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BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer may induce a pathological complete response (pCR) but increase surgical morbidity due to radiation-induced fibrosis. In this study the association between pCR and postoperative surgical morbidity was investigated. METHODS: Patients in the Netherlands with rectal cancer who underwent nCRT followed by total mesorectal excision between 2009 and 2017 were included. Data were stratified into patients who underwent resection with creation of a primary anastomosis and those who had a permanent stoma procedure. The association between pCR and postoperative morbidity was investigated in univariable and multivariable logistic regression analyses. RESULTS: pCR was observed in 976 (12·2 per cent) of 8003 patients. In 3472 patients who had a primary anastomosis, the presence of pCR was significantly associated with surgical complications (122 of 443 (27·5 per cent) versus 598 of 3029 (19·7 per cent) in those without pCR) and anastomotic leak (35 of 443 (7·9 per cent) versus 173 of 3029 (5·7 per cent) respectively). Multivariable analysis also showed associations between pCR and surgical complications (adjusted odds ratio (OR) 1·53, 95 per cent c.i. 1·22 to 1·92) and pCR and anastomotic leak (adjusted OR 1·41, 1·03 to 2·05). Of 4531 patients with a permanent stoma, surgical complications were observed in 120 (22·5 per cent) of 533 patients with a pCR, compared with 798 (20·0 per cent) of 3998 patients with no pCR (adjusted OR 1·17, 0·94 to 1·46). CONCLUSION: Patients with a pCR in whom an anastomosis was created were at increased risk of developing an anastomotic leak.

ANTECEDENTES: La quimiorradioterapia neoadyuvante (neoadjuvant chemoradiotherapy, nCRT) para el cáncer de recto localmente avanzado puede inducir una respuesta patológica completa (pathological complete response, pCR), pero también puede aumentar la morbilidad quirúrgica debido a la fibrosis inducida por la radiación. En este estudio se investigó la asociación entre pCR y morbilidad quirúrgica postoperatoria. MÉTODOS: Se incluyeron los pacientes con cáncer de recto que recibieron nCRT seguida de resección total del mesorrecto entre 2009 y 2017 en los Países Bajos. Los datos se estratificaron en pacientes en los que se realizó una resección con anastomosis primaria y en los que se realizó una resección con estoma permanente. La asociación entre pCR y morbilidad postoperatoria se investigó mediante análisis de regresión logística univariable y multivariable. RESULTADOS: Se observó una pCR en 976 (12,2%) de 8.003 pacientes. En el grupo de pacientes con anastomosis primaria (n = 3472), la presencia de pCR se asoció significativamente con complicaciones quirúrgicas (n = 122; 27,5% versus n = 598; 19,7% sin pCR) y fuga anastomótica (n = 35; 7,9 % versus n = 173; 5,7% sin pCR). Las asociaciones entre la pCR y las complicaciones quirúrgicas y la pCR y la fuga anastomótica también se confirmaron en los análisis multivariables (razón de oportunidades ajustada, odds ratio, OR ajustado: 1,53; i.c. del 95%: 1,22-1,92; OR ajustado: 1,41; i.c. del 95%: 1,03-2,05, respectivamente). En el grupo con estoma permanente (n = 4.531), se observaron complicaciones quirúrgicas en 120 pacientes (22,5%) en los casos con presencia de pCR en comparación con 798 pacientes (20%) en ausencia de pCR (OR ajustado: 1,17; i.c. del 95%: 0,94-1,46). CONCLUSIÓN: Los pacientes con pCR en los que se realizó una anastomosis tenían mayor riesgo de presentar una fuga anastomótica.

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AIM: The aim of this study was to develop and externally validate a clinically, practical and discriminative prediction model designed to estimate in-hospital mortality of patients undergoing colorectal surgery. METHOD: All consecutive patients who underwent elective or emergency colorectal surgery from 1990 to 2005, at the Zaandam Medical Centre, The Netherlands, were included in this study. Multivariate logistic regression analysis was performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) linking the explanatory variables to the outcome variable in-hospital mortality, and a simplified Identification of Risk in Colorectal Surgery (IRCS) score was constructed. The model was validated in a population of patients who underwent colorectal surgery from 2005 to 2011 in Barcelona, Spain. Predictive performance was estimated by calculating the area under the receiver operating characteristic curve. RESULTS: The strongest predictors of in-hospital mortality were emergency surgery (OR = 6.7, 95% CI 4.7-9.5), tumour stage (OR = 3.2, 95% CI 2.8-4.6), age (OR = 13.1, 95% CI 6.6-26.0), pulmonary failure (OR = 4.9, 95% CI 3.3-7.1) and cardiac failure (OR = 3.7, 95% CI 2.6-5.3). These parameters were included in the prediction model and simplified scoring system. The IRCS model predicted in-hospital mortality and demonstrated a predictive performance of 0.83 (95% CI 0.79-0.87) in the validation population. In this population the predictive performance of the CR-POSSUM score was 0.76 (95% CI 0.71-0.81). CONCLUSIONS: The results of this study have shown that the IRCS score is a good predictor of in-hospital mortality after colorectal surgery despite the relatively low number of model parameters.

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AIM: The aetiology of colonoscopic perforation and factors related to poor outcome of surgical treatment were studied. METHOD: A single-centre review was conducted of all patients who underwent surgical treatment of a colonoscopic perforation, identified from a prospective registry of 21,981 consecutive colonoscopies carried out between 1993 and 2009. RESULTS: There were 29 (eight women) patients of mean age 73 years including 10 who had a nonelective colonoscopy. The perforation was not immediately recognized in 12 patients and in the remaining 17, seven were initially managed conservatively. The causes of perforation were barotrauma (11), mechanical force (14) and polypectomy-related (3). Barotrauma was more frequent in emergency colonoscopy and mechanical force in elective colonoscopy. The outcome of surgery was as follows: mortality 10%, complications 34.5%, reoperation 14%, secondary surgery 23% and permanent colostomy 3%. The only factor related to in-hospital mortality was an increased American Society of Anesthesiologists (ASA) score. CONCLUSION: Colonoscopic perforation requiring surgery is a catastrophic event with high mortality, morbidity and reoperation rates.

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