Postoperative morbidity following chemoradiation for locally advanced low rectal cancer

A comparative multicentre study evaluating gluteal turnover flap for wound closure after abdominoperineal resection for rectal cancer

Background

The aim of this study was to compare perineal wound healing between gluteal turnover flap and primary closure in patients undergoing abdominoperineal resection (APR) for rectal cancer.

Methods

Patients who underwent APR for primary or recurrent rectal cancer with gluteal turnover flap in two university hospitals (2016–2021) were compared to a multicentre cohort of primary closure (2000–2017). The primary endpoint was uncomplicated perineal wound healing within 30 days. Secondary endpoints were long-term wound healing, related re-interventions, and perineal herniation. The perineal hernia rate was assessed using Kaplan Meier analysis.

Results

Twenty–five patients had a gluteal turnover flap and 194 had primary closure. The uncomplicated perineal wound-healing rate within 30 days was 68% (17/25) after gluteal turnover flap versus 64% (124/194) after primary closure, OR 2.246; 95% CI 0.734–6.876; p = 0.156 in multivariable analysis. No major wound complications requiring surgical re-intervention occurred after flap closure. Eighteen patients with gluteal turnover flap completed 12-month follow-up, and none of them had chronic perineal sinus, compared to 6% (11/173) after primary closure (p = 0.604). The symptomatic 18-month perineal hernia rate after flap closure was 0%, compared to 9% after primary closure (p = 0.184).

Conclusions

The uncomplicated perineal wound-healing rate after the gluteal turnover flap and primary closure after APR is similar, and no chronic perineal sinus or perineal hernia occurred after flap closure. Future studies have to confirm potential benefits of the gluteal turnover flap.

Predictive immunohistochemical features for tumour response to chemoradiotherapy in rectal cancer

Background

Reduced expression of cluster of differentiation (CD) 133 and cyclo‐oxygenase (COX) 2, and increased density of CD8+ tumour‐infiltrating lymphocytes, are associated with a favourable tumour response to preoperative chemoradiotherapy (CRT). This study aimed to evaluate these markers in relation to tumour response after preoperative CRT in two rectal cancer cohorts.

Methods

Patients with low rectal cancer who underwent radical resection and preoperative short‐term CRT in 2001–2007 (retrospective cohort) and long‐term CRT in 2011–2017 (prospective cohort) were analysed. Pretreatment biopsies were stained immunohistochemically using antibodies to determine CD133 and COX‐2 expression, and increased CD8+ density. Outcome measures were tumour regression grade (TRG), tumour downstaging and survival.

Results

For 95 patients in the retrospective cohort, the incidence of TRG 3–4 was 67 per cent when two or three immunohistochemistry (IHC) features were present, but only 20 per cent when there were fewer features (P < 0·001). The incidence of tumour downstaging was higher in patients with at least two IHC features (43 versus 22 per cent with fewer features; P = 0·029). The 49 patients in the prospective cohort had similar rates to those in the retrospective cohort (TRG 3–4: 76 per cent for two or more IHC features versus 25 per cent with fewer features, P < 0·001; tumour downstaging: 57 versus 25 per cent respectively, P = 0·022). Local recurrence‐free survival rates in patients with more or fewer IHC features were similar in the retrospective and prospective cohort (P = 0·058 and P = 0·387 respectively).

Conclusion

Assessment of CD133, COX‐2 and CD8 could be useful in predicting a good response to preoperative CRT in patients with lower rectal cancer undergoing neoadjuvant therapy. Further studies are needed to validate the results in larger cohorts and investigate a survival benefit.

Anorectal dysfunction after laparoscopic low anterior rectal resection for rectal cancer with and without radiotherapy (manometry study)

BACKGROUND AND OBJECTIVES

The aim was to evaluate the impact of radiotherapy (RT) on anorectal function of patients with low rectal cancer undergoing low anterior resection (LAR).

METHODS

Prospective clinical cohort study conducted to assess the functional outcome by means of high-resolution anorectal manometry and LARS score.

RESULTS

In total, 65 patients were enrolled in the study (27 patients underwent LAR without RT, 38 patients underwent RT and LAR). There were no statistically significant differences between study subgroups regarding demographic and clinical data; postoperative morbidity was significantly higher in irradiated patients. One year after the surgery, mean LARS score was significantly higher in patients who underwent RT and surgery. Major LARS was detected in 37.0% of irradiated patients and in 14.8% of patients after surgery alone. Anorectal manometry revealed significantly lower resting pressures in patients after RT and LAR; the squeeze pressures were similar. Rectal compliance and all volumes describing rectal sensitivity (first sensation, urge to defecate, and discomfort volume) were significantly lower in irradiated patients.

CONCLUSIONS

RT significantly deteriorates the functional outcome of patients after LAR. Manometry revealed internal sphincter dysfunction, reduced capacity, and compliance of neorectum, which seem to have a significant correlation with LARS presence/seriousness.

A Phase I Clinical Trial of the Phosphatidylserine-targeting Antibody Bavituximab in Combination With Radiation Therapy and Capecitabine in the Preoperative Treatment of Rectal Adenocarcinoma

OBJECTIVES

There is interest in improving the tumoricidal effects of preoperative radiotherapy for rectal carcinoma by studying new radiosensitizers. The safety and toxicity profile of these combination regimens needs rigorous clinical evaluation. The primary objective of this study was to evaluate the toxicity of combining bavituximab, an antibody that targets exposed phosphatidylserine, with capecitabine and radiation therapy.

MATERIALS AND METHODS

Patients with stage II or III rectal adenocarcinoma were enrolled on a phase I study combining radiation therapy, capecitabine, and bavituximab. A standard 3+3 trial designed was used.

RESULTS

In general, bavituximab was safe and well tolerated in combination with radiation therapy and capecitabine in the treatment of rectal adenocarcinoma. One patient at the highest dose level experienced a grade III infusion reaction related to the bavituximab. One tumor demonstrated a complete pathologic response to the combination treatment.

CONCLUSIONS

Bavituximab is safe in combination with capecitabine and radiation therapy at the doses selected for the study. Further clinical investigation would be necessary to better define the efficacy of this combination.

Identification of molecular characteristics induced by radiotherapy in rectal cancer based on microarray data

The present study aimed to reveal the molecular characteristics induced by radiotherapy in rectal cancer at the transcriptome level. Microarray data (ID, GSE26027) downloaded from the Gene Expression Omnibus database were re-analyzed to identify differentially expressed genes (DEGs) between rectal cancer tissues during and prior to radiotherapy. The DEGs were then inputted into the database for annotation, visualization and integrated discovery, an online tool to perform enrichment analyses, and into the search tool for the retrieval of interacting genes/proteins database to identify protein-protein interactions (PPIs). Subsequently, a PPI network was constructed, which was screened for densely connected modules. Furthermore, protein domain enrichment analysis was performed. In total, 690 DEGs, including 179 upregulated and 511 downregulated DEGs, were found in rectal cancer tissues during and prior to radiotherapy. The upregulated DEGs were significantly enriched in 'positive regulation of transport' and 'regulation of cardiac muscle contraction', while the downregulated DEGs were most markedly enriched in 'cell migration', 'cell-cell signaling', 'extracellular matrix organization' and 'blood vessel development', including prostaglandin-endoperoxide synthase 2, transforming growth factor β-induced, 68 kDa endothelin receptor type A, brain-derived neurotrophic factor, TIMP metallopeptidase inhibitor 1, and serpin family E member 1, which were the top 6 hub nodes in the PPI network. Furthermore, 2 protein domains were significantly enriched by PPI modules, including: The collagen triple helix repeat (CTHR) family members collagen type (COL) 5A2, COL9A3, COL6A3, COL21A1, COL5A3, COL11A1, COL7A1 and CTHR-containing-1; and the olfactory receptor family (OR) members OR7E24, OR7A17, OR6A2, OR1F1, OR10H3 and OR7A10. A total of 7 upregulated DEGs were characterized as tumor suppressor genes, and 8 downregulated DEGs were characterized as oncogenes. The biological processes or protein domains enriched by upregulated or downregulated DEGs may improve the understanding of molecular characteristics in response to radiotherapy.

Which Patients With Rectal Cancer Do Not Need Radiotherapy?

According to current guidelines, the standard treatment for locally advanced rectal cancer patients is preoperative (chemo)radiotherapy followed by total mesorectal excision surgery and adjuvant chemotherapy. Improvements in surgical techniques, imaging modalities, chemotherapy regimens, and radiotherapy delivery have reduced local recurrence rates to less than 10%. The current challenge in rectal cancer treatment lies in the prevention of distant metastases, which still occur in more than 25% of the patients. The decrease in local recurrence rates, the need for more effective systemic treatments, and the increased awareness of treatment-induced toxicity raise the question as to whether a more selective use of radiotherapy is advocated.

Predictors of Pathologic Complete Response Following Neoadjuvant Chemoradiotherapy for Rectal Cancer

BACKGROUND

Some patients with rectal cancer who receive neoadjuvant chemoradiotherapy (nCRT) achieve a pathologic complete response (pCR) and may be eligible for less radical surgery or non-operative management. The aim of this study was to identify variables that predict pCR after nCRT for rectal cancer and to examine the impact of pCR on postoperative complications.

METHODS

A retrospective review was performed of the NCDB from 2006 to 2011. Patients with rectal cancer who received nCRT followed by radical resection were included in this study. Multivariable analysis of the association between clinicopathologic characteristics and pCR was performed, and propensity-adjusted analysis was used to identify differences in postoperative morbidity between pCR and non-pCR patients.

RESULTS

A total of 23,747 patients were included in the study. Factors associated with pCR included lower tumor grade, lower clinical T and N stage, higher radiation dose, and delaying surgery by more than 6-8 weeks after the end of radiation, while lack of health insurance was linked with a lower likelihood of pCR. Complete response was not associated with an increased risk of major postoperative complications.

CONCLUSIONS

Several clinical, pathologic, and treatment variables can help to predict which patients are most likely to have pCR after nCRT for rectal cancer. Awareness of these variables can be valuable in counseling patients regarding prognosis and treatment options.

Prognostic factors for postoperative morbidity and tumour response after neoadjuvant chemoradiation followed by resection for rectal cancer

BACKGROUND AND PURPOSE

In patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation followed by rectal resection, postoperative morbidity is a significant clinical problem. Pathologic complete tumour response seems to give the best prognosis in the long term. Little is known about the factors that are associated with postoperative complications and pathologic complete response. The aim of this retrospective study was to identify and describe these factors.

METHODS

Ninety-nine consecutive patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation (50 Gy and capecitabine) followed by surgery at our institute between January 2007 and May 2012 were identified. Postoperative complications were graded according to the Clavien-Dindo classification. Pathologic tumour response was categorized as complete response or no/partial response.

RESULTS

Postoperative complications occurred in 68 patients (69%) and grade 3-5 complications in 25 patients (25%). The 30-day and 90-day mortality were 1% (n = 1) and 2% (n = 2), respectively. A young age (p = 0.021) and a preoperative or postoperative blood transfusion (p = 0.015) independently predicted complications. Intraoperative or postoperative blood transfusion (p = 0.007) and ypT0-1 stage (p = 0.037) were independent predictors for grade 3-5 complications. Complete response rate was 22% (n = 22); 4% (n = 4) of patients showed no response. No independent factors predicting complete response were found.

CONCLUSIONS

Neoadjuvant chemoradiation followed by rectal resection is associated with significant postoperative morbidity but minimal postoperative mortality. A complete response rate of 22% was achieved.

Human phosphatidylethanolamine-binding protein 4 promoted the radioresistance of human rectal cancer by activating Akt in an ROS-dependent way

Human phosphatidylethanolamine-binding protein 4(hPEBP4) is a novel anti-apoptosis molecule associated with the resistance of tumors to apoptotic agents. Here we sought to investigate the role of hPEBP4 in the radioresistance of rectal cancer. Immunohistochemistry analysis showed hPEBP4 was expressed in 27/33 of rectal cancer specimens, but only in 2/33 of neighboring normal mucosa. Silencing the expression of hPEBP4 with siRNA significantly reduced the clonogenic survival and enhanced the apoptosis of rectal cancer cells on irradiation. Instead, forced overexpression of hPEBP4 promoted its survival and decreased the apoptosis. Western blot showed hPEBP4 could increase the radiation-induced Akt activation, for which reactive oxygen specimen(ROS) was required. The radioresistance effect of hPEBP4 was reversed after given LY-294002 to inhibit Akt activation or antioxidant to abolish the ROS production. We also confirmed that effect of hPEBP4 in vivo with nude mice. Thus we concluded that hPEBP4, specifically expressed in rectal cancer cells, is associated with radioresistance of rectal cancer, implying that modulation of hPEBP4 may have important therapeutic implications in radiotherapy of rectal cancer.

hPEBP4 as a predictive marker for the pathological response of rectal cancer to preoperative radiotherapy

PURPOSE

The ability to predict tumor sensitivity toward radiotherapy is important in the personalized application of preoperative radiotherapy for patients with rectal cancer. The aim of the present study was to test the human phosphatidylethanolamine-binding protein 4 (hPEBP4) as a predictive marker of tumor response to preoperative radiotherapy in patients with rectal cancer.

METHOD

A retrospective analysis was conducted, consisting of 86 patients with locally advanced rectal cancer who underwent short-course preoperative radiotherapy (20 Gy in five fractions for 1 week) followed by a radical resection. Both pretreatment biopsy specimens and resected primary tumor tissue were collected. Immunohistochemistry and tumor regression grading system were used to evaluate the expression of hPEBP4 in the pretreatment biopsy specimens and the response of rectal cancer to radiotherapy, respectively. Expression of hPEBP4 was correlated with tumor regression in the resected specimen and the clinical outcome of the patients as well.

RESULTS

We found that high expression of hPEBP4 was associated with radioresistance in both univariate and multivariate analyses, and patients with a high hPEBP4 expression had a poorer progression-free survival than those with low hPEBP4 expression.

CONCLUSION

Our study revealed the independent predictive values of hPEBP4 in response of rectal cancer to preoperative radiotherapy, which suggests that upregulating hPEBP4 might be a potential mechanism by which rectal cancer cells avoid the destructive effects of radiotherapy.

Neoadjuvant chemotherapy in MRI-staged high-risk rectal cancer in addition to or as an alternative to preoperative chemoradiation?

BACKGROUND

For patients with resectable rectal cancer chemoradiation (CRT) or short-course preoperative radiotherapy (SCPRT) reduces locoregional failure, without extending disease-free survival (DFS) or overall survival (OS). Compliance to postoperative adjuvant chemotherapy is poor. Neoadjuvant chemotherapy (NACT) offers an alternative strategy.

METHODS

A systematic computerised database search identified studies exploring NACT alone or NACT preceding/succeeding radiation. The primary outcome measure was pathological complete response (pCR). Secondary outcome measures included acute toxicity, surgical morbidity, circumferential resection margin, locoregional failure, DFS and OS.

RESULTS

Four case reports, 12 phase I/II studies, 4 randomised phase II and one randomised phase III study evaluated chemotherapy before CRT. Four prospective studies reviewed chemotherapy after CRT. Three phase II studies investigated chemotherapy using FOLFOX plus bevacizumab without radiotherapy. In 24 studies of 1271 patients, pCR varied from 7% to 36%, but with no impact on metastatic disease.

CONCLUSIONS

NACT before CRT delivers does not compromise CRT but has not increased pCR rates, R0 resection rate, improved DFS or reduced metastases. NACT following CRT is an interesting strategy, and the utility of NACT alone could be explored compared with SCPRT or CRT in selected patients with rectal cancer where the impact of radiotherapy on DFS and OS is marginal.

Neoadjuvant treatment in rectal cancer: do we always need radiotherapy-or can we risk assess locally advanced rectal cancer better?

There is good quality evidence that preoperative radiotherapy reduces local recurrence but there is little impact on overall survival. This is not completely unexpected as radiotherapy is a localised treatment and local control may not prevent systemic failure. Optimal quality-controlled surgery for patients with operable rectal cancer in the trial setting can be associated with local recurrence rates of less than 10 % whether patients receive radiotherapy or not (Quirke et al. 2009). However, despite the reassuring results of randomised trials, concerns remain that radiotherapy increases surgical morbidity (Horisberger et al. 2008; Stelzmueller et al. 2009; Swellengrebel et al. 2011), which can compromise the delivery of postoperative adjuvant chemotherapy. There are also significant late effects from pelvic radiotherapy (Peeters et al. 2005; Lange et al. 2007) and a risk of second malignancies (Birgisson et al. 2005; van Gijn et al. 2011). If preoperative radiotherapy does not impact on survival, can it be omitted in selected cases? The answer is yes-with the proviso that we are using good quality magnetic resonance imaging and good quality TME surgery within the mesorectal plane and the predicted risk of subsequent metastatic disease justifies its use. In this case, the concept of neoadjuvant chemotherapy (NACT) is a potentially attractive alternative strategy which might have less early and long-term side effects compared to preoperative radiotherapy-particularly where the MRI predicts a high risk of metastatic disease in the context of a modest risk of local recurrence. This chapter discusses a more precise method of risk categorisation for locally advanced rectal cancer, and discusses possible options for neoadjuvant chemotherapy (NACT).

Locally advanced rectal cancer: a comparison of management strategies

Traditionally, there has been a high local recurrence rate in rectal cancer and 10-40% of patients require a permanent stoma. Both short-course preoperative radiotherapy (SCPRT) and long-course preoperative chemoradiation (CRT) are used to reduce the risk of local recurrence and enable a curative resection. Total mesorectal excision has reduced the rate of local recurrence (even without radiotherapy) to below 10%, but has highlighted a high risk of metastatic disease in 30-40% of patients. Current trials suggest that in resectable cancers, where the preoperative magnetic resonance imaging (MRI) suggests the circumferential resection margin (CRM) is not potentially involved, then SCPRT and CRT are equivalent in terms of outcomes such as local recurrence, disease-free survival (DFS) and overall survival (OS). For patients with more advanced disease, where the CRM is breached or threatened according to the MRI, the integration of more active chemotherapy and biological agents into chemoradiation is an attractive strategy because of the high risk of metastases. However, in none of the trials published in the last decade has chemoradiation impacted on DFS or OS. We examine the strategies of neoadjuvant, concurrent, consolidation (after chemoradiation and before surgery) and postoperative adjuvant chemotherapy with cytotoxic agents, and the integration of biological agents for future potential strategies of treatment. We also compare the trials and compare the different strategies of long-course preoperative radiotherapy and SCPRT; the intensification of preoperative radiation and chemoradiation with dose escalation of external beam radiotherapy, using brachytherapy, intra-operative radiotherapy, hyperfractionation, and various available techniques such as intensity-modulated radiotherapy. We recommend examining dose escalation of radiotherapy to the primary tumour where MRI predicts a threatened CRM. Of the potential treatment strategies involving cytotoxic agents, such as neoadjuvant, concurrent, consolidation and postoperative adjuvant chemotherapy, the most promising would appear to be consolidation chemotherapy following chemoradiation in locally advanced disease, and neoadjuvant chemotherapy in MRI-selected patients who do not require radiation. Improvement in the quality of surgery is also an important future goal.

Pretreatment CD133 and cyclooxygenase-2 expression as the predictive markers of the pathological effect of chemoradiotherapy in rectal cancer patients

BACKGROUND

CD133 confers chemoradioresistance properties to cells and has recently been used to identify cancer-initiating cells.

OBJECTIVE

We investigated whether the overexpression of CD133 and cyclooxygenase-2 can be used as predictive markers of tumor response to preoperative chemoradiotherapy in patients with rectal cancer.

SETTING

The study was conducted at the National Defense Medical College Hospital in Japan.

PATIENTS

We recruited 96 patients who underwent a single regimen of preoperative short-term chemoradiotherapy (20 Gy in 5 fractions with 400 mg/day Tegafur/Uracil for 1 week) and radical resection.

DESIGN

This was a retrospective study. We obtained pretreatment biopsy specimens of these patients and immunostained these specimens with antibodies for CD133, cyclooxygenase-2, p53, p27, p21, and epidermal growth factor receptor. The resected primary tumor was evaluated according to 2 different tumor regression grading systems that were based on the degrees of fibrosis and cytological alterations.

RESULTS

Positivity for CD133 or cyclooxygenase-2 expression was associated with chemoradioresistance, which was determined by the degree of fibrosis, in both univariate (P = .02 and P = .0003) and multivariate (P = .03 and P = .001) analyses. Univariate and multivariate analyses of the degree of cytological alterations also revealed a significant association between chemoradioresistance and the expression of CD133 (P = .005 and P = .003) and cyclooxygenase-2 (P = .005 and P = .03), whereas other markers failed to associate.

LIMITATIONS

The information on patients' outcome was not available.

CONCLUSIONS

Our study revealed the independent predictive values of CD133 and cyclooxygenase-2 expressions in histological tumor regression after preoperative chemoradiotherapy.

Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: a matched case-control study of short-term outcomes

BACKGROUND

Neoadjuvant chemoradiation (nCRT) currently is commonly incorporated into the multimodal treatment of locally advanced rectal cancers. This study aimed to compare the short-term outcomes and oncologic adequacy of laparoscopic and conventional open surgery for rectal cancer after nCRT.

METHODS

A series of 72 patients who underwent laparoscopic surgery (Lap group) for rectal cancer after nCRT were matched for type of surgery, gender, and American Society of Anesthesiologists (ASA) class with 72 patients who underwent conventional surgery during the same time period (Open group). The short-term outcomes were compared between the two groups of patients.

RESULTS

No significant difference was found between the two groups in terms of age, distance of tumor from the anal verge, body mass index, or posttreatment pathologic stage of the disease. There were significant differences between the Lap and Open groups in terms of blood loss (median: 200 vs 400 ml; P < 0.001), duration of surgery (median: 270 vs 240 min; P < 0.001), time to passing of first flatus (median: 2 vs 3 days; P < 0.001), time to start of normal diet (median: 5 vs 6 days; P < 0.001), and hospital stay (median: 12 vs 15 days; P < 0.001). A significant difference in the number of lymph nodes harvested was not identified between the two groups, although more patients in the Open group had a positive circumferential resection margin than in the Lap group (10 vs 1%; P = 0.03). The short-term benefits of laparoscopic surgery also were observed when the 64 patients who underwent abdominoperineal resection (APR) in each of the two groups were compared separately.

CONCLUSION

Laparoscopic surgery for rectal cancer, especially laparoscopic APR, after nCRT is safe and associated with earlier recovery of bowel function, a shorter hospital stay, and an oncologically adequate specimen compared with conventional open surgery.

Preoperative oxaliplatin, capecitabine, and external beam radiotherapy in patients with newly diagnosed, primary operable, cT₃NxM0, low rectal cancer: a phase II study

PURPOSE

In patients with locally advanced rectal cancer (LARC), preoperative chemoradiation is known to improve local control, and down-staging of the tumor serves as a surrogate for survival. Intensification of the systemic therapy may lead to higher downstaging rates and, thus, enhance survival. This phase II study investigated the efficacy and safety of preoperative capecitabine and oxaliplatin in combination with radiotherapy.

PATIENTS AND METHODS

Patients with LARC of the mid and lower rectum, T₃NxM0 staged by MRI received radiotherapy (total dose 45 Gy) in combination with oral capecitabine (825 mg/m² twice a day on radiotherapy days; weeks 1-4) and oxaliplatin 50 mg/m² intravenously (days 1, 8, 15, and 22). Efficacy was evaluated as rate of tumor down-categorization at the T level.

RESULTS

A total of 59 patients were enrolled (19 women, 40 men; median age of 61 years) and all were evaluable for efficacy and toxicity. Down-categorization at the T level was observed in 53% with pathological complete response in 6 patients (10%). Actual total radiotherapy, oxaliplatin and capecitabine doses received were 97%, 90%, and 93% of the protocol-specified preplanned doses, respectively. Grade 3/4 toxicity was observed in 15 patients (25%). The most frequent was diarrhea (12%).

CONCLUSIONS

Preoperative chemoradiation with capecitabine and oxaliplatin is feasible in patients with MRI-proven cT₃ LARC. The only clinically relevant toxicity was diarrhea. Overall, efficacy of the multimodality treatment was good, but not markedly exceeding that of 5-FU- or capecitabine-based chemoradiation approaches.

Anastomotic Leak Rate after Low Anterior Resection for Rectal Cancer after Chemoradiation Therapy

Anastomotic leak may be the most concerning complication after colorectal anastomosis. To compare open with laparoscopic rectal resection, we must have accurate leak rates in patients who have received neoadjuvant chemoradiation therapy to serve as a benchmark for comparison. All patients who had preoperative chemoradiation therapy with rectal resection and low pelvic anastomosis for cancer in a single colorectal practice over a 7-year period were retrospectively reviewed. All patients had proximal diversion and a contrast enema study before stoma reversal. Eighty-seven consecutive patients were included in the study. Average age was 58 years. Fifty-nine per cent of patients were male. Sixty-six per cent were smokers. Pathologic T stage was 5 per cent TO, 16 per cent T1, 28 per cent T2, 47 per cent T3, and 5 per cent T4. Seventy-five per cent of patients were pathologically lymph node-negative. Average time to stoma reversal was 122 days. Total anastomotic leak rate was 10.3 per cent (8% clinical leaks). Five (56%) patients with leak successfully underwent reversal of their diverting stoma (average time to reversal, 290 days). Patients who had the complication of anastomotic leakage had less likelihood of stoma reversal and a significantly prolonged time to stoma reversal.