Laparoscopic lavage for perforated diverticulitis in the LapLav study: population-based registry study.

BACKGROUND: The standard treatment for Hinchey III perforated diverticulitis with peritonitis was resection with or without a stoma, but recent trials have shown that laparoscopic lavage is a reasonable alternative. This registry-based Swedish study investigated results at a national level to assess safety in real-world scenarios. METHODS: Patients in Sweden who underwent emergency surgery for perforated diverticulitis between 2016 and 2018 were studied. Inverse probability weighting by propensity score was used to adjust for confounding factors. RESULTS: A total of 499 patients were included in this study. Laparoscopic lavage was associated with a significantly lower 90-day Comprehensive Complication Index (20.9 versus 32.0; odds ratio 0.77, 95 per cent compatibility interval (c.i.) 0.61 to 0.97) and overall duration of hospital stay (9 versus 15 days; ratio of means 0.84, 95 per cent c.i. 0.74 to 0.96) compared with resection. Patients had 82 (95 per cent c.i. 39 to 140) per cent more readmissions following lavage than resection (27.2 versus 21.0 per cent), but similar reoperation rates. More co-morbidity was noted among patients who underwent resection than those who had laparoscopic lavage. CONCLUSION: Laparoscopic lavage is safe in routine care beyond trial evaluations.

Diverticulitis comprises inflammation in pouches (diverticula) of the large intestine. In the most severe instances, this inflammation can cause perforation of the bowel with purulent or faecal peritonitis. If this happens, surgery is needed. The traditional method has been resection of the inflamed bowel with a stoma. A new technique has been proposed whereby the abdomen is rinsed with saline laparoscopically and a drain is placed (laparoscopic lavage). This study aimed to compare these two methods in terms of clinical short-term outcomes, with a focus on complications. It was found that laparoscopic lavage had fewer complications than resectional surgery and a shorter hospital stay. The new method was safe when used in Swedish routine care.

Postoperative non-steroidal anti-inflammatory drug use and oncological outcomes of rectal cancer.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are known to suppress the inflammatory response after surgery and are often used for pain control. This study aimed to investigate NSAID use after radical surgical resection for rectal cancer and long-term oncological outcomes. METHODS: A cohort of patients who underwent anterior resection for rectal cancer between 2007 and 2013 in 15 hospitals in Sweden was investigated retrospectively. Data were obtained from the Swedish Colorectal Cancer Registry and medical records; follow-up was undertaken until July 2019. Patients who received NSAID treatment for at least 2 days after surgery were compared with controls who did not, and the primary outcome was recurrence-free survival. Cox regression modelling with confounder adjustment, propensity score matching, and an instrumental variables approach were used; missing data were handled by multiple imputation. RESULTS: The cohort included 1341 patients, 362 (27.0 per cent) of whom received NSAIDs after operation. In analyses using conventional regression and propensity score matching, there was no significant association between postoperative NSAID use and recurrence-free survival (adjusted hazard ratio (HR) 1.02, 0.79 to 1.33). The instrumental variables approach, including individual hospital as the instrumental variable and clinicopathological variables as co-variables, suggested a potential improvement in the NSAID group (HR 0.61, 0.38 to 0.99). CONCLUSION: conventional modelling did not demonstrate an association between postoperative NSAID use and recurrence-free survival in patients with rectal cancer, although an instrumental variables approach suggested a potential benefit.

Quality of life in patients with resectable rectal cancer during the first 24 months following diagnosis.

AIM: An increasing number of patients survive rectal cancer, resulting in more patients living with the side-effects of the treatment. Exploring quality of life before and after treatment enables follow-up and additional treatment to be adjusted to the patient's needs. The aim of the study was to describe the quality of life during the 24 months following diagnosis and to identify risk factors for poor quality of life. METHOD: This is a prospective cohort study of patients with rectal cancer followed up by extensive questionnaires. Patients from 16 surgical departments in Denmark and Sweden from 2012 to 2015 were included. The self-assessed quality of life was measured with a seven-point Likert scale. RESULTS: A total of 1110 patients treated with curative intent were included, and the response rate at the 24-month follow-up was 71%. Patients with rectal cancer assessed their quality of life before start of treatment as poorer than that of a reference population. At the 12- and 24-month follow-up, the quality of life on group level had recovered to the same level as for the reference population. Risk factors for poor quality of life included bother with urinary, bowel and stoma function. A reference population was used for comparison. CONCLUSION: The quality of life of patients with resectable rectal cancer recovered to levels comparable to a reference population 12 and 24 months after diagnosis. Our results indicate that the urinary, bowel and stoma function has an impact on quality of life.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon.

AIM: The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons. METHODS: The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements. RESULTS: This guideline contains 38 evidence based consensus statements on the management of diverticular disease. CONCLUSION: This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

Increasing incidence of colorectal cancer among the younger population in Sweden.

BACKGROUND: The incidence of colorectal cancer in patients aged less than 50 years is increasing in Western countries. This population-based study investigated the age- and sex-specific incidence of colorectal cancer over time in Sweden, and characterized trends in tumour localization and stage at diagnosis. METHODS: Patients diagnosed with colorectal cancer between 1970 and 2016 were identified from the Swedish Cancer Registry, and categorized by sex, age and tumour location. The incidence and average annual percentage change (AAPC) were estimated and compared between age groups. RESULTS: There was an overall increase in the incidence of colorectal cancer between 1970 and 2006, but a decrease in 2006-2016 (AAPC -0·55 (95 per cent c.i. -1·02 to -0·07) per cent). The largest increase in colonic cancer was in 1995-2005 in women aged less than 50 years (AAPC 2·30 (0·09 to 4·56) per cent versus 0·04 (-1·35 to 1·44) and - 0·67 (-1·62 to 0·28) per cent in women aged 50-74 and 75 years or more respectively). Since 1990, rectal cancer increased in patients of both sexes aged below 50 years, with higher AAPC values in women (2006-2016: 2·01 (-1·46 to 5·61) per cent versus 0·20 (-2·25 to 2·71) per cent in men). Younger patients were more likely than those aged 50-74 and 75 years or more to present with stage III-IV colonic (66·2, 57·6 and 49·6 per cent respectively) and rectal (61·2, 54·3 and 51·3 per cent) cancer. From the mid 1990s, rates of proximal and distal colorectal cancer, and rectal cancer were increased in patients aged less than 50 years. CONCLUSION: The overall incidence of colorectal cancer in Sweden decreased in the past decade. However, in patients under 50 years of age the incidence of colorectal cancer - proximal, distal and rectal - continued to increase over time.

ANTECEDENTES: La incidencia del cáncer colorrectal (CCR) en pacientes < 50 años está aumentando en los países occidentales. El objetivo de este estudio de base poblacional fue investigar las tendencias y la incidencia específica por edad y sexo del CCR a lo largo del tiempo en Suecia, así como caracterizar las tendencias en la localización tumoral y en el estadio del CCR en el momento del diagnóstico. MÉTODOS: Los pacientes diagnosticados con CCR entre 1970 y 2016 fueron identificados a partir del Registro de Cáncer de Suecia. Se clasificaron por sexo, edad y localización del tumor. Se calcularon la incidencia media y el promedio del cambio porcentual anual (average annual percentage change, AAPC), comparándose entre los grupos de edad. RESULTADOS: Globalmente, la incidencia de CCR aumentó entre 1970-2006, pero se observó una disminución de 0,6% (i.c. del 95% -1,02 a 0,07) entre 2006-2016. El AAPC del cáncer de colon aumentó con el tiempo tanto en mujeres como en varones. En particular, el mayor aumento se observó entre 1995-2005 en mujeres de < 50 años, que presentaron un AAPC de cáncer de colon de 2,3% (i.c. del 95% 0,09 a 4,56), mayor en comparación con los grupos de edad más avanzada (50-74 años: 0,04%; i.c. del 95% -1,35 a 1,44; grupo de edad 75+: -0,67%; i.c. del 95% -1,62 a 0,28), aunque el análisis de datos proporcionó valores limitados de i.c del 95%. En los varones de < 50 años, el AAPC del cáncer de colon aumentó en un 1,2% (i.c. del 95% -0,80 a 3,21) entre 2006-2016, pero la diferencia no fue significativa en comparación con otros grupos de edad. Desde 1990, los cánceres rectales aumentaron en pacientes de < 50 años, en ambos sexos y en particular en mujeres más que en varones (2006-2016: mujeres 2,0%, i.c. del 95% −1,46 a 5,61 versus varones 0,2%, i.c. del 95% -2,25 a 2,71). En comparación con los grupos de mayor edad, los pacientes de < 50 años tenían más probabilidades de presentar cáncer de colon en estadio III/IV (66%, 58% y 50% en los grupos de edad de < 50, 50-74 y mayores de 75 años, respectivamente) y cáncer de recto (61%, 54% y 51% en los grupos de edad de < 50, 50-74 y mayores de 75 años, respectivamente). Desde mediados de los 90 se observaron tasas cada vez mayores de CCR proximal, distal y de cáncer de recto en pacientes de < 50 años. CONCLUSIÓN: La incidencia global de CCR en Suecia disminuyó en la última década. Sin embargo, en pacientes menores de 50 años, la incidencia del cáncer colorrectal, proximal, distal y rectal ha continuado aumentando a lo largo del tiempo.

Low anterior resection syndrome in a Scandinavian population of patients with rectal cancer: a longitudinal follow-up within the QoLiRECT study.

AIM: Low anterior resection syndrome (LARS) is common after low anterior resection. Our aim was to evaluate the prevalence and 'bother' (subjective, symptom-associated distress) of major LARS after 1 and 2 years, identify possible risk factors and relate the bowel function to a reference population. METHOD: The QoLiRECT (Quality of Life in RECTal cancer) study is a Scandinavian prospective multicentre study including 1248 patients with rectal cancer, of whom 552 had an anterior resection. Patient questionnaires were distributed at diagnosis and after 1, 2 and 5 years. Data from the baseline and at 1- and 2-year follow-up were included in this study. RESULTS: The LARS score was calculated for 309 patients at 1 year and 334 patients at 2 years. Prevalence was assessed by a generalized linear mixed effects model. Major LARS was found in 63% at 1 year and 56% at 2 years. Bother was evident in 55% at 1 year, decreasing to 46% at 2 years. Major LARS was most common among younger women (69%). Among younger patients, only marginal improvement was seen over time (63-59%), for older patients there was more improvement (62-52%). In the reference population, the highest prevalence of major LARS-like symptoms was noted in older women (12%). Preoperative radiotherapy, defunctioning stoma and tumour height were found to be associated with major LARS. CONCLUSION: Major LARS is common and possibly persistent over time. Younger patients, especially women, are more affected, and perhaps these patients should be prioritized for early stoma closure to improve the chance of a more normal bowel function.

The Handling of the Rectal Stump Does Not Affect Severe Morbidity After Subtotal Colectomy For Ulcerative Colitis: A Retrospective Cohort Study.

BACKGROUND AND AIMS: Colectomy due to ulcerative colitis is associated with complications. One severe complication is the risk for blow-out of the remaining rectal remnant. The aim of this study was to compare the frequency and severity of complications in patients with the rectal remnant left subcutaneously versus patients with the rectal remnant left intra-abdominally. A secondary aim was to identify risk factors for complications. MATERIALS AND METHODS: Consecutive patients at two tertiary centers in Sweden were retrospectively reviewed regarding surgical procedures; complications classified according to Clavien-Dindo; and possible risk factors for complications such as preoperative medication, emergency surgery, and body mass index. RESULTS: 307 patients were identified. Minor complications were more common than previously reported (85%-89%). Severe surgical complications were not related to the handling of the rectal remnant. Leaving the rectal remnant subcutaneously was associated with local wound problems. Risk factors for severe complications were emergency surgery and preoperative medication with 5-aminosalicylic acid. CONCLUSION: Minor complications after colectomy for ulcerative colitis are very common and need to be addressed. Leaving the rectal stump intra-abdominally seems safe and may be advantageous to reduce local wound morbidity.

Urinary dysfunction in patients with rectal cancer: a prospective cohort study.

AIM: Urinary dysfunction is one of many complications after treatment for rectal cancer. The aim of this study was to evaluate the prevalence of patient-reported urinary dysfunction at the time of diagnosis and at 1-year follow-up and to assess the risk factors linked to urinary incontinence. METHOD: Patients with newly diagnosed rectal cancer were included in the QoLiRECT study between 2012 and 2015. Questionnaires from the time of diagnosis and 1-year follow-up were analysed, with 1085 and 916 patients, respectively, eligible for analysis. Regression analyses were made to investigate possible risk factors for incontinence. The patient cohort was also compared with a cohort from the Swedish general population. RESULTS: At baseline, the prevalence of urinary dysfunction (14% of women, 8% of men) was similar to that in the general population. At 1-year follow-up, 20% of patients experienced urinary incontinence (29% of women, 14% of men). Emptying difficulties were experienced by 46% (41% of women, 49% of men) and urgency by 58% across both sexes. Abdominoperineal excision and urinary dysfunction at baseline were found to be independent risk factors for incontinence at 1-year follow-up. Among patients who were continent at baseline, risk factors were female sex, physical inactivity at baseline, comorbidity and abdominoperineal excision. CONCLUSION: Urinary dysfunction is frequent among patients with rectal cancer, with up to a two-fold increase in symptoms 1 year after diagnosis. Unfortunately, few factors are modifiable and these results stress the importance of informing patients of possible outcomes related to urinary dysfunction after treatment for rectal cancer.

Self-reported sexual dysfunction in patients with rectal cancer.

AIM: Patients with rectal cancer often experience sexual dysfunction after treatment. The aim of this study was to evaluate sexual function in a prospective cohort of patients regardless of treatment and tumour stage and explore what factors might affect sexual activity 1 year after diagnosis. METHOD: The QoLiRECT study (Quality of Life in RECTal cancer) is a prospective study on the health-related quality of life in patients with rectal cancer in Denmark and Sweden. Questionnaires were completed at diagnosis and 1 year. Clinical data were retrieved from national quality registries. RESULTS: Questionnaire data were available from 1085 patients at diagnosis and 920 patients at 1 year. Median age was 69 years (range 25-100). At diagnosis, 29% of the women and 41% of the men were sexually active, which was lower than an age-matched reference population. This was further reduced to 25% and 34% at 1 year. Risk factors for sexual inactivity were absence of sexual activity prior to the diagnosis and the presence of a stoma. Women experienced reduced lubrication and more dyspareunia at 1 year compared with the time of diagnosis. In men, erectile dysfunction increased from 46% to 55% at 1 year. CONCLUSION: Sexual activity in patients with rectal cancer is lower at diagnosis compared with the population norm and is further reduced at 1 year. The presence of a stoma contributed to reduced sexual activity after operation. Sexual dysfunction was difficult to evaluate due to low sexual activity in the cohort. In men, erectile dysfunction is common.

Functional outcomes from a randomized trial of early closure of temporary ileostomy after rectal excision for cancer.

BACKGROUND: Low anterior resection syndrome (LARS) has a significant impact on postoperative quality of life. Although early closure of an ileostomy is safe in selected patients, functional outcomes have not been investigated. The aim was to compare bowel function and the prevalence of LARS in patients who underwent early or late closure of an ileostomy after rectal resection for cancer. METHODS: Early closure (8-13 days) was compared with late closure (after 12 weeks) of the ileostomy following rectal cancer surgery in a multicentre RCT. Exclusion criteria were: signs of anastomotic leakage, diabetes mellitus, steroid treatment and postoperative complications. Bowel function was evaluated using the LARS score and the Memorial Sloan Kettering Cancer Center Bowel Function Instrument (BFI). RESULTS: Following index surgery, 112 participants were randomized (55 early closure, 57 late closure). Bowel function was evaluated at a median of 49 months after stoma closure. Eighty-two of 93 eligible participants responded (12 had died and 7 had a permanent stoma). Rates of bowel dysfunction were higher in the late closure group, but this did not reach statistical significance (major LARS in 29 of 40 participants in late group and 25 of 42 in early group, P = 0·250; median BFI score 63 versus 71 respectively, P = 0·207). Participants in the late closure group had worse scores on the urgency/soiling subscale of the BFI (14 versus 17; P = 0·017). One participant in the early group and six in the late group had a permanent stoma (P = 0·054). CONCLUSION: Patients undergoing early stoma closure had fewer problems with soiling and fewer had a permanent stoma, although reduced LARS was not demonstrated in this cohort. Dedicated prospective studies are required to evaluate definitively the association between temporary ileostomy, LARS and timing of closure.

Two-year results of the randomized clinical trial DILALA comparing laparoscopic lavage with resection as treatment for perforated diverticulitis.

BACKGROUND: Traditionally, perforated diverticulitis with purulent peritonitis was treated with resection and colostomy (Hartmann's procedure), with inherent complications and risk of a permanent stoma. The DILALA (DIverticulitis - LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) and other randomized trials found laparoscopic lavage to be a feasible and safe alternative. The medium-term follow-up results of DILALA are reported here. METHODS: Patients were randomized during surgery after being diagnosed with Hinchey grade III perforated diverticulitis at diagnostic laparoscopy. The primary outcome was the proportion of patients with one or more secondary operations from 0 to 24 months after the index procedure in the laparoscopic lavage versus Hartmann's procedure groups. The trial was registered as ISRCTN82208287. RESULTS: Forty-three patients were randomized to laparoscopic lavage and 40 to Hartmann's procedure. Patients in the lavage group had a 45 per cent reduced risk of undergoing one or more operations within 24 months (relative risk 0·55, 95 per cent c.i. 0·36 to 0·84; P = 0·012) and had fewer operations (ratio 0·51, 95 per cent c.i. 0·31 to 0·87; P = 0·024) compared with those in the Hartmann's group. No difference was found in mean number of readmissions (1·37 versus 1·50; P = 0·221) or mortality between patients randomized to laparoscopic lavage or Hartmann's procedure. Three patients in the lavage group and nine in the Hartmann's group had a colostomy at 24 months. CONCLUSION: Laparoscopic lavage is a better option for perforated diverticulitis with purulent peritonitis than open resection and colostomy.

Urogenital function 3 years after abdominoperineal excision for rectal cancer.

AIM: 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 3 years after abdominoperineal excision, and to compare outcomes with a reference population and a cohort of patients operated for prostate cancer. METHOD: 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 24 months after surgery. RESULTS: 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. CONCLUSION: 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.

Timely access to care in the treatment of rectal cancer and the effect on quality of life.

AIM: The aim of this study was to investigate if a delay in a patient's first contact with a healthcare professional, and any subsequent delay in diagnosis, affected self-assessed quality of life prior to start of treatment for rectal cancer. METHOD: Questionnaires were administered when patients had been informed of the diagnosis and planned treatment. The primary end-point was self-assessed quality of life according to a seven-point Likert scale. The response variables were dichotomized and analysed by unadjusted and adjusted binary logistic regression. RESULTS: A reported duration of symptoms longer than 4 months was found to be associated with a lower quality of life than a reported duration of symptoms of less than 3 months. Furthermore, a reported period of longer than 2 months from first contact with a healthcare professional to a diagnosis was found to correlate with lower quality of life compared with a period shorter than 2 months. However, when adjusting for possible confounding variables the duration of symptoms and time to diagnosis were not found to affect self-assessed quality of life. Several variables were found to have significant influence in the statistical model, including sense of coherence, the presence of negative intrusive thoughts, comorbidity, depressed mood, male sex and comorbidity. CONCLUSION: One conclusion of our study is that further efforts to shorten delay in rectal cancer care with the aim of improving quality of life may be futile. To improve the patient's quality of life at diagnosis other interventions should be considered, such as screening for depression and/or negative intrusive thoughts.

Complications and Morbidity associated with Loop Ileostomies in Patients with Ulcerative Colitis.

BACKGROUND AND AIMS: Loop ileostomies are frequently used as diversion of the fecal stream to protect a distal anastomosis. The aim of this study was to identify complications and morbidity related to loop ileostomies in patients with ulcerative colitis at a nonemergent setting. MATERIAL AND METHODS: Consecutive patients with ulcerative colitis who received a loop ileostomy at a tertiary referral center in Sweden from January 2006 until December 2012 were included and studied retrospectively. RESULTS: In total, 71 patients were identified, and the median age was 39 years. A majority (94%) of the patients underwent proctectomy or proctocolectomy with primary construction of an ileal pouch-anal anastomosis. In total, 38 patients (54%) had one or more postoperative complications at index surgery. Stoma-related complications were seen in 49% where parastomal skin irritation was most common. In total, 18% of the patients were re-admitted due to morbidity related to the ileostomy, and the leading cause was high volume output. Complications related to closure were seen in 29% of the patients, and of these, 30% required surgical intervention. In total, five patients (7%) developed a symptomatic leakage in the ileo-ileal anastomosis. There was no mortality. CONCLUSION: Loop ileostomies in this young patient cohort resulted in considerable morbidity. Closure of the ileostomy was also associated with complications. Although the diverting loop ileostomy is constructed to decrease the clinical consequences of an anastomotic leakage, the inherent morbidity should be considered. Preventive measures for parastomal skin problems could improve results.

Risk of recurrence of sigmoid volvulus: a single-centre cohort study.

AIM: Sigmoid volvulus is a condition with a tendency to recur if treated conservatively. Little is known about the best type of treatment or when to perform definitive surgery. The aim of this study was to review treatment, and assess the outcome, of sigmoid volvulus in adult patients treated at a Swedish university hospital. METHOD: The medical records of patients treated for sigmoid volvulus at Sahlgrenska University Hospital, Sweden from January 2000 to September 2016 were reviewed retrospectively. Median follow-up time was 8.3 years. RESULTS: One hundred and sixty-eight patients were included with a total of 453 admissions for sigmoid volvulus. Nonoperative decompression was attempted as the initial treatment in 438/453 (97%), with a success rate of 92% (403/438), which was not influenced by whether it was the first episode or a recurrence. Without planned surgery, recurrence occurred after 84% of successful nonoperative decompressions with a median of two recurrences (1-16). Recurrence was less common after the first episode compared with subsequent episodes. Median time until recurrence was 58 days. Mortality after planned surgery following successful decompression was 3.3% (2/61) compared with 13% (6/46) following emergency surgery. CONCLUSION: In our cohort, the recurrence rate of sigmoid volvulus following successful nonoperative decompression was high. Still, more than 20% of patients did not experience a recurrence after their first episode. Nonoperative decompression could thus be suggested as the sole treatment for the first episode of volvulus. However, after the second episode it is probable that early planned surgery would improve outcome and reduce health-care consumption.

Quality of life in a randomized trial of early closure of temporary ileostomy after rectal resection for cancer (EASY trial).

BACKGROUND: A temporary ileostomy may reduce symptoms from anastomotic leakage after rectal cancer resection. Earlier results of the EASY trial showed that early closure of the temporary ileostomy was associated with significantly fewer postoperative complications. The aim of the present study was to compare health-related quality of life (HRQOL) following early versus late closure of a temporary ileostomy. METHODS: Early closure of a temporary ileostomy (at 8-13 days) was compared with late closure (at more than 12 weeks) in a multicentre RCT (EASY) that included patients who underwent rectal resection for cancer. Inclusion of participants was made after index surgery. Exclusion criteria were signs of anastomotic leakage, diabetes mellitus, steroid treatment, and signs of postoperative complications at clinical evaluation 1-4 days after rectal resection. HRQOL was evaluated at 3, 6 and 12 months after resection using the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires QLQ-C30 and QLQ-CR29 and Short Form 36 (SF-36®). RESULTS: There were 112 patients available for analysis. Response rates of the questionnaires were 82-95 per cent, except for EORTC QLQ-C30 at 12 months, to which only 54-55 per cent of the patients responded owing to an error in questionnaire distribution. There were no clinically significant differences in any questionnaire scores between the groups at 3, 6 or 12 months. CONCLUSION: Although the randomized study found that early closure of the temporary ileostomy was associated with significantly fewer complications, this clinical advantage had no effect on the patients' HRQOL. Registration number: NCT01287637 (https://www.clinicaltrials.gov).

Nonsteroidal anti-inflammatory drugs and the risk of anastomotic leakage after anterior resection for rectal cancer.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been widely used in colorectal surgery due to their opioid-sparing effect. However, several studies have indicated an increased risk of anastomotic leakage following NSAID treatment, although conflicting results exist. The primary goal of this study was to further examine whether postoperative NSAIDs are independently associated with anastomotic leakage after anterior resection for rectal cancer. METHODS: Patients who underwent anterior resection for rectal cancer during 2007-2013 in 15 different hospitals in three healthcare regions in Sweden were included in the study. Registry data and information from patient records were retrieved. The association between NSAID treatment (for at least two days in the first postoperative week) and symptomatic anastomotic leakage (within 90 days) was evaluated with multiple logistic regression, with adjustment for pertinent confounding factors. RESULTS: Some 1495 patients were included in the study. Of these, 27% received postoperative NSAIDs for at least two days in the first postoperative week. Symptomatic anastomotic leakage occurred in 11% and 14% in the NSAID and non-NSAID group, respectively. With adjustment for confounders, the odds ratio for leakage among patients who received NSAIDs compared with those who did not was 0.88 (95% CI 0.65-1.20). No differences were seen between non-selective and COX-2-selective NSAIDs. CONCLUSION: Postoperative NSAID treatment does not seem to increase the risk of symptomatic anastomotic leakage after anterior resection for rectal cancer. NSAID use appears to be safe, but a well-powered randomized clinical trial is warranted.