LAUSR

BACKGROUND Total neoadjuvant therapy is an alternative to neoadjuvant chemoradiation alone for rectal cancer and has the benefits of more completion of planned therapy, increased down-staging, earlier treatment of micrometastases, and assessment of chemosensitivity; however, it may increase surgical complications, especially with increased radiation-to-surgery interval. OBJECTIVE To determine the impact of total neoadjuvant therapy on postoperative complications compared to neoadjuvant chemoradiation alone. DESIGN Retrospective cohort study. SETTINGS Single tertiary referral center. PATIENTS Stage II/III rectal cancer patient who underwent total neoadjuvant therapy or long-course neoadjuvant chemoradiation followed by surgical resection from 2018-2020. MAIN OUTCOME MEASURES Severe postoperative complications (Clavien-Dindo grade ≥3). RESULTS Of 181 patients, 86 (47.5%) underwent total neoadjuvant therapy and 95 (52.5%) underwent neoadjuvant chemoradiation. There was no difference in severe postoperative complications or any complications. There was also no difference in the rate of complete total mesorectal excision or negative circumferential margin. Total neoadjuvant therapy had a mean operative time of 355.5 minutes and estimated blood loss of 263.6 mL compared to 326.7 minutes and 297.5 mL in the neoadjuvant chemoradiation group. Total neoadjuvant therapy patients had a lower mean lymph node yield compared to neoadjuvant chemoradiation patients. On multivariable analysis, total neoadjuvant therapy was associated with increased operative time (OR = 1.19, p < 0.001) and estimated blood loss (OR = 1.22, p < 0.001) and decreased lymph node yield (OR = 0.67, p < 0.001). There was no difference in severe complications or any complications. LIMITATIONS Selection bias uncontrolled by modelling. CONCLUSIONS We found no difference in risk of postoperative complications between patients who received total neoadjuvant therapy versus neoadjuvant chemoradiation. Total neoadjuvant therapy patients had longer operations and greater estimated blood loss. This may be a reflection of increased operative difficulty as a result of increased radiation-to-surgery interval and/or the effects of chemotherapy; however, the absolute differences were small and therefore should be interpreted cautiously. See Video Abstract at http://links.lww.com/DCR/C44.