Surgical Aspects and Prognostic Factors in the Management of Rectal Cancer

Survival among patients with stage IV rectal cancer is poor and surgical treatment for this disease is associated with morbidities such as small bowel obstruction, complications with a diverting loop ileostomy, and functional bowel disturbances. The overall aim of this thesis was to assess risk factors and morbidity after surgery for rectal cancer and to evaluate factors affecting survival in patients with stage IV rectal cancer. Paper I a prospective study on patients with rectal cancer with loop ileostomy who underwent stoma closure in a 23-hour hospital stay setting. Results were compared with a group who underwent standard in-hospital stoma closure prior to the start of the study, selected retrospectively as controls. No differences were found in the number of complications or the frequency of re-hospitalization or re-operation, indicating that ileostomy closure in a 23-hour hospital stay setting in these selected patients was feasible and safe with high patient satisfaction. Paper II a population-based study with data gathered prospectively. In total, 11% of the patients developed small bowel obstruction (SBO), mostly during the first year after rectal cancer surgery. Surgical treatment for SBO was performed in 4.2% of the patients, and the mechanism was stoma-related in one-fourth. Rectal resection without anastomoses, age, morbidity, and previous radiotherapy (RT) was not associated with admission to the hospital or surgery for SBO. Re-laparotomy due to complications after rectal cancer surgery was an independent risk factor for admission for treating SBO. Paper III a population-based study with data gathered prospectively on bowel function at 1 year after anterior resection or stoma reversal. No associations were found between any defecatory dysfunction and the part of the colon used for anastomosis, the level of the vascular tie, or gender. An association was observed between higher anastomotic level and a lower risk of incontinence and clustering. At 1 year after loop ileostomy closure, the risks of incontinence, clustering, and urgency increased by up to fourfold. Paper IV a case-control study aiming to identify patient-, tumor-, and treatment-related prognostic factors for 5-year survival in patients with rectal cancer with synchronous stage IV disease. Patient-related factors did not differ between groups. Among the tumor-related factors, multiple site metastases, bilobar liver metastases, and increasing numbers of liver metastases were associated with poor survival. Prognostic treatment-related factors were preoperative RT, metastasectomy, and radical resection of the primary tumor. The most important prognostic factor for long-term survival was metastasectomy