Optimisation of surgical care for rectal cancer

Optimisation of surgical care means weighing the risk of treatment related morbidity against the patients’ potential benefits of a surgical intervention. The first part of this thesis focusses on the anaemic patient undergoing colorectal surgery. Hypothesizing that a more profound haemoglobin increase with intravenous iron may contribute to a superior optimisation of the patient’s condition and possibly a decrease in postoperative morbidity. The second part investigates the boundaries of organ preservation in the treatment of early rectal cancer. Organ preservation should still be seen as an experimental treatment that should only be offered in the controlled setting of a clinical trial. The third part focusses on the complications following rectal cancer surgery. By providing a cross-sectional overview of provided surgical care in the Netherlands we have tried to identify fields for improvement of current clinical practice. Anastomotic leakage being identified as one of the most dreaded complications following rectal cancer surgery. We have investigated three treatment strategies that could be used as a step-up approach (from minimally invasive towards more invasive surgery) for patients with anastomotic leakage or a pelvic abscess. Regarding stoma formation, we identified two strategies being applied in the Netherlands in the approach of rectal cancer. Surgical units that almost routinely diverted their anastomoses had a higher rate of low anastomoses, while the units that selectively constructed a diverting stoma, more often decided to perform a Hartmann’s procedure. Remarkably, anastomotic leakage did not differ between these two strategies with a similar permanent stoma rate at end of follow-up in patients who had a primary anastomosis.