Total neoadjuvant therapy (TNT) for rectal adenocarcinoma (RAC) involves multi-agent chemotherapy and radiation before definitive surgery. Previous studies of the rest period (time between radiation and surgery) and pathologic complete response (pCR) have produced mixed results. The objective of this study was to evaluate the relationship between the rest period and pCR. This study utilized the National Cancer Database (NCDB) to retrospectively analyze 5997 stage-appropriate RAC cases treated with TNT from 2016 to 2020. The overall pCR rate was 18.6%, with most patients undergoing induction chemotherapy followed by long-course chemoradiation (81.5%). Multivariable logistic regression models revealed a significant non-linear relationship between the rest period and pCR (p = 0.033), with optimal odds at 14.7–15.9 weeks post radiation (odds ratio: 1.49, 95% confidence interval: 1.13–1.98) when compared to 4.0 weeks. Medicaid, distance to the treatment facility, and community education were associated with decreased odds of pCR. Findings highlight the importance of a 15–16-week post-radiation surgery window for achieving pCR in RAC treated with TNT and socioeconomic factors influencing pCR rates. Findings also emphasize the need for clinical trials to incorporate detailed analyses of the rest period and social determinant of health to better guide clinical practice.

Our case highlights a 41-year-old male with a past medical history of severe diverticular disease since age 30, diabetes mellitus type 2, hypertension, protein calorie malnourishment, and body mass index of 50 kg/m2 who presented for a large bowel obstruction. Active surgical issues included: chronic incisional hernia, enterocutaneous fistulae, and a megacolon secondary to a recto-sigmoid anastomotic stricture. In collaboration with a colorectal surgeon and by using a multimodal approach, we successfully addressed the patient’s gastrointestinal issues and incisional hernia. The multimodal approach included botulinum toxin A (BTA) injections to the abdominal wall flat muscles (external oblique, internal oblique, and transverse abdominus), installation of an abdominal reapproximation anchor (ABRA) dynamic tissue system (DTS), and porcine urinary bladder matrix (PUBM) xenografts. The patient received BTA injections prior to the index operation, which lasted over 12 hours. The ABRA DTS assisted in achieving primary fascial closures. Definitive closure of this class 4 wound was facilitated by the antimicrobial and accelerated wound healing properties of PUBM as well as a unique multimodal approach to achieve exemplary results in a patient with multiple complex surgical issues.