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The Association of Preoperative Anemia and the Postoperative Course and Oncological Outcome in Patients Undergoing Rectal Cancer Surgery

A Multicenter Snapshot Study

Bruns, Emma R.J. M.D.1,2; Borstlap, Wernard A. M.D., Ph.D.1; van Duijvendijk, Peter M.D., Ph.D.2; van der Zaag-Loonen, Hester J. M.D., Ph.D.3; Buskens, Christianne J. Ph.D.1; van Munster, Barbara C. M.D., Ph.D.4,5; Bemelman, Willem A. Ph.D., M.D.1; Tanis, Pieter J. M.D., Ph.D.1

Diseases of the Colon & Rectum: July 2019 - Volume 62 - Issue 7 - p 823–831
doi: 10.1097/DCR.0000000000001360
Original Contribution: Colorectal Cancer
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BACKGROUND: There is still controversy about the relationship between preoperative anemia and outcomes after rectal cancer surgery.

OBJECTIVE: The aim of this study was to analyze the association between preoperative anemia and postoperative complications and the survival of patients undergoing surgery for rectal cancer in the era of laparoscopic surgery and modern perioperative care.

DESIGN: This was a cohort study.

SETTINGS: Data were gathered from 71 hospitals in The Netherlands.

PATIENTS: Patients who underwent resection for rectal cancer in 2011, for whom preoperative hemoglobin level was registered, were included.

INTERVENTIONS(s): There were no interventions.

MAIN OUTCOME MEASURES: Short-term outcome parameters were any postoperative complication or mortality within 30 days postoperatively, and pelvic infectious complications defined as anastomotic leakage and presacral abscess. Long-term outcomes were chronic sinus diagnosed at any time during 3-year follow-up, 3-year local and distant recurrence rates, and 3-year overall survival.

RESULTS: Of 2095 patients, 1857 had a registered preoperative hemoglobin level; 576 (31%) of these patients anemic and 1281 (69%) were nonanemic. Preoperative anemia was not independently associated with postoperative complications (HR, 1.1; 95% CI, 0.9–1.4; p = 0·24) or 30-day mortality (HR, 1.4, 95% CI, 0.7–2.8; p = 0·29). Preoperative anemia was associated with 3-year overall survival (HR, 2.1; 95% CI, 1.7–2.5; p < 0.0001), after multivariable analysis (HR, 1.4; 95% CI, 1.1–1.8; p = 0·008), and with local recurrence rate (HR, 1.6; 95% CI, 1.1–2.4; p = 0.026), but not with distant recurrence rate (HR, 1.2; 95% CI, 1.0–1.5; p = 0.054).

LIMITATIONS: Preoperative anemia appeared to have only limited association with postoperative and disease-specific outcome after rectal cancer surgery in contrast to published meta-analysis of small historical series.

CONCLUSIONS: Anemia is associated with overall survival. It might be considered as one of the warning signs in identifying high-risk patients. See Video Abstract at

1Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands

2Department of Surgery, Gelre Hospitals, Apeldoorn, The Netherlands

3Department of Epidemiology, Gelre Hospitals, Apeldoorn, The Netherlands

4Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, The Netherlands

5Department of Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

Funding/Support: None reported.

Financial Disclosure: None reported.

Correspondence: Emma R.J. Bruns, M.D., Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands. E-mail:

© 2019 The American Society of Colon and Rectal Surgeons