Cancer Registry, Swedish Registry of Liver and Bile Surgery and medical records. ResultsPatients who had a hepatobiliary unit (HBU) at the nearest hospital were more likely to undergo liver surgery (HBU+, 37% (n = 106), compared to HBU−, 22% (n = 60); p = 0.001) and had a better median survival (p < 0.001). No sex differences were observed. In multivariate Cox regression analyses of overall survival, assessment by an MDT that included a liver surgeon was independently linked to better survival (HR 0.574, 0.433–0.760). ConclusionThere were no sex differences in access to liver surgery or overall survival, however, there were geographical inequalities, where residency near a hospital with HBU was associated with increased overall survival and the possibility to receive liver surgery. Assessment at MDT with liver surgeon present was associated with greater survival, indicating its important role for treatment.

Hartmann's Procedure Versus Intersphincteric Abdominoperineal Excision in Patients with Rectal Cancer: Report from the Swedish Colorectal Cancer Registry (SCRCR).

The primary outcome was to compare overall postoperative surgical complications within 30 days after Hartmann's procedure (HP) compared with intersphincteric abdominoperineal excision (iAPE). The secondary outcome was major surgical complications (Clavien-Dindo ≥ III). There is uncertainty regarding the optimal surgical method in patients with rectal cancer when an anastomosis is unsuitable. Rectal cancer patients with a tumor height >5 cm, registered in the Swedish Colorectal Cancer Registry who received HP or iAPE electively in 2017-2020 were included, (HP, n = 696; iAPE, n = 314). Logistic regression analysis adjusting for body mass index, American Society of Anesthesiologists classification, sex, age, preoperative radiotherapy, tumor height, cancer stage, operating hospital, and type of operation was performed. Patients in the HP group were older and had higher American Society of Anesthesiologists scores. The mean operating time was less for HP (290 vs 377 min). Intraoperative bowel perforations were less frequent in the HP group, 3.6% versus 10.2%. Overall surgical complication rates were 20.3% after HP and 15.9% after iAPE (P = 0.118). Major surgical complications were 7.5% after HP and 5.7% and after iAPE (P = 0.351). Multiple regression analysis indicated a higher risk of overall surgical complications after HP (odds ratio: 1.63; 95% confidence interval = 1.09-2.45). HP was associated with a higher risk of surgical complications compared with iAPE. In patients unfit for anastomosis, iAPE may be preferable. However, the lack of statistical power regarding major surgical complications, prolonged operating time, increased risk of bowel perforation, and lack of long-term outcomes, raises uncertainty regarding recommending intersphincteric abdominoperineal excision as the preferred surgical approach.

Diverting ostomy prior to neoadjuvant treatment in rectal cancer should be used selectively: A retrospective single-center cohort study.

Rectal cancer patients commonly benefit from neoadjuvant therapy before resection surgery. For these patients, an elective ostomy diversion is frequently considered, despite the absence of conclusive evidence when a diversion is advantageous. This is a retrospective observational single-center study on a 4-year consecutive rectal cancer cohort undergoing neoadjuvant therapy, aiming at improving the understanding of risks and benefits associated with ostomy diversion. Baseline characteristics, tumor-specific data, clinical events, and outcomes were collected using the Swedish Colorectal Cancer Registry and medical records. Thirty-two (30.2%) of the 106 included patients presented with endoscopic impassable tumors at diagnosis, of which 18 (56.2%) had diverting ostomy. Three out of 14 with impassable tumor and no diversion developed a bowel obstruction. None of the patients with an endoscopically passable tumor at diagnosis (n = 74) experienced a bowel obstruction. The elective diversions (n = 40) were not associated with serious complications (Clavien-Dindo grade ⩾ 3b). Patients with a diverting ostomy (n = 30) had similar time intervals from diagnosis to neoadjuvant treatment and to definite tumor resection as those without diversion but experienced more complex primary tumor resections in terms of blood loss and operation time. An elective diverting ostomy is a relatively safe procedure in rectal cancer patients requiring neoadjuvant therapy. More than one out of five non-diverted patients with endoscopically impassable rectal tumors developed bowel obstruction and would potentially have benefited from an elective diversion.

Risk of recurrence in high-risk T1 colon cancer following endoscopic and surgical resection: registry-based cohort study.

Endoscopic resection of T1 colon cancer (CC) is currently limited by guidelines related to risk of lymph node metastases. However, clinical outcome following endoscopic and surgical resection is poorly investigated. A retrospective multicentre national cohort study was conducted on prospectively collected data from the Swedish colorectal cancer registry on all non-pedunculated T1 CC patients undergoing surgical and endoscopic resection between 2009 and 2021. Patients were categorized on the basis of deep submucosal invasion (Sm2-3), lymphovascular invasion (LVI), poor tumour differentiation, and R1/Rx into low- and high-risk cases. The primary outcomes of interest were recurrence rates and disease-free interval (DFI, defined as time from treatment to date of recurrence) according to resection methods and risk factors (sex, age at diagnosis, histologic grade, LVI, perineural invasion, mucinous subtype, submucosal invasion, tumour location, resection margin and nodal positivity in the surgical group). In total, 1805 patients undergoing endoscopic (488) and surgical (1317) resection with 60.0 months median follow-up were included. Recurrence occurred in 18 (3.7%) endoscopically and 48 (3.6%) surgically resected patients. Adjuvant treatment was administered in 7.4% and 0.2% of the cases respectively in the surgical and endoscopically treated patients. Five-year DFI was 95.6% after endoscopic and 96.2% after surgical resection, with no significant difference when adjusting for confounding factors (HR 1.03, 95% c.i. 0.56 to 1.91, P = 0.920). There were no statistically significant differences in recurrence comparing endoscopic (1.7%) versus surgical (3.6%) low-risk and endoscopic (5.4%) versus surgical (3.8%) high-risk cases. LVI was the only significant risk factor for recurrence in multivariate Cox regression (HR 3.73, 95% c.i. 1.76 to 7.92, P < 0.001). This study shows no difference in recurrence after endoscopic and surgical resection in high-risk T1 CC. Although it was not possible to match groups according to treatment, the multivariate analysis showed that lymphovascular invasion was the only independent risk factor for recurrence.

Importance of resection margin after resection of colorectal liver metastases in the era of modern chemotherapy: population-based cohort study.

Resection margin has been associated with overall survival following liver resection for colorectal liver metastasis. The aim of this study was to examine how resection margins of 0.0 mm, 0.1-0.9 mm and ≥1 mm influence overall survival in patients resected for colorectal liver metastasis in a time of modern perioperative chemotherapy and surgery. Using data from the national registries Swedish Colorectal Cancer Registry and Swedish National Quality Registry for Liver, Bile Duct and Gallbladder Cancer, patients that had liver resections for colorectal liver metastasis between 2009 and 2013 were included. In patients with a narrow or unknown surgical margin the original pathological reports were re-reviewed. Factors influencing overall survival were analysed using a Cox proportional hazard model. A total of 754 patients had a known margin status, of which 133 (17.6%) patients had a resection margin <1 mm. The overall survival in patients with a margin of 0 mm or 0.1-0.9 mm was 42 (95% c.i. 31 to 53) and 48 (95% c.i. 35 to 62) months respectively, compared with 75 (95% c.i. 65 to 85) for patients with ≥1 mm margin, P < 0.001. Margins of 0 mm or 0.1-0.9 mm were associated with poor overall survival in the multivariable analysis, HR 1.413 (95% c.i. 1.030 to 1.939), P = 0.032, and 1.399 (95% c.i. 1.025 to 1.910), P = 0.034, respectively. Despite modern chemotherapy the resection margin is still an important factor for the survival of patients resected for colorectal liver metastasis, and a margin of ≥1 mm is needed to achieve the best possible outcome.

Minor impact of anastomotic leakage in anterior resection for rectal cancer on long-term male urinary and sexual function

PurposeAnastomotic leakage after anterior resection for rectal cancer induces bowel dysfunction, but the influence on urinary and sexual function is largely unknown. This cross-sectional cohort study evaluated long-term effect of anastomotic leakage on urinary and sexual function in male patients.MethodsPatients operated with anterior resection for rectal cancer in 15 Swedish hospitals 2007–2013 were identified. Anastomotic leakage and other clinical variables were retrieved from the Swedish Colorectal Cancer Registry and medical records. Urinary and sexual dysfunction were evaluated at 4 to 11 years after surgery using the International Prostate Symptom Score, International Index of Erectile Function, and European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire CR29. The effect of anastomotic leakage on average scores of urinary and sexual dysfunction was evaluated as a primary outcome, and the single items permanent urinary catheter and sexual inactivity as secondary outcomes. The association of anastomotic leakage and functional outcomes was analyzed using regression models with adjustment for confounders.ResultsAfter a median follow-up of 84 months (interquartile range: 67–110), 379 out of 864 eligible men were included. Fifty-nine (16%) patients had anastomotic leakage. Urinary incontinence was more common in the leakage group, with an adjusted mean score difference measured by EORTC QLQ ColoRectal–29 of 8.69 (95% confidence interval: 0.72–16.67). The higher risks of urinary frequency, permanent urinary catheter, and sexual inactivity did not reach significance.ConclusionAnastomotic leakage after anterior resection had a minor negative impact on urinary and sexual function in men.

Short-term results in a population based study indicate advantage for minimally invasive rectal cancer surgery versus open

BackgroundThe aim of this study was to determine if minimally invasive surgery (MIS) for rectal cancer is non-inferior to open surgery (OPEN) regarding adequacy of cancer resection in a population based setting.MethodsAll 9,464 patients diagnosed with rectal cancer 2012–2018 who underwent curative surgery were included from the Swedish Colorectal Cancer Registry. Primary outcomes: Positive circumferential resection margin (CRM < 1 mm) and positive resection margin (R1). Non-inferiority margins used were 2.4% and 4%. Secondary outcomes: 30- and 90-day mortality, clinical anastomotic leak, re-operation < 30 days, 30- and 90-day re-admission, length of stay (LOS), distal resection margin < 1 mm and < 12 resected lymph nodes. Analyses were performed by intention-to-treat using unweighted and weighted multiple regression analyses.ResultsThe CRM was positive in 3.8% of the MIS group and 5.4% of the OPEN group, risk difference -1.6% (95% CI -1.623, -1.622). R1 was recorded in 2.8% of patients in the MIS group and in 4.4% of patients in the OPEN group, risk difference -1.6% (95% CI -1.649, -1.633). There were no differences between the groups in adjusted unweighted and weighted analyses. All analyses demonstrated decreased mortality and re-admissions at 30 and 90 days as well as shorter LOS following MIS.ConclusionsIn this population based setting MIS for rectal cancer was non-inferior to OPEN regarding adequacy of cancer resection with favorable short-term outcomes.

Hartmann’s procedure in rectal cancer surgery is often an intraoperative decision: a retrospective multicenter study

PurposeThis study aimed to investigate patient-related factors predicting the selection of rectal cancer patients to Hartmann’s procedure as well as to investigate how often, and on what grounds, anterior resection is intraoperatively changed to Hartmann’s procedure.MethodsProspectively collected data from the Swedish Colorectal Cancer Registry regarding patients with rectal cancer operated upon from January 1 2007 to June 30 2017 in the county of Skåne were retrospectively reviewed. Data were expanded with further details from medical charts. A univariable analysis was performed to investigate variables associated with unplanned HP and significant variables included in a multivariable logistic regression analysis.ResultsAltogether, 1141 patients who underwent Hartmann’s procedure (275 patients, 24%), anterior resection (491 patients, 43%), or abdominoperineal resection (375 patients, 33%) were included. Patients undergoing Hartmann’s procedure were significantly older and had more frequently comorbidity. The decision to perform Hartmann’s procedure was made preoperatively in 209 (76%) patients, most commonly because of a comorbidity (27%) or oncological reasons (25%). Patient preference was noted in 8% of cases. In 64 cases (23%), the decision was made intraoperatively, most often due to anastomotic difficulties (60%) and oncological reasons (22%). Anastomotic difficulties were most often reported due to technical difficulties, a low tumor or neoadjuvant radiotherapy. Male gender was a significant risk factor for undergoing unplanned Hartmann’s procedure.ConclusionsThe decision to perform Hartmann’s procedure was frequently made intraoperatively. Hartmann’s procedure should be considered and discussed preoperatively in old and frail patients, especially in the presence of mid-rectal cancer and/or male gender, since these factors increase the risk of intraoperative anastomotic difficulties.

Despite multi-disciplinary team discussions the socioeconomic disparities persist in the oncological treatment of non-metastasized colorectal cancer

BackgroundThe introduction of national guidelines should eliminate previously observed associations between socioeconomic status (SES) and colorectal cancer treatment. The aim of the study was to investigate whether inequalities remain. MethodsCRCBaSe, a register-linkage originating from the Swedish Colorectal Cancer Registry, was used to identify information on patient and tumour characteristics, for 83,460 patients with stage I-III disease diagnosed 2008–2021. SES was measured as disposable income (quartiles) and the highest level of education. Outcomes of interest were emergency surgery, multidisciplinary team (MDT) conference discussion, and oncological treatment. Differences in treatment between SES groups were explored using multivariable logistic regression adjusted for year of diagnosis, age at diagnosis, sex, civil status, comorbidities, tumour location and stage. ResultsPatients in the highest income quartile had a lower risk of emergency surgery (OR 0.73 95%CI 0.68–0.80), a higher chance of being discussed at the preoperative (OR 1.39 95%CI 1.28–1.51) and postoperative MDT (OR 1.41 95%CI 1.30–1.53), receiving neoadjuvant (OR 1.15 95%CI 1.06–1.25) and adjuvant treatment (OR 2.04 95%CI 1.88–2.20). Higher education level increased the odds of MDT discussion but was not associated with oncological treatment. The proportion of patients discussed at the MDT increased, with almost all patients discussed since 2016. Despite this, treatment differences remained when patients diagnosed since 2016 were analysed separately. ConclusionThere were significant differences in how patients with different SES were treated for colorectal cancer. Further action is required to investigate the drivers of these differences as well as their impact on mortality and, ultimately, eliminate the inequalities.

Mortality and morbidity after colorectal cancer resection surgery in elderly patients: a retrospective population-based study in Sweden.

Colorectal cancer is primarily a condition of older adults, and surgery is the cornerstone of treatment. As life expectancy is increasing and surgical techniques and perioperative care are developing, curative surgery is often conducted even in ageing populations. However, the risk of morbidity, functional decline, and mortality following colorectal cancer resection surgery are known to increase with increasing age. This study aims to describe real-world data about postoperative mortality and morbidity after resection surgery for colorectal cancer in the elderly (≥ 70years) compared to younger patients (< 70years), in a Swedish setting. A cohort study including all patients diagnosed with colorectal cancer in a Swedish region of 1.7 million inhabitants between January 2016 and May 2020. Patients were identified through the Swedish Colorectal Cancer Registry, and all baseline and outcome variables were extracted from the registry. The following outcome measures were compared between the two age groups: 90-day mortality rates, postoperative complications, postoperative intensive care, reoperations, readmissions, and 1-year mortality. To adjust the analyses for baseline confounders in the comparison of the outcome variables, the following methods were used: marginal matching, calliper (ID matching), and logistic regression adjusted for baseline confounders. The cohort consisted of 5246 patients, of which 3849 (73%) underwent resection surgery. Patients that underwent resection surgery were significantly younger than those who did not (mean ± SD, 70.9 ± 11.4years vs 73.7 ± 12.8years, p < 0.001). Multivariable analyses revealed that both 90-day and 1-year mortality rates were higher in older patients that underwent resection surgery (90-day mortality OR 2.12 [95% CI 1.26-3.59], p < 0.005). However, there were no significant differences in postoperative intensive care, postoperative complications, reoperations, or readmissions. Elderly patients suffer increased postoperative mortality after resection surgery for colorectal cancer compared to younger individuals. Given the growing elderly population that will continue to require surgery for colorectal cancer, more efficient ways of determining and handling individual risk for older adults need to be implemented in clinical practice.