Management of patients with rectal prolapse: the 2017 Dutch guidelines

Background

Rectal prolapse—both external rectal prolapse and internal rectal prolapse—is a disabling condition. In view of the overwhelming number of surgical procedures described for the treatment of rectal prolapse, a comprehensive update concerning the diagnostic and therapeutic pathway for this condition is required to draw recommendations for clinical practice. This initiative was commissioned by the Dutch Association for Surgery (Nederlandse Vereniging voor Heelkunde) as a multidisciplinary collaboration.

Methods

Nine questions outlining the diagnostic approach, conservative and surgical management of rectal prolapse were selected. A systematic literature search for evidence was then conducted in the Medline and Embase databases.

Results

Recommendations included diagnostic approach, methods to assess complaints of fecal incontinence and/or obstructive defecation and treatment options, both conservative and surgical. A level of evidence was assigned to each statement following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system.

Conclusions

These guidelines for clinical practice are useful in the diagnosis and treatment of rectal prolapse. There are many statements requiring a higher level of evidence due to a lack of studies.

     

Surgical management of rectal prolapse

Purpose

Rectal prolapse is uncommon; however, the true incidence is unknown because of underreporting, especially in the elderly population. Full-thickness rectal prolapse, mucosal prolapse and internal prolapse are three different clinical entities, which are often combined and constitute rectal prolapse. The aim of the study is to present our experience in the surgical management of rectal prolapse.

Methods

In a 6-year period (2004–2010), 27 patients were surgically treated for rectal prolapse. The majority of patients were women (25 women, two men) and their mean age was 72.36 years. The operations performed were two Delorme’s procedures, five STARR (Stapled TransAnal Rectal Resection), 14 Wells procedures, two Wells combined with Thiersch, one Altemeier, one sigmoid resection combined with Wells and two Thiersch.

Results

An emergency sigmoidostomy was performed on a patient after Wells operation due to obstructive ileus. One death occurred on the 5th postoperative day due to pulmonary embolism. Two recurrences observed 8 months postoperatively, one in a patient after STARR operation and one in a patient after Thiersch technique. The great majority of patients are completely relieved of symptoms.

Conclusions

The application of different modalities in the treatment of rectal prolapse is attributed to the fact that cause, degree of prolapse and symptoms, vary from one patient to another. Successful approach depends on many factors, including the status of a patient’s anal sphincter muscle before surgery, whether the prolapse is internal or external and the overall condition of the patient.

     

Stapled transanal longitudinal posterior proctectomy (STALPP) in total rectal prolapse: a 7-year experience

Background

Surgical management of complete rectal prolapse is challenging. We present our results with the novel technique stapled transanal longitudinal posterior proctectomy (STALPP) in patients with complete rectal prolapse.

Methods

We performed a retrospective study in two hospitals from January 2005 to December 2012. Twenty-one patients with complete rectal prolapse were included. In all patients, STALPP was performed. The study variables were operative time, intraoperative bleeding, number of cartridges used, length of rectum prolapsed through the anus, length of rectal wall resected, length of hospital stay and preoperative and postoperative Wexner continence score and manometric measurement of anal canal resting tone and squeeze pressure.

Results

The median length of prolapsed tissue was 13 cm; the mean Wexner score in the preoperative and postoperative period was 15.95 and 4.95, respectively (p = 0.025). The mean resting tone improved from 23.3 to 32.85 mmHg postoperatively (p = 0.03), as did maximal squeeze pressure from 31 to 62.7 mmHg (p = 0.003). Median operative time was 65 min; median intraoperative bleeding was 12 ml; there was no postoperative bleeding, and no reinterventions were required. The median number of cartridges used was 4. The median length of resected wall in the right posterolateral sector was 8 and 6 cm in the left. The median length of hospital stay was 4 days, and the mean follow-up period was 2 years. No mortality was reported.

Conclusions

Stapled transanal longitudinal posterior proctectomy is a safe and feasible surgical alternative for patients with complete rectal prolapse.

     

Anastomotic leakage following low anterior resection for rectal cancer

Aim

Aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication.

Patients and methods

Between 1990 and 2009, 170 patients underwent low anterior resection with total mesorectal excision (TME).

Results

A total of 14 (8.2%) anastomotic leaks were confirmed. Reoperation was carried out in six patients with major leaks. Eight patients with minor leaks were treated conservatively by nutritional support and antibiotic therapy.

Conclusion

The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low.

     

Robotic ventral mesh rectopexy for rectal prolapse: a single-institution experience

Background

Robotic ventral mesh rectopexy (RVMR) is an appealing approach for the treatment of rectal prolapse and other conditions. The aim of this study was to evaluate the outcomes of RVMR for rectal prolapse.

Methods

We performed a retrospective chart review for patients who underwent RVMR for rectal prolapse at our institution between July 2012 and May 2016. Any patient who underwent RVMR during this time frame was included in our analysis. Any cases involving colorectal resection or other rectopexy techniques were excluded.

Results

Of the 24 patients who underwent RVMR, 95.8% of patients were female. Median age was 67.5 years old (IQR 51.5–73.3), and 79.2% of patients were American Society of Anesthesiologists class III or IV. Median operative time was 191 min (IQR 164.3–242.5), and median length of stay was 3 days (IQR 2–3). There were no conversions, RVMR-related complications or mortality. Patients were followed for a median of 3.8 (IQR 1.2–15.9) months. Full-thickness recurrence occurred in 3 (12.4%) patients. Rates of fecal incontinence improved after surgery (62.5 vs. 41.5%, respectively) as did constipation (45.8 vs. 33.3%, respectively). No patients reported worsening symptoms postoperatively. Only one (4.2%) patient reported de novo constipation postoperatively.

Conclusions

RVMR is a feasible, safe and effective option for the treatment of rectal prolapse, with low short-term morbidity and mortality. Multicenter and long-term studies are needed to better assess the benefits of this procedure.

     

Perineal Stapled Prolapse Resection: A New Procedure for External Rectal Prolapse

Purpose

A perineal approach to treating rectal prolapse is ideal for frail patients. Recently, internal rectal redundancy has been successfully treated with transanal resection using the Contour® Transtar? stapler. This technique has been modified to the perineal stapled prolapse resection. The surgical technique and the preliminary results of the new procedure for external rectal prolapse are presented.

Methods

Patients not suited for transabdominal treatment were included prospectively for perineal stapled prolapse resection in two colorectal centers. Feasibility, complications, and reinterventions were assessed.

Results

In 14 of 15 patients, perineal stapled prolapse resection was performed without complications in a median operating time of 33 (range, 22–52) minutes. One procedure was changed to an Altemeier because of a staple line disruption. Two patients required reintervention as a result of postoperative hemorrhage. No other severe complications occurred. At follow-up, all patients were well and showed no early recurrence of prolapse.

Conclusions

Perineal stapled prolapse resection is a new surgical procedure for external rectal prolapse, which is easy and quick to perform. Functional results and long-term recurrence rate must be investigated further.

     

Should we offer ventral rectopexy to patients with recurrent external rectal prolapse?

Background

For patients with rectal prolapse undergoing Ventral Rectopexy (VR), the impact of prior prolapse surgery on prolapse recurrence is not well described.

Purpose

The purpose of this study was to compare recurrence rates after VR in patients undergoing primary and repeat rectal prolapse repairs.

Design

This study is a prospective cohort study.

Methods

IRB-approved prospective data registry of consecutive patients undergoing VR for full-thickness external rectal prolapse between 2009 and 2015.

Main outcome measures

Rectal prolapse recurrence was defined as either external prolapse through the anal sphincters or symptomatic rectal mucosa prolapse warranting additional surgery. Preoperative and postoperative morbidity and functional outcomes were analyzed. Actuarial recurrence rates were calculated using the Kaplan-Meier method.

Results

A total of 108 VRs were performed during the study period. Seventy-two were primary and 36 repeat repairs. Seven cases were open, 23 laparoscopic, and 78 robotic. Six cases were converted from laparoscopic/robotic to open. In 63 patients, VR was combined with gynecological procedures. There were no statistical differences between primary or recurrent prolapse for the following: demographics, operative time, concomitant gynecologic procedures, complications, blood loss, and graft material type. Length of stay was longer in patients with a history of prior prolapse surgery (p = 0.01). Prolapse recurrence rates for primary repairs were reported at 1.4, 6.9, and 9.7% and for recurrent prolapse procedures 13.9, 25, and 25% at 1, 3, and 5 years (p = 0.13). Mean length of follow-up was similar between groups. Time to recurrence was significantly shorter in patients undergoing repeat prolapse surgery 8.8 vs 30.7 months (p = 0.03).

Conclusions

VR is a better option for patients undergoing primary rectal prolapse repair.

     

Robot-guided neuromapping during nerve-sparing taTME for low rectal cancer

Purpose

Intraoperative pelvic neuromapping with electrophysiological evaluation of autonomic nerve preservation during robotic total mesorectal excision (TME) for rectal cancer is conventionally performed by the bedside assistant with a hand-guided probe. Our goal was to return autonomy over the neuromonitoring process to the colorectal surgeon operating the robotic console.

Methods

A recently described prototype microfork electrostimulation probe was evaluated intraoperatively during abdominal robotic-assisted transanal TME (taTME) surgery for low rectal cancer in three consecutive male patients.

Results

An intraoperative video demonstrates the good control and maneuverability of the prototype probe with electrophysiological confirmation of bilateral pelvic autonomic nerve preservation.

Conclusions

This study presents the first in situ application of a new microfork probe for fully robot-guided neuromapping in three patients undergoing TME surgery for low rectal cancer.

     

Rectal axis and enterocele on proctogram may predict laparoscopic ventral mesh rectopexy outcomes for rectal intussusception

Background

Laparoscopic ventral mesh rectopexy (LVMR) has become a well-established treatment for symptomatic high-grade internal rectal prolapse. The aim of this study was to identify proctographic criteria predictive of a successful outcome.

Methods

One hundred and twenty consecutive patients were evaluated from a prospectively maintained pelvic floor database. Pre- and post-operative functional results were assessed with the Wexner constipation score (WCS) and Fecal Incontinence Severity Index (FISI). Proctogram criteria were analyzed against functional results. These included grade of intussusception, presence of enterocele, rectocele, excessive perineal descent and the orientation of the rectal axis at rest (vertical vs. horizontal).

Results

Ninety-one patients completed both pre- and post-operative follow-up questionnaires. Median pre-operative WCS was 14 (range 10–17), and median FISI was 20 (range 0–61), with 28 patients (31%) having a FISI above 30. The presence of an enterocele was associated with more frequent complete resolution of obstructed defecation (70 vs. 52%, p = 0.02) and fecal incontinence symptoms (71 vs. 38%, p = 0.01) after LVMR. Patients with a more horizontal rectum at rest pre-operatively had significantly less resolution of symptoms post-operatively (p = 0.03).

Conclusions

These data show that proctographic findings can help predict functional outcomes after LVMR. Presence of an enterocele and a vertical axis of the rectum at rest may be associated with a better resolution of symptoms.

     

One decade of rectal prolapse surgery: a national study

Purpose

We aimed to investigate the development of common procedures used as treatment for rectal prolapse over a decade and to determine if the choice of primary operation affects the reoperation rate.

Methods

This is a retrospective analysis of operative data from a National Data Registry, Landspatientregisteret (LPR), from the period of January 1, 2004 to December 31, 2014. All hospitalized surgical treatments are registered in LPR.

Results

Sixteen hundred and twenty-five patients with rectal prolapse underwent 1834 operations. There were 94% women and mean age at surgery was 71.6 ± 18.1 years, with no difference over the 11 years. The types of operations performed differed (p?<?0.0001), with an increase in overall number of operations and increasing use of laparoscopic procedures. There were 209 reoperations, of which 129 patients were primarily operated with a perineal procedure. The mean age at reoperation was 72.8 ± 17.3 years. The most frequently used reoperation was laparoscopic rectopexy. The overall reoperation rate was 16%: 10% for both open and laparoscopic rectopexy, and for perineal procedures 26% (p?<?0.001). The overall 30-day mortality was 2.1% and there was no difference in mortality between the procedures (p?=?0.23).

Conclusions

The overall number of rectal prolapse operations was increasing. There was a clear trend towards extended use of laparoscopic rectopexy both as primary procedure and as reoperation. The highest reoperation rates were for the perineal procedures.

     

Trends in the treatment of rectal prolapse: a population analysis

Purpose

Rectal prolapse is a common condition, with conflicting opinions on optimal surgical management. Existing literature is predominantly composed of case series, with a dearth of evidence demonstrating current, real-world practice. This study investigated recent national trends in management of rectal prolapse in the Republic of Ireland (ROI).

Methods

This population analysis used a national database to identify patients admitted in the ROI primarily for the management of rectal prolapse, as defined by the International Classification of Diseases, 10th Revision (ICD-10). Demographics, procedures, comorbidities, and outcomes were obtained for patients admitted from 2005 to 2015 inclusive.

Results

There were 2648 admissions with a primary diagnosis of rectal prolapse; 39.3% underwent surgical correction. The majority were treated with either a perineal resection (47.2%) or an abdominal rectopexy ± resection (45.1%). The population-adjusted rate of operative intervention increased over the study period, from 25 to 42 per million (p?<?0.001), with no change in the mean age of patients over time (p?=?0.229). The application of a laparoscopic approach increased over time (p?=?0.001). Patients undergoing an abdominal rectopexy were younger than those undergoing a perineal procedure (64.1?±?17.3 versus 75.2?±?15.5 years, p?<?0.001) despite having a similar Charlson Comorbidity Index (p?=?0.097). The mortality rate for elective repair was 0.2%.

Conclusions

Despite the popularization of ventral mesh rectopexy over the study period, perineal resection Delorme’s procedure remains the most common procedure employed for the correction of rectal prolapse in the ROI, with specific approach determined by age.

     

Magnetic resonance imaging (MRI)-based indication for neoadjuvant treatment of rectal carcinoma and the surrogate endpoint CRM status

Aim

Is it possible to reduce the frequency of neoadjuvant therapy for rectal carcinoma and nevertheless achieve a rate of more than 90% circumferential resection margin (CRM)-negative resection specimens by a novel concept of magnetic resonance imaging (MRI)-based therapy planning?

Materials and methods

One hundred eighty-one patients from Berlin and Mainz, Germany, with primary rectal carcinoma, without distant metastasis, underwent radical surgery with curative intention. Surgical procedures applied were anterior resection with total mesorectal excision (TME) or partial mesorectal excision (PME; PME for tumours of the upper rectum) or abdominoperineal excision with TME.

Results

With MRI selection of the highest-risk cases, neoadjuvant therapy was given to only 62 of 181 (34.3%). The rate of CRM-negative resection specimens on histology was 170 of 181 (93.9%) for all patients, and in Berlin, only 1 of 93 (1%) specimens was CRM-positive. Patients selected for primary surgery had CRM-negative specimens on histology in 114 of 119 (95.8%). Those selected for neoadjuvant therapy had a lower rate of clear margin: 56 of 62 (90%).

Conclusion

By applying a MRI-based indication, the frequency of neoadjuvant treatment with its acute and late adverse effects can be reduced to 30–35% without reduction of pathologically CRM-negative resection specimens and, thus, without the danger of worsening the oncological long-term results. This concept should be confirmed in prospective multicentre observation studies with quality assurance of MRI, surgery and pathology.

     

Laparoscopic versus open surgery for rectal cancer: a meta-analysis of 3-year follow-up outcomes

purpose

We wished to evaluate the effectiveness of laparoscopic and open surgery for patients with rectum cancer through a meta-analysis.

Methods

We searched PubMed, EMBASE, and Cochrane database until June 30, 2015, to identify eligible studies. Randomized controlled trials comparing laparoscopic with open surgery for rectum cancer were included. Meta-analysis was performed using the search strategy following the requirement of the Cochrane Library Handbook. Three-year overall survival (OS) and disease-free survival (DFS) were the main endpoints.

Results

Eight randomized controlled trials comprising 3145 patients matched the selection criteria. Meta-analysis showed no significant difference between laparoscopic and open surgery in 3-year overall survival (OS) and disease-free survival (DFS) (hazard ratio (HR)_{3-year OS} = 0.83, 95 % CI [0.68–1.01]; P = 0.06; HR_{3-year DFS} = 0.89, 95 % CI [0.75,1.05]; P = 0.16). No evidence of publication bias was observed.

Conclusion

Our meta-analysis supported the notion that based on the 3-year DFS and OS, oncological outcomes are comparable after laparoscopic and open surgery for rectal cancer.

     

Laparoscopic ventral rectopexy in male patients with external rectal prolapse is associated with a high reoperation rate

Background

Laparoscopic ventral rectopexy has been used to treat male patients with external rectal prolapse, but evidence to support this approach is scarce. The aim of this study was to evaluate the results of this new abdominal rectopexy surgical technique in men.

Methods

This was a retrospective multicenter study. Adult male patients who were operated on for external rectal prolapse using ventral rectopexy in five tertiary hospitals in Finland between 2006 and 2014 were included in the study. Patient demographics, detailed operative, postoperative and short-term follow-up data were collected from patient registers in participating hospitals. A questionnaire and informed consent form was sent to all patients. The questionnaire included scores for anal incontinence, obstructed defecation syndrome, urinary symptoms and sexual dysfunction. The main outcome measure was the incidence of recurrent rectal prolapse. Surgical morbidity, the need for surgical repair due to recurrent symptoms and functional outcomes were secondary outcome measures.

Results

A total of 52 adult male patients with symptoms caused by external rectal prolapse underwent ventral rectopexy. The questionnaire response rate was 64.4 %. Baseline clinical characteristics and perioperative results were similar in the responder and non-responder groups. A total of 9 (17.3 %) patients faced complications. There were two (3.8 %) serious surgical complications during the 30-day period after surgery that necessitated reoperation. None of the complications were mesh related. Recurrence of the prolapse was noticed in nine patients (17 %), and postoperative mucosal anal prolapse symptoms persisted in 11 patients (21 %). As a result, the reoperation rate was high. Altogether, 17 patients (33 %) underwent reoperation during the follow-up period due to postoperative complications or recurrent rectal or mucosal prolapse. According to the postoperative questionnaire data, patients under 40 had good functional results in terms of anal continence, defecation, urinary functions and sexual activity.

Conclusions

Laparoscopic ventral rectopexy is a safe surgical procedure in male patients with external prolapse. However, a high overall reoperation rate was noticed due to recurrent rectal and residual mucosal prolapse. This suggests that the ventral rectopexy technique should be modified or combined with other abdominal or perineal methods when treating male rectal prolapse patients.

     

A mucinous cystadenoma in rectal cuff of a patient with familial adenomatous polyposis

Introduction

Familial adenomatous polyposis (FAP) may be associated with some extracolonic manifestations which in this vein, it is known as Gardner’s syndrome. To our knowledge, so far, there is no report of mucinous cystadenoma in association with FAP.

Case presentation

We report a 31-year-old woman with FAP who underwent total proctocolectomy with ileal pouch-anal anastomosis 5 years earlier. During endoscopic surveillance, she was found to have a submucosal lesion in rectal cuff.

Results

Endoscopic ultrasound (EUS) revealed a round submucosal anechoic lesion measuring about 3 cm originating from the second layer of the rectal cuff. Surgical resection was performed and a cystic tumor was removed. Histologic examination was consistent with mucinous cystadenoma.

Conclusion

FAP can be associated with mucinous cystadenoma.

     

Phantom rectal sensations following abdominoperineal excision of the rectum (APER) and vertical rectus abdominis myocutaneous (VRAM) flap perineal reconstruction

Aim

Phantom rectum is the sensation of an intact and/or functioning rectum, despite excision at surgery. Abdominoperineal excision of the rectum (APER) may be complemented by reconstructive operations and recently it was reported that patients undergoing APER and vertical rectus abdominis myocutaneous (VRAM) flap reconstruction are more prone to develop phantom sensations at an earlier timeframe and have more persistent symptoms than those who do not have perineal repairs. The aim of this study was to determine the prevalence of phantom rectal sensations in a cohort of these patients.

Method

Patients who underwent APER and VRAM flap reconstruction for anorectal carcinomas were identified from May 2008 to July 2012. Patients completed a questionnaire evaluating their experience of rectal symptoms post-surgery.

Results

Thirty-four of 47 eligible patients were enrolled in the study. PR sensations were experienced by 50 % of patients, the majority of which (65 %) were present for >1 year. The commonest sensation reported was the feeling of faeces in a normal rectum (24 %). Disturbances in quality of life were apparent in 44 %; notably, sleep was affected, patients expressed increased feelings of stress/sadness, heightened levels of anxiety and limitation of daily activities as consequences of PR symptoms. Few patients sought medical advice.

Conclusion

Fifty percent of patients experience PR sensations post-surgery, comparable with reported data for patients who have undergone APER alone. The addition of VRAM reconstruction does not significantly alter the prevalence of PR symptoms. This paper provides further evidence that phantom rectum occurs frequently and thus all patients undergoing excision of the rectum should be counselled appropriately.

     

Self-reported wellbeing and body image after abdominoperineal excision for rectal cancer

Purpose

Patients with low rectal cancer are often operated with an abdominoperineal excision (APE) rendering them a permanent stoma. The surgical procedure itself, the cancer diagnosis, and the permanent stoma might all affect quality of life. The aim of this study was to explore wellbeing and body image 3 years after APE in a population-based cohort of patients.

Methods

All patients with rectal cancer operated with an APE between 2007 and 2009 were identified using the Swedish ColoRectal Cancer Registry. A total of 545 patients answered a questionnaire 3 years after surgery. Two open-ended questions were analyzed with a mixed method design using both qualitative and quantitative content analysis. Main themes and sub-themes on wellbeing and body image were identified.

Results

Three main themes were identified: bodily limitations, mental suffering, and acceptance. Bodily limitations included other symptoms than stoma-related problems. A majority of patients expressed acceptance to their situation regardless of bodily limitations and mental suffering. However, 18 % did not describe any acceptance of their current situation.

Conclusions

Most patients expressed acceptance reflecting wellbeing 3 years after APE for rectal cancer. There is, however, a subset of patients (18 %) who describe bodily limitations and mental suffering without acceptance and who require further support. Many aspects of the portrayed bodily limitations and mental suffering could be prevented or treated.

Trial registration

NCT01296984.

     

Sexual dysfunction following rectal cancer surgery

Introduction

Sexual and urological problems after surgery for rectal cancer are common, multifactorial, inadequately discussed, and untreated. The urogenital function is dependent on dual autonomic sympathetic and parasympathetic innervation, and four key danger zones exist that are at risk for nerve damage during colorectal surgery: one of these sites is in the abdomen and three are in the pelvis. The aim of this study is to systematically review the epidemiology of sexual dysfunction following rectal cancer surgery, to describe the anatomical basis of autonomic nerve-preserving techniques, and to explore the scientific evidence available to support the laparoscopic or robotic approach over open surgery.

Methods

According to the PRISMA guidelines, a comprehensive literature search of studies evaluating sexual function in patients undergoing rectal surgery for cancer was performed in Medline, Scopus, Web of Science, Embase, and Cochrane Central Register of controlled trials.

Results

An increasing number of studies assessing the incidence and prevalence of sexual dysfunction following multimodality treatment for rectal cancer has been published over the last 30 years. Significant heterogeneity in the prevalence of sexual dysfunction is reported in the literature, with rates between 5 and 90%.

Conclusions

There is no evidence to date in favor of any surgical approach (open vs laparoscopic vs robotic). Standardized diagnostic tools should be routinely used to prospectively assess sexual function in patients undergoing rectal surgery.

     

Pretreatment identification of patients likely to have pathologic complete response after neoadjuvant chemoradiotherapy for rectal cancer

Purpose

In selected patients, a wait-and-see strategy after chemoradiotherapy for rectal cancer might be feasible provided that the probability of pathologic complete response (pCR) is high. This study aimed to identify clinical parameters associated with pCR. Furthermore, we attempted to identify subgroups with increased probability of pCR that might aid in clinical decision making.

Methods

A total of 6444 patients that underwent surgical resection of a single primary carcinoma of the rectum after neoadjuvant chemoradiotherapy (nCRT) between January 2009 and December 2016 in the Netherlands were included in the study. Data on the outcome variable, pCR, and potential covariates were retrieved from a nationwide database. The variables included in the analysis were selected based on previous studies and were analyzed using univariate and multivariate logistic regression analyses.

Results

pCR was observed in 1010 patients (15.7%). Pretreatment clinical tumor stage and signs of obstruction were independently associated with pCR. Nodal stage and presence of metastatic disease decreased chances of pCR significantly. The best response rate was observed in patients diagnosed with a non-obstructive, well-/moderately differentiated adenocarcinoma of the lower rectum with no clinical apparent nodal or distant metastatic disease (pCR ratio 18.8%). The percentage of patients demonstrating pCR decreased in case of symptoms of pretreatment obstruction or poorly differentiated tumors (pCR ratio of 11.8 and 6.7%, respectively).

Conclusion

This nationwide study confirms several of the previously reported clinical predictors of pCR.

     

Preoperative hypoalbuminemia is an independent risk factor for increased high-grade morbidity after elective rectal cancer resection

Purpose

This study investigated the association of preoperative hypoalbuminemia and postoperative complications after elective resection for rectal cancer.

Methods

From September 2009 to December 2014, all patients who underwent elective rectal resection for adenocarcinoma of the rectum were identified using a prospective colorectal cancer database. Hypoalbuminemia was defined as a serum albumin < 35 g/L. Characteristics and outcomes of hypoalbuminemic patients were compared to those of patients with normal albumin levels. Potential risk factors for postoperative major morbidity, defined as Clavien-Dindo ≥ grade 3, were analyzed by both univariate and multivariate analyses.

Results

Three hundred seventy patients met the inclusion criteria. Hypoalbuminemic patients (67/370 (18%)) were significantly older and had more advanced tumor stages and more comorbidities (more ASA III, higher percentage of diabetics). Furthermore, they were more likely to undergo abdominoperineal resection instead of low anterior resection and less likely to be operated laparoscopically. On univariate analysis, a higher BMI, advanced tumor stages, diabetes, open procedures, pre- and postoperative hypoalbuminemia, a higher decrease in albumin (? preop-postop), and conversion were significantly associated with postoperative high-grade morbidity. On multivariate analysis, diabetes, advanced tumor stages, a higher decrease in the albumin level, as well as preoperative hypoalbuminemia turned out to be independent risk factors for postoperative high-grade morbidity.

Conclusions

Hypoalbuminemia is an independent risk factor for postoperative high-grade morbidity. As a low-cost and easy accessible test, serum albumin should be used as a prognostic tool to detect patients at risk for adverse outcomes after resection for rectal cancer.