Abstract Introduction A substantial share of anastomotic leakage after anterior resection for rectal cancer is diagnosed late in the postoperative period. It is often assumed that these leaks in reality occur earlier. We aimed to investigate this assumption using the systemic inflammatory response in terms of C-reactive protein (CRP) elevation. Methods This retrospective cohort study included patients who underwent anterior resection for rectal cancer at 11 centres between 2014 and 2018 with one-year follow-up concerning anastomotic leakage. Exposure was diagnosis of an early leak (≤14 days) compared to late leak (>14 days), while outcome was the maximum CRP level within the first 14 postoperative days. Linear regression modelling with adjustment for confounding was performed. Results Some 1118 patients were included. Of these, 109 (9.8%) patients had a leakage within 14 days, while 122 (10.9%) were diagnosed later. Median maximum CRP was 108.5 g/L (IQR: 61–169) in patients without leakage, compared to 270 g/L (IQR: 200–370) and 167.5 g/L (IQR: 120–237) in patients with an early and late leakage, respectively (P = 0.0001). Compared with patients without leakage, the adjusted CRP increase was 132 g/L (95% c.i.: 113–152) for early leaks and 42 g/L (95% c.i.: 24–60) for late leaks. Discussion Maximum CRP within the first two postoperative weeks was markedly higher in patients with an anastomotic leakage occurring later than 14 days, in comparison to patients without any leakage. These findings can be interpreted as corroborating the hypothesis that at least some of these later diagnosed leaks in fact were earlier leaks, not yet detected.

OBJECTIVE:Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has improved outcomes in colorectal cancer (CRC) patients with peritoneal metastases (PM), yet evidence regarding perioperative risk and long-term survival in those 75 years or older remains uncertain. The aim of this study was to evaluate whether age ≥75 years impacts on overall survival (OS) and postoperative in-hospital morbidity, according to Clavien-Dindo classification (CD), compared with patients aged <75 years. METHOD:This population-based study collected data from the National Swedish HIPEC Registry, including patients with colorectal PM operated with CRS-HIPEC. Patients were stratified by age (≤74 vs ≥75) with OS as primary outcome. Secondary outcomes were in-hospital mortality, postoperative morbidity and disease free survival (DFS). Potential variables assessed for association with OS were Complete Cytoreduction Score (CCS), Peritoneal Carcinomatosis Index (PCI) score, p/ypN stage of the primary tumor, postoperative morbidity and age. RESULTS:A total of 592 patients were operated between 2004 and 2021, of which 553 were ≤74 years and 39 were ≥75 years. OS did not differ between age groups (p = .951). Factors affecting OS negatively were high CCS (p = .004), PCI ≥21 (p = .009) and p/ypN2 (p = .041). No difference was observed in DFS (p = .525). The rate of CD grade III-IV was 27% in patients ≤74 years and 21% in patients ≥75 years (p = .495). The in-hospital mortality rate was 1.3% in patients ≤74 and none in patients ≥75 years. Reoperation rates were similar between groups. CONCLUSION:These results indicate that age above 74 should not automatically exclude patients from undergoing CRS-HIPEC. Careful selection ensures favorable survival without an increase in postoperative morbidity.

The present nationwide population-based study compared minimally invasive surgery (MIS) with open surgery (OPEN) for colorectal cancer during a period when MIS was introduced in Sweden. The primary analyses demonstrated that MIS was not inferior compared with OPEN regarding short-term outcome for patients operated 2012-2018, nor for long-term outcome assessed as overall survival with surgery performed 2010-2016. In secondary analyses employing Cox regression models, several short-term advantages for MIS were demonstrated, such as lower early mortality, shorter hospital stay and decreased reoperation rate. Regarding long-term outcome, with adjustment for potential statistical confounders, overall survival was better with MIS as compared with OPEN both for colon and rectal cancer, with a relative decrease in risk for overall 5-year mortality by 13% and 12 %, respectively. The authors conclude that MIS was introduced in a safe and well controlled manner, and suggest that MIS should be equally offered to all suitable patients across Sweden.

BACKGROUND:Anastomotic leakage is a serious complication following anterior resection for rectal cancer and may increase the risk of long-term bowel dysfunction. This study aimed to assess the long-term impact of anastomotic leakage on major low anterior resection syndrome (major LARS) at a uniform follow-up time. METHODS:We conducted a nationwide cohort study using the Swedish Colorectal Cancer Registry. Patients who underwent anterior resection for rectal cancer between 2015 and 2017 received the validated LARS questionnaire by mail 3 years after surgery. The primary outcome was major LARS among patients without a permanent stoma. Propensity score weighting was used to adjust for confounding, with covariates chosen using a directed acyclic graph. Sensitivity analyses included a dose-response analysis based on reoperation and an evaluation of a composite outcome of major LARS or permanent stoma. RESULTS:Of 1778 patients contacted, 1178 responded (66.2%). Among 1033 stoma-free patients, 52 (5.0%) had experienced a symptomatic anastomotic leak. Major LARS was reported in 69.2% and 52.9% of patients with and without leakage, respectively. Symptomatic anastomotic leakage increased the risk of major LARS (OR 2.09; 95% CI: 1.13-3.87) and this risk was higher in patients requiring reintervention (OR 2.78; 95% CI: 0.87-8.91) and when including permanent stoma in the outcome (OR 3.90; 95% CI: 2.20-6.91). CONCLUSION:Anastomotic leakage significantly increased the risk of major LARS 3 years after anterior resection for rectal cancer. These findings underscore the importance of preventing anastomotic leakage to reduce long-term functional morbidity in patients who survive rectal cancer.

BACKGROUND:Frailty is known to adversely affect post-operative mortality and morbidity following colorectal cancer resection, but its impact on long-term quality of life and functional outcomes after colon cancer surgery is less clear. This study aims to evaluate the impact of frailty at the time of diagnosis on quality of life, impact on daily activities, and contentment with treatment one year after colon cancer resection. METHOD:Data were obtained from the prospective, multicentre Quality of Life in Colon Cancer (QoLiCOL) study. Patients aged ≥70 years who underwent colon cancer surgery in Region Västra Götaland, Sweden, were collected from the QoLiCOL database (n = 347). Clinical data were retrieved from national quality registries. Frailty was retrospectively assessed by reviewing medical records using the Clinical Frailty Scale-9 (CFS-9), with scores ≥4 classified as frail. Outcomes included self-reported quality of life, treatment-related impact on activities of daily living, and treatment satisfaction one year post-operatively. Directed Acyclic Graphs (DAGs) of variables known to affect the outcome variables were made before analyses, and potential confounders were adjusted for in the final analyses. Comparisons between frail and non-frail groups were performed using ordinal logistic regression and logistic regression, with results reported as odds ratios (OR). RESULTS:The prevalence of frailty in the cohort was 29%, with a median CFS-9 value of 4 (range 4-6) in the frail group, indicating very mild to moderate frailty. No significant differences were observed between frail and non-frail older adults in self-assessed quality of life, treatment-related impact on daily activities or treatment satisfaction one year after surgery. Notably, both groups reported improved quality of life at one year compared with baseline. Only a small proportion of participants (n = 8; 2%) reported not being content with their treatment. CONCLUSION:Among older adults who were alive one year after colon cancer surgery, mild to moderate frailty does not appear to negatively influence long-term quality of life, effect on daily activities, or satisfaction with treatment. Frail and non-frail patients reported similar levels of well-being and contentment with their care one year post-operatively.

Abstract Introduction Anastomotic leakage after anterior resection for rectal cancer is a serious and common complication. Meta-analyses suggest a link between diabetes and leakage, but studies lack detail on diabetes duration and treatment. In this population-based study, we aimed to assess the impact of diabetes, as well as medication and long-term glycaemic control, on the incidence and severity of anastomotic leakage. Methods This registry-based study included patients from the Swedish Colorectal Cancer Registry who underwent anterior resection for rectal cancer between 2011–2023. Diabetes status were extracted through cross-linking with the National Diabetes Registry. Prevalent diabetes was investigated as a predictive factor. Mixed-effects logistic and ordinal regression was used, considering clustering effects and confounding from demographics, tumour characteristics, and operative approach. Results A total of 8160 patients were included, of whom 1023 (13%) had diabetes. Among the latter, 141 (14%) experienced anastomotic leakage within 30 days of surgery, compared to 696 (11%) in patients without diabetes. Diabetes was demonstrated to be predictive of any leakage, with an adjusted OR of 1.40 (95% c.i.: 1.14–1.73). Similarly, diabetes was associated with a common OR of 1.39 (95% c.i. 1.12–1.74), indicating that the odds of a shift from no leakage to leakage without reoperation or from leakage without reoperation to leakage with reoperation, was 1.39 times greater in diabetics. Discussion Prevalent diabetes is an independent risk factor of anastomotic leakage after anterior resection for rectal cancer, with a corresponding dose-response relationship for leakage severity. Further analyses are needed to define subgroups at particular risk.

Background This retrospective cohort study compared short-term outcomes between robotic-assisted and conventional laparoscopic surgery for rectal cancer using data from the Swedish Colorectal Cancer Registry. Method All patients undergoing elective minimally invasive surgery for rectal cancer between 2014 and 2021 and registered in the Swedish Colorectal Cancer Registry were assessed for eligibility, with patients who underwent robotic-assisted and laparoscopic rectal cancer resection included in the study. The primary outcome was a positive circumferential resection margin (CRM+). Secondary outcomes included conversion to open surgery, total mesorectal excision (TME) specimen quality, and 30-day overall and surgical complications. Multivariable logistic regression analyses were performed. Results Of 12 703 patients registered during the study period, 10 914 underwent abdominal resection; of these, 5874 were analysed in this study (3578 robotic-assisted; 2296 conventional laparoscopic surgery). There was no difference in CRM+ between the robotic-assisted and conventional laparoscopic surgery groups (6.5% versus 5.9%, respectively; P = 0.291). Conversion to open surgery was more frequent in the conventional laparoscopic surgery group (16.1% versus 9.1%; P < 0.001). In addition, 30-day surgical complications were more common in the robotic-assisted laparoscopic surgery group (21.5% versus 19.3%; P = 0.044), including a higher rate of anastomotic leakage (10.9% versus 7.4%; P = 0.001). In multivariable analysis, neither technique was an independent predictor of CRM+ (odds ratio (OR) 0.99; 95% confidence interval (c.i.) 0.75 to 1.30; P = 0.925). For secondary outcomes robotic-assisted laparoscopic surgery reduced the risk of conversion to open surgery (OR 0.51; 95% c.i. 0.41 to 0.63; P < 0.001), but resulted in fewer complete TME specimens (OR 0.66; 95% c.i. 0.52 to 0.83; P < 0.001). Conclusion No short-term oncological advantage in terms of radial margin positivity was demonstrated between the two techniques. Findings regarding conversion rates, TME specimen quality, and anastomotic leakage warrant further investigation.

BACKGROUND AND AIMS:To evaluate survival according to treatment strategy among nonagenarians diagnosed with colorectal cancer in Sweden. METHODS:This retrospective population-based register study used data from the Swedish Colorectal Cancer Registry. All patients aged ⩾90 years diagnosed with colorectal cancer in Sweden between 2010 and 2019 were included. Patient demographics, tumour characteristics, treatment data, and perioperative outcomes were analysed. Overall survival and relative survival were assessed. RESULTS:A total of 2055 nonagenarians with colorectal cancer were identified. The median age was 91 (range: 90-106), and 1254 (61%) were women. Overall, 1026 patients (50%) underwent bowel resection, of whom 655 (64%) had elective surgery.Among patients undergoing bowel resection, 1- and 3-year overall survival rates were 71% and 37%, respectively. Relative survival was comparable to that of the general population matched for age, sex, and calendar year. Patients who underwent elective resection had significantly longer median survival than those undergoing emergency surgery (37 vs 22 months, p < 0.001). Emergency resection was associated with higher 30- and 90-day mortality than elective resection (15% vs 4%; p < 0.001 and 26% vs 5%; p < 0.001, respectively).In multivariable Cox regression analysis restricted to patients undergoing bowel resection, male sex (hazard ratio = 1.30; standard error = 0.08; p < 0.001), emergency surgery (hazard ratio = 1.70; standard error = 0.09; p < 0.001), advanced tumour stage (hazard ratio = 1.61; standard error = 0.05; p < 0.001), and higher American Society of Anaesthesiologists score (hazard ratio = 1.35; standard error = 0.06; p < 0.001) were independently associated with an increased risk of death. CONCLUSION:Half of all nonagenarians diagnosed with colorectal cancer underwent bowel resection. Survival following resection was comparable to that expected in the age-matched general population, whereas emergency surgery was associated with substantially higher short-term mortality and poorer long-term survival.

BACKGROUND:Anastomotic leakage after anterior resection for rectal cancer is associated with long-term morbidity, such as bowel dysfunction, but its impact on health-related quality of life remains insufficiently studied. The aim of this study was to evaluate the association between anastomotic leakage and health-related quality of life 3 years after surgery. METHODS:In this population-based prospective cohort study, patients who underwent anterior resection for rectal cancer in Sweden between 2015 and 2017 were identified through the Swedish Colorectal Cancer Registry. Health-related quality of life was assessed 3 years after surgery using the EORTC QLQ-C30 and QLQ-CR29 questionnaires. The primary outcome was the QLQ-C30 summary score. Targeted maximum likelihood estimation was applied to estimate the adjusted effect of anastomotic leakage on health-related quality of life. RESULTS:Of 1778 eligible patients, 1178 (66.3%) responded, including 104 (8.8%) with anastomotic leakage. Patients with anastomotic leakage reported a lower mean QLQ-C30 summary score compared to those without anastomotic leakage (80 vs 86, p < 0.001). After adjustment for confounders, anastomotic leakage was associated with a 4-point difference in summary score (p < 0.01). Patients with anastomotic leakage also reported worse body image. Compared with patients without anastomotic leakage, those with anastomotic leakage and no stoma reported more perianal skin irritation, while those with a stoma more frequently reported stool leakage from the stoma bag. CONCLUSIONS:Anastomotic leakage after anterior resection is associated with a small negative effect on overall health-related quality of life 3 years after surgery. Nevertheless, specific functional impairments-particularly related to body image, and stoma- or perianal symptoms-persist and warrant attention. These findings highlight the importance of patient counseling and long-term follow-up after anastomotic leakage.

Abstract Introduction Organ preserving strategies in the management of rectal cancer are emerging. Neoadjuvant treatment can induce a clinical complete response (cCR), enabling an opportunistic watch-and-wait approach. The Watch-and-Wait (WoW) study, a national prospective observational study of patients with cCR after neoadjuvant treatment, was initiated in Sweden in 2017.The primary endpoint was three-year disease-free survival (DFS). Secondary endpoints included regrowth rate, distant metastasis (DM) rate and outcomes after salvage surgery for regrowth. Methods Patients with rectal adenocarcinoma who obtained cCR after neoadjuvant treatment were included in a structured watch-and-wait program, with prespecified follow-up intervals to detect regrowth or DM. Inclusion and follow-up were performed at eight dedicated centers. Neoadjuvant therapy was according to national guidelines. Patients with regrowth were advised resection surgery. Results A total of 211 patients with cCR were included between January 2017 and February 2023. Three-year DFS was 91% (191/211) and regrowth rate was 27% (57/211). Fifty-five out of 57 (96%) patients with regrowth underwent salvage surgery with R0 rate of 96% (53/55). Distant metastases occurred in 13/211 (6%) patients overall; 4/150 (3%) among those with sustained cCR and 9/57 (16%) among patients who developed regrowth. Discussion Patients with a cCR following neoadjuvant treatment for rectal cancer had an excellent three-year DFS after an opportunistic watch-and-wait approach. Regrowth rates were similar to previous studies, and successful salvage surgery was performed in nearly all patients. The study supports the safe adoption of opportunistic watch-and-wait for selected patients in a centralized Swedish setting.

AIM:To investigate postoperative inflammatory response as assessed by C-reactive protein (CRP) levels in patients undergoing anterior resection (AR) for rectal cancer by minimally invasive surgery (MIS). METHOD:All patients diagnosed with rectal cancer between 2011 and 2021 undergoing AR by MIS without conversion at one university hospital were included. Open surgery was not included. Patient data were obtained from the Swedish Colorectal Cancer registry and from local patient charts, including CRP levels preoperatively and postoperative day (POD) 1-5. RESULTS:A total of 123 patients were identified with rectal cancer, of which the proportion of laparoscopic surgery (LAP) was 31% (n = 38) and robotic assisted rectal cancer surgery (ROBOT) 69% (n = 85). The proportion of women was 37%, median age 69, median body mass index 26, 25% had ASA class ≥3, 27% had neoadjuvant radiotherapy, 12% had neoadjuvant radiotherapy combined with chemotherapy, and 59% had a planned defunctioning stoma. No complications were noted in 44.7% of LAP and in 51.8% of ROBOT. Complications defined as Clavien-Dindo grade ≥IIIb were 10.5% in LAP and 9.4% in ROBOT. Hospital stay was a median 9.5 days in LAP and 10 in ROBOT. The median CRP values in LAP and ROBOT preoperatively were 3 and 4 (P = .845), on POD 1: 100 and 110 (P = .865); POD 2: 218 and 145 (P = .159); POD 3: 181 and 141 (P = .097); POD 4: 128 and 95 (P = .502), and on POD 5: 73 and 71 (P = .785), respectively. CONCLUSION:Postoperative inflammatory response as assessed by postoperative CRP values was not statistically different between LAP and ROBOT. CRP levels on POD 2-4 were numerically lower in ROBOT. The clinical relevance of this finding warrants further investigation.

AIM:Accumulated data suggest that routine use of defunctioning stoma in low anterior resection for rectal cancer may cause kidney injury, bowel dysfunction and a higher risk of permanent stomas. We aim to study whether avoidance of a diverting stoma in selected patients is safe and reduces adverse consequences. METHODS:SELSA is a multicentre international prospective observational study nesting an open-label randomized clinical trial. All patients with primary rectal cancer planned for low anterior resection are eligible. Patients operated with curative intent, aged <80 years, with an American Society of Anaesthesiologists' fitness grade I or II, and a low predicted risk of anastomotic leakage are eligible to 1:1 randomization between no defunctioning stoma (experimental arm) or a defunctioning stoma (control arm). The primary outcome is the composite measure of 2-year stoma-free survival without major low anterior resection syndrome (LARS). Secondary outcomes include anastomotic leakage, postoperative mortality, reinterventions, stoma-related complications, quality of life measures, LARS score, and permanent stoma rate. To be able to state superiority of any study arm regarding the main outcome, with 90% statistical power and assuming 25% attrition, we aim to enrol 212 patients. Patient inclusion will commence in the autumn of 2024. CONCLUSION:The SELSA study is investigating a tailored approach to defunctioning stoma use in low anterior resection for rectal cancer in relation to the risk of anastomotic leakage. Our hypothesis is that long-term effects will favour the selective approach, enabling some patients to avoid a defunctioning stoma. TRIAL REGISTRATION:Swedish Ethical Review Authority approval (2023-04347-01, 2024-02418-02 and 2024-03622-02), Regional Ethics Committee Denmark (H-24014463), and ClinicalTrials.gov (NCT06214988).

AIM:To investigate short- and long-term kidney injury incidence in patients undergoing low anterior resection for rectal cancer, comparing those with and without a defunctioning ileostomy. METHOD:We identified all Swedish rectal cancer patients ≤80 years old, with ASA fitness grade ≤III and tumour height ≤12 cm from the anal verge, who underwent anterior resection between 2007 and 2021 using CRCBaSe, a nationwide registry linkage. Patients who received a defunctioning ileostomy during surgery were compared with those who did not. Outcomes included chronic kidney failure, chronic kidney disease, acute kidney injury, and dehydration. Cox proportional hazards models were fitted for each outcome, using overlap weights derived from propensity scores for receiving a defunctioning ileostomy. Stoma reversal impact and mediation by anastomotic leakage were also examined. RESULTS:Among 5286 patients, 4623 (87%) received a defunctioning ileostomy and 663 (13%) did not. A defunctioning ileostomy was not significantly associated with chronic kidney failure (HR 1.68, 95% CI: 0.19-15.16) or chronic kidney disease (HR 1.65, 95% CI: 0.91-2.98) but increased risks of acute kidney injury (HR 3.01, 95% CI: 1.61-5.64) and dehydration (HR 4.02, 95% CI: 2.33-6.94). Risks declined after stoma reversal. Stomas reduced anastomotic leakage with negligible mediation effects on short-term kidney damage. CONCLUSION:A defunctioning ileostomy after low anterior resection increases the risks of acute kidney injury and dehydration but not chronic kidney failure or chronic kidney disease. These risks decrease following stoma reversal, highlighting the need for careful perioperative management.

Rutegård, Martin M.D., Ph.D.; Segelman, Josefin M.D., Ph.D.; Matthiessen, Peter M.D., Ph.D.; Lydrup, Marie-Louise M.D., Ph.D.; Park, Jennifer M.D., Ph.D. Author Information

Treatment for rectal cancer is associated with urinary and sexual dysfunction. Few studies describe urinary and sexual function after neoadjuvant (chemo)radiotherapy and a watch and wait (WoW) approach. This study aimed to evaluate the prevalence and change over time in patient-reported urinary and sexual dysfunction in patients within the Swedish watch and wait study. The Swedish Watch and Wait (WoW) study is a multicenter prospective cohort study including patients with clinical complete response (cCR) after (chemo)radiotherapy for rectal cancer. A total of 211 patients with cCR (stage I-III rectal cancer) were included between January 2017 and February 2023. Questionnaires were collected at baseline, 6 months, 1 year, and 2 years post-treatment. Questionnaire data were available for 173 patients at baseline and 136 at two years. The median age was 66 years (60% male). Neoadjuvant treatment was given as short-course radiotherapy (SCRT) (27.5%), SCRT combined with chemotherapy (66.5%), long-course chemoradiotherapy (4.9%) and other treatments (1.1%). Urinary incontinence during daytime increased from 9,2 % at baseline to 14,7% two years after treatment. Erectile dysfunction was stable: 24,0 % at baseline and 23,5 % at two years follow-up. In women, sexual function including arousal, lubrication and orgasm decreased during follow-up. Urinary and sexual dysfunction is seen in patients treated with neoadjuvant therapy without subsequent surgery. Urinary incontinence slightly increased during follow-up. Female sexual function decreased, whereas erectile dysfunction remained stable during follow-up. The results are encouraging but also indicate that dysfunction is present, albeit to a lesser extent than if surgery is part of the treatment.

Aim The selective use of defunctioning stomas in anterior resection for rectal cancer hinges on accurately predicting anastomotic leakage. The aim of this study was to develop a prediction model for use in a prospective randomized clinical trial. Method Colorectal Cancer Database (CRCBaSe) Sweden was used to identify patients who underwent low anterior resection for rectal cancer 2007-2021. Eligibility criteria mirrored the forthcoming SELective defunctioning Stoma Approach in low anterior resection for rectal cancer (SELSA) trial, including patients <80 years of age and with American Society of Anaesthesiologists' (ASA) physical status grade of 30 kg/m(2) (OR 1.82; 95% CI: 1.21-2.74), and radiotherapy (OR 1.90; 95% CI: 1.35-2.69). The bootstrapped area under the curve (AUC) was 0.64 (95% CI: 0.62-0.65), with a negative predictive value of 94.6% (95% CI: 93.7%-95.6%). For the validation cohort, the corresponding estimates were 0.66 (95% CI: 0.59-0.74) and 89.5% (95% CI: 86.2%-92.5%). Conclusion Accuracy of anastomotic leakage prediction using registry-based data is moderate; however, the model's ability to rule out a >10% risk is considered appropriate for trial use.

Defunctioning stoma (DS) has been suggested to mitigate the consequences of anastomotic leak (AL) after low anterior resection. Stoma reversal (SR) is commonly delayed for nonmedical reasons in many healthcare systems. This study investigated the impact of the elapsed time from AR to SR on postoperative 90-day complications. The secondary aim was to explore the independent factors associated with a delayed SR. This multicenter retrospective cohort study included rectal cancer patients who underwent anterior resection (AR) and DS between 2014 and 2018. Multivariable logistic regression was used to evaluate the influence of the elapsed time from AR to SR on postoperative complications within 90 days. Out of 905 patients subjected to AR with DS, 116 (18

AIM:This study aimed to estimate the impact of socioeconomic status on the probability of receiving open (OPEN) or minimally invasive surgery (MIS) for curative abdominal rectal cancer resection. METHODS:All patients diagnosed with rectal cancer clinical Stage I-III during the period 2010-2021 who underwent curative abdominal resection surgery, MIS or OPEN, were included. Patients were identified in the Colorectal Cancer Database, a register-linkage based on the Swedish Colorectal Cancer Register and linked to several national Swedish health-related and demographic registers. Socioeconomic factors, sex, patient and tumour characteristics, number of previous surgical procedures and category of hospital were collected. Exposures were level of education (categorized as 6-9, 10-12, >12 years), household income (quartiles 1-4) and country of birth (Sweden, Nordic countries outside Sweden, Europe outside the Nordic countries, outside Europe), and outcome was MIS or OPEN. Multivariable logistic regression models were fitted for each exposure, adjusted for age, sex, cT and cN, level of tumour, and number of previous abdominal surgical procedures. RESULTS:A total of 13 778 patients were included of whom 43.6% underwent MIS (n = 6007) and 56.4% OPEN (n = 7771). Highest level of education (OR for highest vs. lowest level of education 1.15; 95% CI 1.03-1.29) and highest household income quartile (OR for highest vs. lowest household income quartile 1.27; 95% CI 1.12-1.44) increased the likelihood of receiving MIS. CONCLUSION:Despite the tax-financed healthcare system in Sweden, rectal cancer patients with the highest level of education and the highest household income had an increased probability of receiving MIS.

Rectal cancer has historically been treated with resection surgery. (Chemo)radiotherapy results in a clinical complete response (cCR) in some patients, which enables a nonoperative management; “watch and wait”. Low Anterior Resection Syndrome (LARS) is a consequence after sphincter-preserving surgery, however similar symptoms can occur after treatment with (chemo)radiotherapy. The aim of this study was to report the prevalence of LARS in Swedish patients treated as watch and wait within a research protocol and to identify trends over time. The WoW study is a multicenter prospective national cohort study including patients with cCR after (chemo)radiotherapy for rectal cancer. The study population consists of 211 patients with stage I-III rectal cancer and cCR included between January 2017 and February 2023. LARS-score was analyzed at baseline, six months and one year. Demography and clinical characteristics are presented in the table. Questionnaires were available for 182 patients in total. LARS-score was possible to analyze for 170 patients at baseline, 136 at six months and 118 at one year, patients reporting a stoma were excluded. Major LARS was reported by 41 (24%) patients at baseline, 35 (26%) at 6 months and 26 (22%) at 12 months. One of four patients in this WoW-cohort reported major LARS and it is persistent after one year. Long-term follow-up is required to see if symptoms change over time to understand the functional outcome of the treatment offered to be able to provide adequate information about possible long-lasting life changes due to treatment.

BACKGROUND:Postoperative death measured 30 days after surgery is a conventional quality metric, whereas intervals up to 90 days are increasingly used, although data-driven time windows have scarcely been investigated. METHODS:The Swedish Colorectal Cancer Registry was used to identify all patients subjected resection for colorectal cancer between 2007 and 2020. All patients were followed up until 180 days after surgery. A join-point statistical hazard model was used to model a declining hazard to a transition point, followed by a stable death rate. This method was subsequently applied to describe postoperative deaths for the entire cohort and subgroups according to tumour location (colon and rectum). RESULTS:Some 56 096 patients electively operated on for colorectal cancer during the study interval were included, with a 30-day and 90-day fatality of 805 (1.43%) and 1458 (2.60%) patients respectively. The derived postoperative fatality window, after which the death rate transitioned to a stable rate, was 23.8 (95% c.i. 21.5 to 28.2) days after surgery. There was no significant difference in the time window between rectal cancer (22.9 days; 95% c.i. 15.1 to 28.4) and colon cancer (27.3 days; 95% c.i. 21.4 to 31.8) patients (P = 0.455). However, postoperative fatality time windows were extended in patients aged at least 80 years and with American Society of Anesthesiologists' grade III or IV. CONCLUSION:The traditional postoperative time window of 30 days was confirmed to be an appropriate metric in elective colorectal cancer surgery when evaluated with a hazards-based statistical framework. Importantly, this time window is influenced by older age and advanced co-morbidity, which could prompt increased vigilance for these patient groups.