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Surgical Aspects and Prognostic Factors in the Management of Rectal Cancer
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Centre for Clinical Research, County of Västmanland.
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Survival among patients with stage IV rectal cancer is poor and surgical treatment for this disease is associated with morbidities such as small bowel obstruction, complications with a diverting loop ileostomy, and functional bowel disturbances. The overall aim of this thesis was to assess risk factors and morbidity after surgery for rectal cancer and to evaluate factors affecting survival in patients with stage IV rectal cancer.

Paper I a prospective study on patients with rectal cancer with loop ileostomy who underwent stoma closure in a 23-hour hospital stay setting. Results were compared with a group who underwent standard in-hospital stoma closure prior to the start of the study, selected retrospectively as controls. No differences were found in the number of complications or the frequency of re-hospitalization or re-operation, indicating that ileostomy closure in a 23-hour hospital stay setting in these selected patients was feasible and safe with high patient satisfaction.

Paper II a population-based study with data gathered prospectively. In total, 11% of the patients developed small bowel obstruction (SBO), mostly during the first year after rectal cancer surgery. Surgical treatment for SBO was performed in 4.2% of the patients, and the mechanism was stoma-related in one-fourth. Rectal resection without anastomoses, age, morbidity, and previous radiotherapy (RT) was not associated with admission to the hospital or surgery for SBO. Re-laparotomy due to complications after rectal cancer surgery was an independent risk factor for admission for treating SBO.

Paper III a population-based study with data gathered prospectively on bowel function at 1 year after anterior resection or stoma reversal. No associations were found between any defecatory dysfunction and the part of the colon used for anastomosis, the level of the vascular tie, or gender. An association was observed between higher anastomotic level and a lower risk of incontinence and clustering. At 1 year after loop ileostomy closure, the risks of incontinence, clustering, and urgency increased by up to fourfold.

Paper IV a case-control study aiming to identify patient-, tumor-, and treatment-related prognostic factors for 5-year survival in patients with rectal cancer with synchronous stage IV disease. Patient-related factors did not differ between groups. Among the tumor-related factors, multiple site metastases, bilobar liver metastases, and increasing numbers of liver metastases were associated with poor survival. Prognostic treatment-related factors were preoperative RT, metastasectomy, and radical resection of the primary tumor. The most important prognostic factor for long-term survival was metastasectomy.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2021. , p. 73
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1764
Keywords [en]
Loop ileostomy, Small bowel obstruction, Defecatory dysfunction, Stage IV rectal cancer
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-450799ISBN: 978-91-513-1268-2 (print)OAI: oai:DiVA.org:uu-450799DiVA, id: diva2:1585916
Public defence
2021-10-08, Centrum för klinisk forskning Västerås,, Ingång 29, Västmanlands sjukhus, Västerås, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2021-09-17 Created: 2021-08-18 Last updated: 2021-10-19
List of papers
1. Loop-ileostomy reversal in a 23-h stay setting is safe with high patient satisfaction
Open this publication in new window or tab >>Loop-ileostomy reversal in a 23-h stay setting is safe with high patient satisfaction
2021 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 56, no 9, p. 1126-1130Article in journal (Refereed) Published
Abstract [en]

Introduction: This study aimed to determine whether day-case closure of loop ileostomy with discharge within 23 h was both feasible and accepted by patients.

Materials and methods: We conducted a prospective pilot study where selected rectal cancer patients with diverting loop ileostomy underwent stoma closure in a 23-h stay setting. Patients were followed up on the third, seventh, and 30th postoperative day and phoned daily during the first week. A comparable group of 30 patients who underwent standard in-hospital stoma closure prior to the start of the study were selected retrospectively as historical controls.

Results: In total, 30 patients (median age, 67 years; range, 41-79 years) were included. All patients met discharge criteria and were discharged within 23 h of surgery, except one. In total, seven patients (23%) were admitted. Two of these patients underwent laparotomy because of anastomotic leakage and small bowel obstruction, respectively. The mean total length of stay was 1.7 days. Most patients (87%) were satisfied with the treatment without feeling neglected or anxious and preferred the 23-h stay setting. In the control group, the mean length of stay was 5 days. Seven patients (23%) were readmitted. Two of these patients underwent laparotomy because of small bowel obstruction and abscess, respectively.

Conclusion: Ileostomy closure in a 23-h stay setting in selected patients with meticulous follow up is feasible and safe with high patient satisfaction.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2021
Keywords
Ileostomy closure, ileostomy reversal, day-case, ·23-h stay, diverting ileostomy closure, patient experience
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-449442 (URN)10.1080/00365521.2021.1947367 (DOI)000669733700001 ()34224302 (PubMedID)
Funder
Region Västmanland, LTV-943053
Available from: 2021-07-26 Created: 2021-07-26 Last updated: 2022-04-27Bibliographically approved
2. Risk factors for small bowel obstruction after open rectal cancer resection
Open this publication in new window or tab >>Risk factors for small bowel obstruction after open rectal cancer resection
2021 (English)In: BMC Surgery, E-ISSN 1471-2482, Vol. 21, no 1, article id 63Article in journal (Refereed) Published
Abstract [en]

Background: Small bowel obstruction (SBO) is observed in around 10% of patients with prior open abdominal surgery. Rectal resection causes the highest readmission rates. The aim of this study was to investigate risk factors for readmission for SBO and causes for SBO in patients who needed surgery following rectal cancer surgery.

Methods: A population-based registry with prospectively gathered data on 752 consecutive patients with rectal cancer who underwent open pelvic surgery between January 1996 and January 2017 was used. Univariable and multivariable regression analysis was performed, and the risk of SBO was assessed.

Results: In total, 84 patients (11%) developed SBO after a median follow-up time of 48 months. Of these patients, 57% developed SBO during the 1st year after rectal cancer surgery. Surgery for SBO was performed in 32 patients (4.3%), and the cause of SBO was stoma-related in one-fourth of these patients. In the univariable analysis previous RT and re-laparotomy were found as risk factors for readmission for SBO. Re-laparotomy was an independent risk factor for readmission for SBO (OR 2.824, CI 1.129-7.065, P = 0.026) in the multivariable analysis, but not for surgery for SBO. Rectal resection without anastomoses, splenic flexors mobilization, intraoperative bleeding, operative time were not found as risk factors for SBO.

Conclusions: One-tenth of rectal cancer patients who had open surgery developed SBO, most commonly within the 1st postoperative year. The risk of SBO is greatest in patients with complications after rectal cancer resection that result in a re-laparotomy.

Place, publisher, year, edition, pages
BioMed Central (BMC)BMC, 2021
Keywords
Small bowel obstruction, Rectal cancer, Surgery, Admission, Risk factors
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-435183 (URN)10.1186/s12893-021-01072-y (DOI)000613227000001 ()33509187 (PubMedID)
Available from: 2021-02-26 Created: 2021-02-26 Last updated: 2024-07-04Bibliographically approved
3. Risk factors for developing Anorectal dysfunction after Anterior Resection
Open this publication in new window or tab >>Risk factors for developing Anorectal dysfunction after Anterior Resection
Show others...
2021 (English)In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 36, no 12, p. 2697-2705Article in journal (Refereed) Published
Abstract [en]

Anterior resection (AR) may result in defecatory dysfunction and the cause is multifactorial. The aim was to explore if dysfunction could be related to the part of the colon used for anastomosis (sigmoid or descending) and to identify other possible risk factors for bowel dysfunction after AR.

This is a retrospective study based on prospectively registered data from a regional registry at the surgical department in Västmanland 1996–2019. Bowel function was registered at 1 year after AR or after stoma reversal. In total, 470 stage I–III rectal cancer patients had AR whereof 412 were included in this study.

Clustering was seen in 57%, incontinence 29%, urgency 22%, and evacuatory dysfunction 16%. The part of the colon used for anastomosis, level of vascular tie, and gender were not significantly associated with defecatory dysfunction. The higher the anastomotic level, the lower the risk of incontinence (OR 0.75; CI 0.63–0.90; p < 0.001) and clustering (OR 0.78; CI 0.67–0.90; p < 0.001). Compared with patients without a loop-ileostomy, an increased risk of clustering (OR 1.89; 1.08–3.31; p = 0.03), incontinence (OR 2.48; 1.29–4.77; p < 0.01), and urgency (OR 4.61; CI 2.02–10.60; p < 0.001) was seen after loop-ileostomy closure. Preoperative radiotherapy had a negative impact on continence and clustering seen mainly in the unadjusted analysis.

The part of the colon used for anastomosis was not a significantly associated functional outcome after anterior resection. Low anastomotic level and having had a diverting ileostomy were independent risk factors associated with negative functional outcomes.

Place, publisher, year, edition, pages
Springer Nature, 2021
Keywords
anorectal dysfunction; anterior resection syndrome; functional bowel disturbance; anterior resection; bowel disturbance; functional outcome; bowel dysfunction
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-449964 (URN)10.1007/s00384-021-04024-3 (DOI)000691949300001 ()34471965 (PubMedID)
Available from: 2021-08-18 Created: 2021-08-18 Last updated: 2023-07-13Bibliographically approved
4. Prognostic factors for survival in stage IV rectal cancer: A Swedish nationwide case-control study
Open this publication in new window or tab >>Prognostic factors for survival in stage IV rectal cancer: A Swedish nationwide case-control study
Show others...
2019 (English)In: Surgial oncology, ISSN 0960-7404, E-ISSN 1879-3320, Vol. 29, p. 102-106Article in journal (Refereed) Published
Abstract [en]

Purpose: The 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 methods: This 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. Results: A 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). Conclusions: The 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.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Rectal cancer, Stage IV, Prognostic factor, Metastases
National Category
Cancer and Oncology
Identifiers
urn:nbn:se:uu:diva-389816 (URN)10.1016/j.suronc.2019.04.005 (DOI)000470833100016 ()31196471 (PubMedID)
Available from: 2019-07-30 Created: 2019-07-30 Last updated: 2021-08-18Bibliographically approved

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