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Postoperative pain score and NACRT predict anastomotic leakage in rectal cancer patients after anterior resectionOne Pain Score Could Save Your Stoma

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Key Takeaway
Consider postoperative pain score and NACRT as predictors for anastomotic leakage risk in rectal cancer surgery.

This retrospective cohort study analyzed 901 rectal cancer patients who underwent anterior resection at Tianjin Medical University Cancer Institute and Hospital. The intervention or comparator was not reported. The primary outcomes were overall anastomotic leakage (AL) and Grade C AL, with incidences of 8.9% (80/901) and 4.7% (42/901), respectively. Key predictors for overall AL included postoperative NRS pain score (OR = 9.556; 95% CI, 6.014-15.184; p < 0.001), neoadjuvant chemoradiotherapy (NACRT) (OR = 3.070; 95% CI, 1.525-6.182; p = 0.002), intersphincteric resection (ISR) (OR = 4.928; 95% CI, 1.340-18.126; p = 0.016), intestinal obstruction (OR = 2.926; 95% CI, 1.105-7.748; p = 0.031), tumor size (OR = 2.238; 95% CI, 1.239-4.042; p = 0.008), and operative time (OR = 2.416; 95% CI, 1.092-5.349; p = 0.030). Diverting stoma (OR = 0.124; 95% CI, 0.031-0.491; p = 0.003) and female gender (OR = 0.410; 95% CI, 0.220-0.765; p = 0.005) were associated with decreased risk. For Grade C AL, predictors included NRS pain score (OR = 6.563; 95% CI, 2.565-16.791; p < 0.001) and NACRT (OR = 7.534; 95% CI, 2.012-28.216; p = 0.003). Discrimination metrics showed C-statistics of 0.872 for overall AL and 0.817 for Grade C AL, with NRS pain score having individual AUCs of 0.812 and 0.759, respectively. Safety and tolerability data were not reported. Limitations include the retrospective design, which precludes causal inferences, and lack of reported follow-up, funding, or conflicts. The study offers a practical tool for early postoperative risk stratification and enhanced monitoring in high-risk patients, but findings should be interpreted cautiously due to observational nature and single-center setting.

The Hidden Danger After Surgery

Imagine you just had major surgery. You are recovering at home. You feel tired, but you think everything is fine. Then, the pain starts to get worse. You take more medicine, but the discomfort does not go away.

This is exactly what happened to many patients in a new study. They had surgery for rectal cancer. Doctors connected their healthy bowel to the rest of their digestive system. This connection is called an anastomosis.

Sometimes, this connection fails. It leaks. This is called an anastomotic leakage. It is a serious problem. It can lead to severe infection and the need for emergency surgery.

Rectal cancer is common. Many people need surgery to remove the tumor. Often, the connection is made low in the pelvis. This area is hard to reach. If a leak happens, it is very difficult to fix quickly.

Current treatments focus on fixing the problem after it appears. But by then, the patient has already suffered a lot. They might need a permanent bag or a long hospital stay.

Doctors need a way to see trouble coming before it happens. They need a warning system that works in the real world, not just in a lab.

The Surprising Shift

For years, doctors looked at many things to guess if a leak might happen. They checked tumor size, how long the surgery took, and if the patient had radiation therapy before.

They also looked at blood tests and imaging scans. But these methods were not perfect. They often missed the warning signs until the patient was already in pain.

But here is the twist. A new study found something simpler. The most important clue was the pain score.

Think of the healing bowel like a fresh scar on your skin. If you pull on it too hard, it might tear. The body sends pain signals when something is wrong.

In this study, researchers found that the pain score was like a smoke alarm. When the pain got high, it meant the connection was under stress. The higher the number on the pain scale, the higher the risk of a leak.

Other factors mattered too. Radiation therapy before surgery made the tissue weaker. A larger tumor also increased the risk. But the pain score stood out above the rest.

Researchers looked at 901 patients who had rectal cancer surgery. They studied records from 2020 to 2024. They tracked who had a leak and who did not.

They used a special math tool to build a prediction model. This tool weighs different factors to give a risk score. It worked very well at predicting leaks.

The results were clear. About 9% of patients had a leak. But the pain score predicted it best.

If a patient had high pain, their risk of a leak jumped significantly. In fact, high pain was the strongest predictor of all. Even better, a simple pain score worked almost as well as a complex computer model.

This means doctors do not need expensive scans to check every patient. They can just ask, "How is your pain?" A high answer means they need to watch that patient closely.

This doesn't mean this treatment is available yet.

If you or a loved one is recovering from rectal surgery, pay attention to your pain. Do not ignore a sudden increase in discomfort. Tell your nurse or doctor immediately.

Early action can prevent a small problem from becoming a crisis. If the pain is high, doctors might change your medicine or check the connection sooner.

This tool helps doctors decide who needs extra care. It ensures that high-risk patients get the attention they need before a leak happens.

This study was done at one hospital. It only looked at patients who had a specific type of surgery. The results might differ in other places or for different surgeries.

Also, this is a prediction tool. It cannot stop a leak from happening. It only helps doctors spot the risk early.

More hospitals will likely use this pain score in the future. It is easy to use and costs nothing extra.

Researchers will continue to test it in different settings. The goal is to make bowel surgery safer for everyone. Until then, listen to your body. Your pain is a valuable message.

Study Details

Study typeCohort
EvidenceLevel 3
PublishedApr 2026
View Original Abstract ↓
ObjectiveThis study aimed to identify predictors of anastomotic leakage (AL), including Grade C AL, after rectal cancer surgery and to establish a risk prediction model for clinical risk stratification.MethodsA retrospective study was conducted on rectal cancer patients who underwent anterior resection (AR) at Tianjin Medical University Cancer Institute and Hospital between November 2020 and November 2024. Clinicopathological variables were analyzed, and multivariable logistic regression was applied to construct predictive models for overall and Grade C anastomotic leakage.ResultsA total of 901 rectal cancer patients were included, with an AL incidence of 8.9% (80/901) and Grade C AL occurring in 4.7% (42/901). Multivariable analysis identified postoperative numerical rating scale (NRS) pain score (OR = 9.556; 95% CI, 6.014-15.184; p < 0.001), neoadjuvant chemoradiotherapy (NACRT) (OR = 3.070; 95% CI, 1.525-6.182; p = 0.002), intersphincteric resection (ISR) (OR = 4.928; 95% CI, 1.340-18.126; p = 0.016), intestinal obstruction (OR = 2.926; 95% CI, 1.105-7.748; p = 0.031), tumor size (OR = 2.238; 95% CI, 1.239-4.042; p = 0.008), operative time (OR = 2.416; 95% CI, 1.092-5.349; p = 0.030), diverting stoma (OR = 0.124; 95% CI, 0.031-0.491; p = 0.003), and gender (female vs. male) (OR = 0.410; 95% CI, 0.220-0.765; p = 0.005) as independent predictors of overall AL. For Grade C AL, NRS pain score (OR = 6.563; 95% CI, 2.565-16.791; p < 0.001) and NACRT (OR = 7.534; 95% CI, 2.012-28.216; p = 0.003) were significant predictors. The nomogram demonstrated strong discrimination, with C-statistics of 0.872 for overall AL and 0.817 for Grade C AL. NRS pain score achieved the highest individual predictive performance (AUC = 0.812 for overall AL; 0.759 for Grade C AL). Combined models integrating NRS with other variables further improved accuracy (AUC = 0.856 for overall AL; 0.817 for Grade C AL). Calibration curves showed excellent agreement between predicted and observed outcomes.ConclusionWe developed a risk prediction model for AL after rectal cancer surgery using preoperative, intraoperative, and early postoperative variables. The NRS pain score was the strongest predictor, and any unexplained rise in pain should raise suspicion of impending AL. This model offers a practical tool for early postoperative risk stratification and enhanced monitoring in high-risk patients.
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