Long-term results of a short-term home-based pre- and postoperative exercise intervention on physical recovery after colorectal cancer surgery (PHYSSURG-C): a randomized clinical trial.

AIM: The aim of this work was to assess the effect of a short-term, home-based exercise intervention before and after colorectal cancer surgery on 12-month physical recovery within a previously reported randomized control trial (RCT). METHOD: PHYSSURG-C is an RCT in six participating hospitals in Sweden. Patients aged ≥20 years planned for elective colorectal cancer surgery were eligible. The intervention consisted of unsupervised moderate-intensity physical activity 2 weeks preoperatively and 4 weeks postoperatively. Usual care was control. The primary outcome measure in PHYSSURG-C was self-assessed physical recovery 4 weeks postoperatively. The predefined long-term follow-up outcomes included: self-assessed physical recovery 12 months postoperatively and reoperations and readmissions 91-365 days postoperatively. The statistical models were adjusted with tumour site (colon or rectum), neoadjuvant therapy (none, radiotherapy or chemo/radiotherapy) and type of surgery (open or laparoscopic). RESULTS: A total of 616 participants were available for the 12-month follow-up. Groups were balanced at baseline regarding demographic and treatment variables. There was no effect from the intervention on self-reported physical recovery [adjusted odds ratio (OR) 0.91, p = 0.60], the risk of reoperation (OR 0.97, p = 0.91) or readmission (OR 0.88, p = 0.58). CONCLUSION: The pre- and postoperative unsupervised moderate-intensity exercise intervention had no effect on long-term physical recovery after elective colorectal cancer surgery. There is still not enough evidence to support clinical guidelines on preoperative exercise to improve outcome after colorectal cancer surgery.

Risk factors for developing anorectal dysfunction after anterior resection.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Loop-ileostomy reversal in a 23-h stay setting is safe with high patient satisfaction.

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. CLINICALTRIALS.GOV NUMBER: (NCT02774447).

Risk factors for small bowel obstruction after open rectal cancer resection.

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.

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

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.

[Splenic injury after sigmoidoscopy]. / Miltlæsion efter sigmoideoskopi.

Endoscopy of colon and rectum is a commonly used diagnostic and therapeutic procedure, which is generally safe although complications such as bleeding and perforation occur. There is, however, a small risk of splenic injury with potentially lethal outcome. We describe a case of splenic injury after sigmoidoscopy in a 48-year-old male.