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Survival in patients with stage IV unresectable rectosigmoid cancer is significantly reduced, and when patients are seen with symptoms of obstruction, it is advisable to perform a diverting colostomy before acute obstruction occurs. The aim of this study was to compare the results of endoscopic stent placement with diverting proximal colostomy in patients with stage IV rectosigmoid cancer and symptoms of chronic subacute obstruction. In a prospective randomized trial, 22 patients with stage IV unresectable rectosigmoid cancer and symptoms of chronic subacute obstruction were randomized to either endoscopic placement of an expandable stent or diverting proximal colostomy. Patients were followed until death. There was no case of mortality or major postoperative complications. Oral feeding and bowel function were restored within 24 hours after endoscopic stent placement and within 72 hours after diverting colostomy. Hospital stays were shorter (mean, 2.6 days) in patients with endoscopic stent placement than in those with diverting stomas (mean, 8.1 days) (P < .05). Mean long-term survival was 297 days (range, 125–612 days) in patients who had stents and 280 days (range, 135–591 days) in patients with stomas (P = NS). No case of mortality during follow-up was related to the procedures. All patients with stomas found them quite unacceptable. The same feelings were present in family members. None of the patients with stents or their family members found any inconvenience about the procedure. Endoscopic expandable stent placement offers a valid solution in patients with stage IV unresectable cancer and symptoms of chronic subacute obstruction, with shorter hospital stays. The procedure is much better accepted, psychologically and practically, by patients and their family members.

ObjectiveColorectal cancer is typically classified into proximal colon, distal colon and rectal cancer. Tumour genetic and epigenetic features differ by tumour location. Considering a possible role of bowel contents (including microbiome) in carcinogenesis, this study hypothesised that tumour molecular features might gradually change along bowel subsites, rather than change abruptly at splenic flexure.DesignUtilising 1443 colorectal cancers in two US nationwide prospective cohort studies, the frequencies of molecular features (CpG island methylator phenotype (CIMP), microsatellite instability (MSI), LINE-1 methylation and BRAF, KRAS and PIK3CA mutations) were examined along bowel subsites (rectum, rectosigmoid junction, sigmoid, descending colon, splenic flexure, transverse colon, hepatic flexure, ascending colon and caecum). The linearity and non-linearity of molecular relations along subsites were statistically tested by multivariate logistic or linear regression analysis.ResultsThe frequencies of CIMP-high, MSI-high and BRAF mutations gradually increased from the rectum (<2.3%) to ascending colon (36–40%), followed by falls in the caecum (12–22%). By linearity tests, these molecular relations were significantly linear from rectum to ascending colon (p<0.0001), and there was little evidence of non-linearity (p>0.09). Caecal cancers exhibited the highest frequency of KRAS mutations (52% vs 27–35% in other sites; p<0.0001).ConclusionsThe frequencies of CIMP-high, MSI-high and BRAF mutations in cancer increased gradually along colorectum subsites from the rectum to ascending colon. These novel data challenge the common conception of discrete molecular features of proximal versus distal colorectal cancers, and have a substantial impact on clinical, translational and epidemiology research, which has typically been performed with the dichotomous classification of proximal versus distal tumours.

To determine the effectiveness of surveillance colonoscopy (SC) and optimize its use by assessing real-world surgically resected cases of ulcerative colitis (UC)-associated colorectal cancer (CRC) and dysplasia. Clinicopathological data of 406 (238 CRC and 168 dysplasia) patients who underwent surgical resection in 10 UC specialized institutions were retrospectively reviewed. The overall survival (OS) rates were compared between the SC and non-SC groups. The incidence of and risk factors for early-onset CRC (<8 years after UC onset) were identified. The distribution of CRC lesions was also assessed. Cancer stages were significantly more advanced in the non-SC group than in the SC group (P < 0.001). The patients in the SC group showed significantly better OS than those in the non-SC group (5-year OS: 89% vs 70%; log-rank test: P = 0.001). Seventeen percent of patients developed CRC within 8 years after UC onset. The age at UC onset was a risk factor and a good predictor of early-onset CRC (<8 years) (P < 0.01; AUC: 0.85). The most common sites of CRC were the rectum (51%) and sigmoid colon (20%). Multiple CRC was identified in 16% of patients. Surveillance colonoscopy was effective and improved the OS in patients with UC. We recommend that patients with late-onset UC (>40 years) undergo SCs earlier because of the high incidence of CRC within 8 years of UC onset. Moreover, the rectum and sigmoid colon should be more thoroughly examined.

Background Curative resection of sigmoid colon and rectal cancer includes “high tie” of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the leakage rate, and it is unclear whether this confers a survival advantage. Accordingly, the IMA may be ligated at a point just below the origin of the left colic artery (LCA) “low tie” combined with lymph node dissection (LND) around the origin of the IMA (low tie with LND). However, no study has investigated the detailed prognostic results between “high tie” and “low tie with LND.” The aim of this study was to assess the utility of “low tie with LND” on survival in patients with sigmoid colon or rectal cancer. Methods A total of 189 sigmoid colon or rectal cancer patients who underwent curative operation from 1997 to 2007 were enrolled in this study. The patient’s medical records were reviewed to obtain clinicopathological information. Overall survival (OS) and relapse-free survival (RFS) rates were calculated using the Kaplan-Meier method, with differences assessed using log-rank test. Results Forty-two and 147 patients were ligated at the origin of the IMA (high tie) and just below the origin of the LCA combined with LND around the origin of the IMA (low tie with LND), respectively. No significant differences were observed in the complication rate and OS and RFS rates in the two groups. Further, no significant difference was observed in the OS and RFS rates in the lymph node-positive cases in the two groups. Conclusions “Low tie with LND” is anatomically less invasive and is not inferior to “high tie” with prognostic point of view.

Biallelic protein-truncating mutations in the adenomatous polyposis coli ( APC ) gene are prevalent in sporadic colorectal cancer (CRC). Mutations may not be fully inactivating, instead producing WNT/ β -catenin signalling levels ‘just-right’ for tumourigenesis. However, the spectrum of optimal APC genotypes accounting for both hits, and the influence of clinicopathological features on genotype selection remain undefined. We analysed 630 sporadic CRCs for APC mutations and loss of heterozygosity (LOH) using sequencing and single-nucleotide polymorphism microarrays, respectively. Truncating APC mutations and/or LOH were detected in 75% of CRCs. Most truncating mutations occurred within a mutation cluster region (MCR; codons 1282–1581) leaving 1–3 intact 20 amino-acid repeats (20AARs) and abolishing all Ser-Ala-Met-Pro (SAMP) repeats. Cancers commonly had one MCR mutation plus either LOH or another mutation 5′ to the MCR. LOH was associated with mutations leaving 1 intact 20AAR. MCR mutations leaving 1 vs 2–3 intact 20AARs were associated with 5′ mutations disrupting or leaving intact the armadillo-repeat domain, respectively. Cancers with three hits had an over-representation of mutations upstream of codon 184, in the alternatively spliced region of exon 9, and 3′ to the MCR. Microsatellite unstable cancers showed hyper-mutation at MCR mono- and di-nucleotide repeats, leaving 2–3 intact 20AARs. Proximal and distal cancers exhibited different preferred APC genotypes, leaving a total of 2 or 3 and 0 to 2 intact 20AARs, respectively. In conclusion, APC genotypes in sporadic CRCs demonstrate ‘fine-tuned’ interdependence of hits by type and location, consistent with selection for particular residual levels of WNT/ β -catenin signalling, with different ‘optimal’ thresholds for proximal and distal cancers.

The unique anatomical characteristics and blood supply of the rectosigmoid junction confer particular significance to its physiological functions and clinical surgeries. However, research on the prognosis of rectosigmoid junction cancer (RSC) is scarce, and reliable clinical prediction models are lacking. This retrospective study included 524 patients diagnosed with RSC who were admitted to the Department of Gastrointestinal and Colorectal Surgery at the First Hospital of Jilin University between January 1, 2017, and June 1, 2019. Univariate and multivariate Cox regression analyses were conducted in this study to identify independent risk factors impacting the survival of RSC patients. Subsequently, models were constructed using six different machine learning algorithms. Finally, the discrimination, calibration, and clinical applicability of each model were evaluated to determine the optimal model. Through univariate and multivariate Cox regression analyses, we identified seven independent risk factors associated with the survival of RSC patients: age (HR = 1.9, 95% CI: 1.3-2.8, P = 0.001), gender (HR = 0.6, 95% CI: 0.4-0.9, P = 0.013), diabetes (HR = 2.0, 95% CI: 1.3-3.1, P = 0.002), tumor differentiation (HR = 2.1, 95% CI: 1.4-3.1, P < 0.001), tumor N stage (HR = 2.02, 95% CI: 1.2-3.4, P = 0.009), distant metastasis (HR = 4.2, 95% CI: 2.7-6.7, P < 0.001), and anastomotic leakage (HR = 2.4, 95% CI: 1.1-5.3, P = 0.034). After evaluating each model, the prediction model based on XGBoost was determined to be the optimal model, with AUC of 0.7856, 0.8484, and 0.796 at 1, 3, and 5 years. It also had the lowest Brier scores at all time points, and decision curve analysis (DCA) demonstrated the best clinical decision benefits compared to other models. We developed a prediction model based on the optimal machine learning, XGBoost, which can assist clinical decision-making and potentially extend the survival of patients with rectosigmoid junction cancer.

Laparoscopy-assisted colectomy is technically feasible, but objective evidence of its benefits remains scarce. This study was done to evaluate the outcomes and operative stress of laparoscopy-assisted colectomy versus the traditional open method in the management of sigmoid complex polyps that cannot be safely or adequately removed by colonofibroscopy. Between January 1997 and December 1999, a total of 42 patients were equally randomized to the laparoscopy group and the laparotomy group by the blocked randomization method. Three patients randomized to the laparoscopy group did not complete the trial; therefore 18 patients treated by laparoscopy-assisted sigmoidectomy and the other 21 treated by the open method were prospectively evaluated. These two groups of patients were well matched in age, gender, symptoms, tumor location, localization method, tumor size, morphology, histopathology, and the accuracy of the clinical diagnosis. Two standardized surgical strategies, the lateral-to-medial and medial-to-lateral dissection sequences, were performed in 14 and 4 patients of the laparoscopy group, respectively, according to whether their tumors were located above or below 20 cm above the anal verge. After evaluating the surgical outcomes, we found that the laparoscopy group was significantly better than the laparotomy group in regard to parameters that included severity of postoperative pain, wound size, postoperative complication rate, and the duration of postoperative ileus, hospitalization, and disability. There was no significant difference in the operating times for these two groups. However, the costs of the laparoscopy group were significantly higher. To evaluate the surgical stress, we measured the serum C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), total lymphocyte count, and CD4+/CD8+ ratio 24 hours before and after surgery. We found that the postoperative serum CRP level and the ESR were significantly less elevated and the total lymphocyte counts and CD4+/CD8+ ratio were significantly less depressed in the laparoscopy group than in the laparotomy group. We thus concluded that laparoscopy-assisted sigmoidectomy can be safely performed with shorter convalescence and less operative stress but at a higher cost. We strongly recommended the use of this technique in the management of sigmoid complex polyps if the patient's economic status permits.

Background With recent advances in genetics research, genetic analysis is increasingly being used in clinical practice. We report a case in which genetic analysis aided in diagnosing a local recurrence of sigmoid colon cancer, initially suspected to be a primary neoplasm of the small intestine. Case presentation A 61-year-old male underwent laparoscopic sigmoidectomy for stage IIIB sigmoid colon cancer, followed by 8 cycles of CAPOX adjuvant chemotherapy, one and a half years prior. A follow-up CT scan performed one and a half years postoperatively revealed a mass in the small intestine near the ileal end, adjacent to the staple line of the previous colonic anastomosis. PET imaging showed high uptake in the small intestine but no significant uptake at the site of the prior anastomotic ring. Based on these findings, a primary small intestine neoplasm was suspected, rather than a local recurrence of the sigmoid cancer, prompting laparoscopic surgery. Intraoperative findings revealed an inflamed mass in the ileum, approximately 30 cm proximal to the cecum, involving staples from the previous anastomotic site. Consequently, an ileocecal resection combined with resection of the prior colonic anastomosis was performed. Macroscopically, the resected specimen revealed a 25-mm Type 2 tumor in the ileum extending into the previous anastomotic site of the large intestine, while the colonic mucosa remained intact. Histopathological examination identified a moderately differentiated tubular adenocarcinoma, consistent with the histology of the primary sigmoid cancer, raising the possibility of local recurrence. To analyze the origin of the ileal tumor, we performed whole-genome sequencing and subsequent PCR direct sequencing. As a result, identical mutations in two key driver genes ( KRAS c.35G > A and PIK3CA c.1624G > A), as well as a mutation in a passenger gene ( BBS9 c.2218_2222del), were identified in the primary and ileal tumors. These findings confirmed that the ileal tumor was a local recurrence rather than a new primary malignancy. Conclusions The present case highlights the practical application of genetic analysis in clinical practice, particularly when clinical diagnosis and histopathological findings are inconclusive or conflicting.

Introduction: Colorectal cancer is the third most common cancer in the male and female population. Surgical treatment of colorectal cancer is based on tumor resection and removal of associated lymph glands. Aim: The aim of the paper is to present data from a five-year retrospective study of the surgical treatment of colorectal cancer at the Clinic for General and Abdominal Surgery at the Clinical Center of the University of Sarajevo. Methods: This is a retrospective five-year clinical trial (2014-2018) of patients with and surgically treated for colorectal cancer at the Clinic for General and Abdominal Surgery at the Clinical Center of Sarajevo University. Results: In the 2014-2018 period, n = 11 172 patients were hospitalized at the Clinic, of which n = 732 were surgically treated for colorectal cancer. 69.80% were operated in an elective program. 30.20% were made as emergencies. 51.09% were male patients and 48.36% were female patients. 97.20% were made by open technique. 2.10% operated by minimally invasive procedure. the most common type of colon tumor is Adenocarcinomas are the most common with 79%. Conclusions: Better prevention and early detection are required to reduce the incidence of patients, which ultimately leads to more effective treatment and longer survival of colon cancer patients. Operative surgical principles must be adapted to modern trends, minimally invasive procedures (laparoscopic surgery, robotic surgery).