Swedish Colorectal Cancer Registry Research Articles

Incidence of wound dehiscence after colorectal cancer surgery: results from a national population-based register for colorectal cancer

BackgroundPatient-related risk factors for wound dehiscence after colorectal surgery remain obscure.MethodsAll open abdominal procedures for colorectal cancer registered in the Swedish Colorectal Cancer Registry (SCRCR, 5) 2007–2013 were identified. Potential risk factors for wound dehiscence were identified by cross-matching between the SCRCR and the National Patient Register (NPR). The endpoint in this study was reoperation for wound dehiscence registered in either the SCRCR or NPR and patients not reoperated were considered controls.ResultsA total of 30,050 patients were included in the study. In a multivariable regression analysis, age > 70 years, male gender, BMI > 30, history of chronic obstructive pulmonary disease, history of generalised inflammatory disease, and duration of surgery less than 180 min were independently and significantly associated with increased risk for wound dehiscence. A history of diabetes, chronic renal disease, liver cirrhosis, and distant metastases was not associated with wound dehiscence. The hazard ratio for postoperative death was 1.24 for patients who underwent reoperation for wound dehiscence compared with that for controls.DiscussionPatients reoperated for wound dehiscence face a significantly higher postoperative mortality than those without. Risk factors include male gender, age > 70 years, obesity, history of chronic obstructive pulmonary disease, and history of generalised inflammatory disease. Patients at high risk for developing wound dehiscence may, if identified preoperatively, benefit from active prevention measures implemented in routine surgical practice.

The Relationship Between Severe Complications, Beta-Blocker Therapy and Long-Term Survival Following Emergency Surgery for Colon Cancer

BackgroundEmergency surgery for colon cancer carries significant morbidity, and studies show more than doubled mortality when comparing elective to emergency surgery. The relationship between postoperative complications and survival has been outlined. Beta-blocker therapy has been linked to improved postoperative outcomes. This study aims to assess the impact of postoperative complications on long-term survival following emergency surgery for colon cancer and to determine whether beta-blockade can reduce complications.Study design This cohort study utilized the prospective Swedish Colorectal Cancer Registry to identify adults undergoing emergency colon cancer surgery between 2011 and 2016. Prescription data for preoperative beta-blocker therapy were collected from the national drug registry. Cox regression was used to evaluate the effect of beta-blocker exposure and complications on 1-year mortality, and Poisson regression was used to evaluate beta-blocker exposure in patients with major complications.ResultsA total of 3139 patients were included with a mean age of 73.1 [12.4] of which 671 (21.4%) were prescribed beta-blockers prior to surgery. Major complications occurred in 375 (11.9%) patients. Those suffering major complications showed a threefold increase in 1-year mortality (adjusted HR = 3.29; 95% CI 2.75–3.94; p < 0.001). Beta-blocker use was linked to a 60% risk reduction in 1-year mortality (adjusted HR = 0.40; 95% CI 0.26–0.62; p < 0.001) but did not show a statistically significant association with reductions in major complications (adjusted IRR = 0.77; 95% CI 0.59–1.00; p = 0.055).ConclusionThe development of major complications after emergency colon cancer surgery is associated with increased mortality during one year after surgery. Beta-blocker therapy may protect against postoperative complications.

Parastomal hernias causing symptoms or requiring surgical repair after colorectal cancer surgery\u2014a national population-based cohort study

PurposeParastomal hernia is a complication with high morbidity that affects the patient’s quality of life. The aim of this study was to assess the cumulative incidence of parastomal hernia in patients who have undergone colorectal cancer surgery and to identify potential risk factors that could predispose to the development of this type of hernia in a large population-based cohort over a long follow-up period.MethodsThe Swedish Colorectal Cancer Registry and the National Patient Register were used to collect study cohort data between January 2007 and September 2013. All patients undergoing colorectal cancer surgery including a permanent stoma were included in the study group.ResultsA total of 39,984 patients were registered during the study period. Of these, 7649 received a permanent stoma. Multivariate proportional hazard analysis, based on 6329 patients for whom all covariates could be retrieved, showed that the only independent risk factor for developing a parastomal hernia was BMI ≥ 30 (HR 1.49; 95% CI 1.02–2.17; p < 0.037). A slightly elevated hazard ratio was found for preoperative radiotherapy (HR 1.36; 95% CI 0.96–1.91; p < 0.070). The cumulative incidence of patients diagnosed or surgically treated for parastomal hernia over a follow-up period of 5 years was 7.7% (95% CI 6.1–9.2%).ConclusionsThe cumulative incidence of parastomal hernia causing symptoms or requiring surgery after 5 years was at least 7.7%. Obesity increases the risk of developing parastomal hernia.

Prognostic factors for survival in stage IV rectal cancer: A Swedish nationwide case–control study

PurposeThe aim was to identify patient-, tumor- and treatment-related prognostic factors for five-year survival in rectal cancer patients with synchronous stage IV disease. Material and methodsThis nationwide case-control study was based on the Swedish Colorectal Cancer Registry with supplementary information from medical records and the Swedish Inpatient Registry during the period 2000–2008. All resected rectal cancer patients with synchronous metastases that survived more than five years were included as cases. The control group consisted of corresponding patients who lived less than five years, matched in a 1:2 based on gender, age, resection of the rectal tumor, and the study period. ResultsA total of 405 patients were identified; 99 long-term survivors (LTS) and 182 short-term survivors (STS). Patient-related factors of symptoms and comorbidity did not differ between LTS and STS. Among the treatment-related factors, multiple site metastases (p = 0.007), bilobar liver metastasis (p = 0.002), and increasing number of liver metastasis (p < 0.001) were associated with STS. Prognostic treatment-related factors were preoperative radiotherapy (p = 0.001), metastasectomy (p < 0.001), and radical resection of the primary tumor (p = 0.014). In the multivariable analysis, the single most important factor for becoming a LTS was a metastasectomy (hazard ratio: 8.474, 95% confidence interval: 4.098–17.543). ConclusionsThe most important prognostic factor for long-term survival in patients with stage IV rectal cancer was metastasectomy, especially liver surgery. With thorough selection of patients for metastasectomy more patients with metastasized rectal cancer may survive beyond five years.

Postoperative complications following colonic resection for cancer are associated with impaired long-term survival.

Surgery for colorectal cancer is associated with a high incidence of postoperative complications. The aim of this study was to analyse whether postoperative complications following radical resection for colorectal cancer are associated with increased recurrence rate and impaired survival. Patients operated for colon cancer between 2007 and 2009 with curative intent were identified through the Swedish Colorectal Cancer Registry. The cohort was divided into three subgroups: patients who developed severe postoperative complications, patients who developed non-severe complications and patients who did not develop any complication (controls). Of 6779 patients included in the study, 640 (9%) developed severe complications, 994 (15%) non-severe complications and 5145 (76%) had no complications. The 5-year overall survival rate was 60.3% in the severe complication group, 64.2% in the non-severe complication group and 72.8% in the control group (P<0.01). The 3-year disease-free survival rate was 66.8%, 70.9% and 77.8% respectively (P<0.01). The recurrence rate did not differ between the three groups. In multivariate analysis, both severe and non-severe complications were found to be risk factors for decreased overall survival at 5 years [hazard ratio (HR) 1.38, 95% CI 1.47-1.92, and HR 1.18, 95% CI 1.27-1.60 respectively; P<0.05) as well as for decreased 3-year disease-free survival (HR 1.37, 95% CI 1.14-1.65, and HR 1.26, 95% CI 1.08-1.48 respectively; P< 0.05). Complications after colonic resection for cancer are associated with impaired 5-year overall survival and 3-year disease-free survival and exhibit more severe postoperative complications, mainly via mechanisms other than cancer recurrence.

Tumour regression after radiotherapy for rectal cancer – Results from the randomised Stockholm III trial

Background and purposeNeoadjuvant radiotherapy (RT) in rectal cancer induces tumour regression with a possible complete response (pCR). The optimal fractionation and timing to surgery is not established. The Stockholm III trial randomly assigned 840 patients to 5 × 5 Gy surgery within one week (SRT), 5 × 5 Gy with surgery after 4–8 weeks, and 2 Gy × 25 with surgery after 4–8 weeks (LRT-delay). The aim of this substudy was to assess tumour regression and correlation to survival. Material and methodsAll available microscopy slides were assessed by one pathologist, blinded to treatment, regarding tumour regression, graded according to the Dworak system (TRG), TNM-stage and other standard histopathology characteristics. Patients’ data were collected from the Swedish ColoRectal Cancer Registry. Outcomes were TRG, pCR-rates, overall survival (OS) and time to recurrence (TTR). Results318, 285 and 94 patients were included in the SRT, SRT-delay and LRT-delay groups. Median follow up was 5.7 years. There were significantly lower tumour stages after SRT-delay. pCR was seen in 1 (0.3%), 29 (10.4%) and 2 (2.2%) patients in SRT, SRT-delay and LRT-delay, respectively. The pCR and Dworak grade 4 were associated with superior survival. pCR vs no-pCR Hazard Ratio (95% Confidence Interval) OS: 0.51 (0.26–0.99) p = 0.046, TTR: 0.27 (0.09–0.86) p = 0.027. ConclusionSRT-delay induces pCR in about 10% of the patients and is in this aspect superior to 25 × 2 Gy. A complete tumour response, TRG 4 using the Dworak system, or a pCR, is associated with superior OS and TTR.

Worse survival in liver metastatic right-sided versus left-sided colorectal cancer

Background: Colorectal cancer (CRC) is the third most common cancer and a quarter develop liver metastases (LM). Differences in epidemiological and molecular patterns between right- and left-sided colon cancer are emerging suggestive of a worse prognosis for right-sided cancer. The aim of the study was to describe the liver metastatic patterns and survival as a function of site of primary tumour. Methods: Patients diagnosed with CRC during 2008 in the region of Stockholm, Sweden, were identified through the Swedish Colorectal Cancer Register and followed for 5 years. Additional information on liver metastatic pattern were retrieved from patient electronic charts. Factors influencing overall survival (OS) were examined using Cox proportional hazards model with 95 per cent confidence interval (c.i.) and OS was compared using log-rank test. Results: LM were more often diagnosed in hindgut cancer (28.4% versus 22.1%, p=0.029) but the number and segmental involvement of LM were less extensive compared to midgut cancer (p=0.001). 5-year OS were significantly worse in liver metastatic midgut cancer compared to hindgut cancer (6.5% vs. 21.6%, p<0.001), still significant in the multivariate analysis of patients with LM (HR=0.56, c.i. 0.39 to 0.79). Conclusion: Detailed population-based data on the metastatic pattern of CRC and survival could assist in more structured and individualized guidelines for follow-up. The results are in agreement with previous publications on the worse prognosis for right-sided cancers.

The presence of lung metastases does not influence survival in liver metastatic colorectal cancer

Background: The indications for liver resection of colorectal cancer liver metastases (CRCLM) are continuously expanding and the presence of extra-hepatic metastases are no longer a contraindication for hepatic resection. The aim of the study was to investigate factors influencing survival among patients with CRCLM. Methods: Patients diagnosed with CRC during 2008 in the region of Stockholm, Sweden, were identified through the Swedish Colorectal Cancer Register and followed for 5 years. Additional information on liver and lung metastatic pattern were retrieved from patient electronic charts. Factors influencing overall survival (OS) were examined using Cox proportional hazards model with 95 per cent confidence interval (c.i.). Results: In this population-based study of 1026 patients with CRC, liver and lung metastases were diagnosed in 26.5% and 16.9%, respectively. Lung metastases were more likely diagnosed in left-sided and rectal cancer as compared to right-sided cancer (19.7% vs. 13.2%, p=0.010). The presence of lung metastases did not significantly influence OS in multivariate analysis, neither in the entire CRC cohort (HR 1.23, c.i. 0.93 to 1.62) or in patients with liver metastatic CRC (HR 1.11, c.i. 0.80 to 1.53). Conclusion: Based on these results, one could speculate in wheatear a subset of patients with inoperable lung metastases – excluding the patient from liver resection of concomitant liver metastases – still could benefit from hepatic surgery.

β-Blockade in Rectal Cancer Surgery: A Simple Measure of Improving Outcomes.

To ascertain whether regular β-blocker exposure can improve short- and long-term outcomes after rectal cancer surgery. Surgery for rectal cancer is associated with substantial morbidity and mortality. There is increasing evidence to suggest that there is a survival benefit in patients exposed to β-blockers undergoing non-cardiac surgery. Studies investigating the effects on outcomes in patients subjected to surgery for rectal cancer are lacking. All adult patients undergoing elective abdominal resection for rectal cancer over a 10-year period were recruited from the prospectively collected Swedish Colorectal Cancer Registry. Patients were subdivided according to preoperative β-blocker exposure status. Outcomes of interest were 30-day complications, 30-day cause-specific mortality, and 1-year all-cause mortality. The association between β-blocker use and outcomes were analyzed using Poisson regression model with robust standard errors for 30-day complications and cause-specific mortality. One-year survival was assessed using Cox proportional hazards regression model. A total of 11,966 patients were included in the current study, of whom 3513 (29.36%) were exposed to regular preoperative β-blockers. A significant decrease in 30-day mortality was detected (incidence rate ratio = 0.06, 95% confidence interval: 0.03-0.13, P < 0.001). Deaths of cardiovascular nature, respiratory origin, sepsis, and multiorgan failure were significantly lower in β-blocker users, as were the incidences in postoperative infection and anastomotic failure. The β-blocker positive group had significantly better survival up to 1 year postoperatively with a risk reduction of 57% (hazard ratio = 0.43, 95% confidence interval: 0.37-0.52, P < 0.001). Preoperative β-blocker use is strongly associated with improved survival and morbidity after abdominal resection for rectal cancer.

High risk of permanent stoma after anastomotic leakage in anterior resection for rectal cancer.

This study investigates how often bowel continuity was restored after anastomotic leakage in anterior resection for rectal cancer and assesses the clinical factors associated with permanent stoma. The Swedish Colorectal Cancer Registry was used to identify cases of anastomotic leakage registered in southern Sweden between January 2001 and December 2011. Patient characteristics, surgical details and clinical information about the anastomotic leakages were retrieved from medical records. Of the 1442 patients operated on with anterior resection in 11 hospitals, 144 (10%) were diagnosed with anastomotic leakage after anterior resection for rectal cancer. After a median follow-up of 87 months (range 21-165), the overall rate of permanent stoma among patients with anastomotic leakage was 65%. Age ≥70years (P=0.02) and re-laparotomy (P<0.001) were independently related to permanent stoma. Compared with nondefunctioned patients with anastomotic leakage, defunctioned patients with anastomotic leakage at the index procedure less often required re-laparotomy at some point during the entire clinical course (P<0.001), but nondefunctioned and defunctioned patients with anastomotic leakage both had permanent stoma to the same extent (67% and 62%, respectively). Anastomotic leakage is highly associated with permanent stoma after anterior resection, especially in patients aged ≥70years. In this cohort of patients with anastomotic leakage, 65% had permanent stoma at long-term follow-up. A defunctioning stoma ameliorates the clinical course but does not affect the end result of bowel continuity in established anastomotic leakage after anterior resection.

Evaluation of the Swedish Colorectal Cancer Registry: an overview of completeness, timeliness, comparability and validity

Background: The Swedish Colorectal Cancer Registry (SCRCR) is a national registry established in 1995 for rectal cancer, and also including colon cancer since 2007. Knowledge of the quality of the registry is vital in order to draw correct conclusions from studies based on the registry. The aim of this study was to assess the completeness, timeliness, comparability and validity of the SCRCR.Material and methods: Completeness, timeliness and comparability of the registry were estimated. From the SCRCR year 2008, 500 cases were randomly selected to examine the validity of the registry and 486 cases were retrieved. Using hospital patient records as source documents, 130 variables in the SCRCR were reabstracted using the SCRCR registration forms and then compared with the original files.Result: During the period 2008–2015, the average completeness of the SCRCR was 98.5% for colon cancer and 98.8% for rectal cancer. Timeliness improved between the years 2008 and 2015, with 98% of the patients registered within 12 months for the year 2015. For most of the variables, comparability was estimated to be reproducible and comparable with other registries. Regarding the validity of the registry, when comparing reabstracted data with the original SCRCR data, average agreement was 90%.Conclusion: The SCRCR can be considered a reliable registry useful for quality assurance and research. Standardization and improvements in journal documentation are needed to improve future evaluation of the source documents.

High Tie or not in Resection for Cancer in the Sigmoid Colon?

The optimal extent of mesenteric resection in colon cancer surgery remains elusive. The aim was to assess the impact on perioperative morbidity and oncological outcome depending on the height of central vessel ligation in sigmoid resection for adenocarcinomas. All cases of stage I-III sigmoid cancers, operated on with locally radical resections (2007-2009), were identified in the Swedish Colorectal Cancer Registry and categorized according to the position of the vascular ligature, that is, ligation of the inferior mesenteric artery, ligation of the superior rectal artery, or ligation of the sigmoid branches. In total, 999 cases were identified and possible to categorize. Although higher ligation level yielded a higher number of lymph nodes, 3- or 5-year overall survival, 5-year disease-free survival, or recurrence rate did not differ between the groups (p = 0.79, p = 0.41, p = 0.67, p = 0.51). No differences in survival were detected after multivariate analysis adjusted for age, sex, T-stage, N-stage, American Society of Anesthesiologists classification, and adjuvant therapy. This large population-based study showed increased lymph node yield but no survival benefit or any decreased recurrence rate by high tie in resection of sigmoid cancer.

Anastomotic leakage after anterior resection in patients with rectal cancer previously irradiated for prostate cancer

IntroductionThere are little data on the post-operative outcome of anterior resection (AR) for rectal cancer in men who had received radiotherapy for prostate cancer previously. The aim of this study was to assess the rate of anastomotic leakage (AL) after AR in these patients. MethodsAll men who underwent bowel resection because of rectal cancer between 2000 and 2016 and had been diagnosed previously with prostate cancer were identified by linking the Swedish Colorectal Cancer Registry with the National Prostate Cancer Register. The medical records of men who underwent AR and had previously received radiotherapy for prostate cancer were reviewed. ResultsIn total, 13299 men had undergone a bowel resection for rectal cancer, 188 of whom had previously received radiotherapy for prostate cancer. Among those who had received radiation therapy, 59 men (31%) had an AR: 50 men (85%) received a diverting ileostomy, 42 men (71%) had an American Society of Anesthesiologists score of 1–2 and 36 men (61%) had tumour stage 1–2. AL was found in 12/59 men (20%), one of whom had a re-laparotomy. There was no 90-day mortality. ConclusionsIn the combined national population-based registries, a minority of patients with rectal cancer had an AR after previous radiotherapy for prostate cancer. These patients were healthy with early cancer stages and, in this selected group of patients, the AL rate was much lower than that reported previously.

Anterior resection for rectal cancer in Sweden: validation of a registry-based method to determine long-term stoma outcome

Background: A permanent stoma after anterior resection for rectal cancer is common. Nationwide registries provide sufficient power to evaluate factors influencing this phenomenon, but validation is required to ensure the quality of registry-based stoma outcomes.Methods: Patients who underwent anterior resection for rectal cancer in the Northern healthcare region of Sweden between 1 January 2007 and 31 December 2013 were reviewed by medical records and followed until 31 December 2014 with regard to stoma outcome. A registry-based method to determine nationwide long-term stoma outcomes, using data from the National Patient Registry and the Swedish Colorectal Cancer Registry, was developed and internally validated using the chart reviewed reference cohort. Accuracy was evaluated with positive and negative predictive values and Kappa values. Following validation, the stoma outcome in all patients treated with an anterior resection for rectal cancer in Sweden during the study period was estimated. Possible regional differences in determined stoma outcomes between the six Swedish healthcare regions were subsequently evaluated with the χ2 test.Results: With 312 chart reviewed patients as reference, stoma outcome was accurately predicted through the registry-based method in 299 cases (95.8%), with a positive predictive value of 85.1% (95% CI 75.8%–91.8%), and a negative predictive value of 100.0% (95% CI 98.4%–100.0%), while the Kappa value was 0.89 (95% CI 0.82–0.95). In Sweden, 4768 patients underwent anterior resection during the study period, of which 942 (19.8%) were determined to have a permanent stoma. The stoma rate varied regionally between 17.8–29.2%, to a statistically significant degree (p = .001).Conclusion: Using data from two national registries to determine long-term stoma outcome after anterior resection for rectal cancer proved to be reliable in comparison to chart review. Permanent stoma prevalence after such surgery remains at a significant level, while stoma outcomes vary substantially between different healthcare regions in Sweden.

Effect of beta-blocker therapy on early mortality after emergency colonic cancer surgery.

Emergency colorectal cancer surgery is associated with significant mortality. Induced adrenergic hyperactivity is thought to be an important contributor. Downregulating the effects of circulating catecholamines may reduce the risk of adverse outcomes. This study assessed whether regular preoperative beta-blockade reduced mortality after emergency colonic cancer surgery. This cohort study used the prospectively collected Swedish Colorectal Cancer Registry to recruit all adult patients requiring emergency colonic cancer surgery between 2011 and 2016. Patients were subdivided into those receiving regular beta-blocker therapy before surgery and those who were not (control). Demographics and clinical outcomes were compared. Risk factors for 30-day mortality were evaluated using Poisson regression analysis. A total of 3187 patients were included, of whom 685 (21·5 per cent) used regular beta-blocker therapy before surgery. The overall 30-day mortality rate was significantly reduced in the beta-blocker group compared with controls: 3·1 (95 per cent c.i. 1·9 to 4·7) versus 8·6 (7·6 to 9·8) per cent respectively (P < 0·001). Beta-blocker therapy was the only modifiable protective factor identified in multivariable analysis of 30-day all-cause mortality (incidence rate ratio 0·31, 95 per cent c.i. 0·20 to 0·47; P < 0·001) and was associated with a significant reduction in death of cardiovascular, respiratory, sepsis and multiple organ failure origin. Preoperative beta-blocker therapy may be associated with a reduction in 30-day mortality following emergency colonic cancer surgery.

Incisional hernia after surgery for colorectal cancer: a population-based register study

BackgroundOur knowledge on the incidence of incisional hernia and risk factors for developing incisional hernia following surgery for colorectal cancer is far from complete.MethodsAll procedures registered in the Swedish Colorectal Cancer Register (SCRCR) 2007–2013 were identified. Patients with comorbid disease diagnoses, registered at admissions and visits prior to the procedure and relevant to this study, were obtained from the National Patient Register (NPR). These diagnoses included cardiovascular disease, connective tissue disorders, liver cirrhosis, renal failure, diabetes, chronic obstructive lung disease and chronic inflammatory conditions. Data on occurrence of incisional hernias were obtained by combining data from the SCRCR and the NPR (International Classification of Diseases code).ResultsDuring 2007–2013, 39,984 procedures were registered in the SCRCR. After excluding laparoscopic procedures, procedures repeated on the same patient, procedures with concomitant liver resection and procedures without laparotomy, 28,913 cases remained for analysis. Five years after surgery, the cumulative incidence of incisional hernia was 5.3%. In multivariate proportional hazard analysis, significantly increased risk for incisional hernia was found for the male gender (hazard ratio [HR] 1.40, 95% confidence interval [CI] 1.21–1.62), operation time exceeding 180 min (HR 1.25, CI 1.08–1.45), body mass index (BMI) > 30 (HR 1.78, CI 1.51–2.09), age < 70 years (HR 1.34, CI 1.16–1.56) and postoperative wound complication (HR 2.09, CI 1.70–2.58).DiscussionMen, patients younger than 70 years and patients with BMI > 30 face a higher risk for incisional hernia. The risk is also increased in cases where the procedure takes longer than 3 h or where postoperative wound complications occur. These patients will benefit from measures aimed at preventing the development of incisional hernia.

Distance to hospital is not a risk factor for emergency colon cancer surgery

PurposeThe purpose of this study is to see if the distance to a hospital performing colon cancer surgery is a risk factor for emergency surgical intervention and to determine the variability between defined but demographically divergent catchment areas.MethodsData on patients living in Västerbotten County who underwent colon cancer surgery between 2007 and 2010 were extracted from the Swedish Colorectal Cancer Register (SCRCR). Of the 436 registrations matching these criteria, 380 patients were used in the analysis, and their distance to the nearest hospital providing care for colorectal cancer (CRC) was estimated using Google Maps™. The correlations between the risk for emergency surgery and the distance to a hospital, gender, age, income level and hospital catchment area were analysed in uni- and multivariate models.ResultsDistance to the nearest hospital had no significant effect on the proportion of emergency operations for colon cancer. There was significant variability in risk for emergency surgery between hospital catchment areas, where the catchment areas of the university hospital and the most rural hospital had a higher proportion than the other local hospital catchment area (OR, 2.00 (p = 0.038) and OR, 2.97 (p = 0.005)). These results were still significant when analysed with multivariate logistic regression (OR, 2.13 (p = 0.026) and OR, 3.05 (p = 0.013)).ConclusionDistance to a hospital performing colon cancer surgery had no effect on the proportion of emergency surgeries. However, a variability between defined catchment areas was seen. Future studies will focus on possible factors behind this variability.

Urogenital function 3years after abdominoperineal excision for rectal cancer.

The aim of this study was to explore urogenital dysfunction and associated risk factors after treatment of rectal cancer, in a large national cohort of patients 3years after abdominoperineal excision, and to compare outcomes with a reference population and a cohort of patients operated for prostate cancer. Patients treated with abdominoperineal excision in 2007-2009 were identified using the Swedish Colorectal Cancer Registry. All consenting patients received a questionnaire. A sample of the Swedish population was contacted and completed a questionnaire. Patients undergoing radical prostatectomy in a prospective multicentre trial received questionnaires 24months after surgery. In the abdominoperineal excision, reference and radical prostatectomy populations 72%, 51% and 91% of the questionnaires were returned. Within the abdominoperineal excision group 36% of the men and 57% of the women were incontinent postoperatively. Fifteen per cent and 37% of men and women in the reference group were incontinent. Two years after radical prostatectomy 49% were incontinent. Seventy-four per cent of the men had erectile dysfunction after abdominoperineal excision. Nineteen per cent of the women experienced reduced ability to reach orgasm. Fewer men and women experienced their present sex life as satisfying after abdominoperineal excision for rectal cancer compared with the reference population. A large proportion of patients endure persistent urogenital dysfunction after abdominoperineal excision for rectal cancer as do men after radical prostatectomy. Effects on sexual and urinary function should be part of preoperative information and after surgery patients should be asked about function in order to identify those in need of further assistance.

Complete mesocolic excision in right-sided colon cancer does not increase severe short-term postoperative adverse events.

The aim was to assess whether complete mesocolic excision (CME) in patients with right-sided colon cancer is related to short-term mortality or postoperative adverse events requiring reoperation. The complete mobilization of an integral mesocolon and central ligation of blood vessels are essential steps in CME surgery. The resultant specimen, with an intact mesocolic fascia and a high number of harvested lymph nodes, is believed to be oncologically favourable. However, it has been suggested that CME surgery may increase the risk of intra-operative severe adverse events, due to exposure of vital retroperitoneal organs and large blood vessels. In a population-based, nested case-control study, all residents in the Stockholm County operated for right-sided colon cancer from 2004 until 2012 were identified from the Swedish Colorectal Cancer Registry. Patients who died within 90days after surgery or were reoperated within 30days after surgery, or during the index hospital stay, were defined as cases. Two controls per case were randomly sampled and individually matched for age, sex, TNM stage and emergency vs elective surgery. Exposure status (CME surgery) was assessed from original surgical reports. The estimated proportion of CME surgery was 14.8% (35 of 236) for cases and 19.5% (92 of 473) for controls. The unadjusted OR for short-term mortality or reoperation after CME surgery was 0.72 (95% CI: 0.47-1.10; P=0.15). The ORs were lower in the late part of the study (0.51; 95% CI: 0.26-1.01) and in high volume hospitals (0.61, 95% CI: 0.35-1.06). The present study does not indicate that CME surgery is associated with an increased risk of severe adverse events such as 90-day mortality or reoperation.

Identification of Inequalities in the Selection of Liver Surgery for Colorectal Liver Metastases in Sweden.

Liver resection for colorectal liver metastases offers a 5-year survival rate of 25%-58%. This study aimed to analyze whether patients with colorectal liver metastases undergo resection to an equal extent and whether selection factors play a role in the selection process. Data were retrieved from the Swedish Colorectal Cancer Registry (2007-2011) for colorectal cancer and colorectal liver metastases. The patients identified were linked to the Swedish Registry of Liver and Bile surgery and the National Patient Registry to identify whether liver surgery or ablative treatment was performed. Analyses for age, sex, type of primary tumor and treating hospital (university, county, or district), American Society of Anesthesiologists class, and radiology for detection of metastatic disease were performed. Of 28,355 patients with colorectal cancer, 21.6% (6127/28,355) presented with liver metastases. Of the patients with liver metastases, 18.5% (1134/6127) underwent liver resection or ablation. The cumulative proportion of liver resection/ablation was 4% (1134/28,355) of all colorectal cancer. If "not bowel resected" were excluded, the proportion slightly increased to 4.7% (1134/24,262). Around 15% of the patients with metastases were registered as referrals for liver surgery. In a multivariable analysis patients treated at a university hospital for primary tumor were more frequently surgically treated for liver metastases (p < 0.0001). Patients with liver metastases from rectal cancer (p < 0.0001) and men more often underwent liver resection (p = 0.006). A difference was found between health-care regions for the frequency of liver surgery (p < 0.0001). Patients >70 years and those with American Society of Anesthesiologists class >2 underwent liver resection less frequently. Magnetic resonance imaging of the liver was more often used in diagnostic work-up in men. Patients with colorectal liver metastases are unequally treated in Sweden, as indicated by the low referral rate. The proximity to a hepatobiliary unit seems important to enhance the patient's chances of being offered liver surgery.