Endoscopist's Satisfaction with the Insertion Phase of Colonoscopy Is a Potential Quality Indicator for Colorectal Polyp Detection: A Propensity Score Matching Study.

Quality indicators during the insertion phase of colonoscopy require exploration. Unsatisfactory insertion experiences cause endoscopist psychophysiological fatigue and affect the quality of their inspection. This comparative study used propensity score matching (PSM) to determine whether endoscopist satisfaction during scope insertion was related to polyp detection rate (PDR). Patients who underwent colonoscopy screening between April 2019 and December 2022 were enrolled in this study. The endoscopist satisfaction score (high and low) during the insertion phase in each examination was recorded based on the level of fatigue and presence of paradoxical scope movement. All examinations were classified into 2 groups: a high and a low satisfaction score group. After PSM with potential confounding factors related to polyp detection (endoscopist, insertion and withdrawal time, and sedative agent use), the PDR and adenoma detection rate (ADR) were compared. Overall, 4142 patients (average age, 54.1 years old; 54.4% male) underwent colonoscopies performed by twelve experienced endoscopists. Analysis using a logistic regression model revealed that a high satisfaction score during the insertion phase was an independent predictor of polyp detection (P < .001, odds ratio 1.79, 95% CI 1.41-2.33), whereas insertion time was not. After PSM, 513 patients from both groups were eligible for comparison. Polyp detection rate and ADR were significantly higher in the high-satisfaction group than in the low-satisfaction group (49.5% vs. 36.6%, P < .001; 35.1% vs. 27.1%, P = .007). The endoscopists' level of satisfaction with the insertion phase was shown to be a potential predictor of PDR in screening colonoscopy.

Is Hyperthermic Intraperitoneal Chemotherapy Appropriate for Colon Cancer?

Colorectal cancer (CRC) with peritoneal metastases is a complex disease and its management presents significant clinical challenges. In well-selected patients at experienced centers, CRS/hyperthermic intraperitoneal chemotherapy (HIPEC) can be performed with acceptable morbidity and is associated with prolonged survival. Based on the results of recent randomized controlled trials, HIPEC using oxaliplatin after CRS with shortened perfusion periods (30 minutes) is no longer recommended. There is a movement toward utilizing mitomycin C as a first-line intraperitoneal agent with extended perfusion times (90-120 minutes); however, there is currently little prospective evidence to support its widespread use.

Laparoscopic D3 right hemicolectomy with intracorporeal anastomosis.

Complete mesocolic excision (CME) with D3 lymphadenectomy for colon cancer has been shown to improve overall as well as disease-free survival compared to conventional right hemicolectomy. Performing a laparoscopic CME/D3 right hemicolectomy with intracorporeal anastomosis (ICA) can be technically demanding even for experienced operators. Here, we present a systematic, standardized approach to the surgery.

Income differences in time to colon cancer diagnosis.

INTRODUCTION: People with low income have worse outcomes throughout the cancer care continuum; however, little is known about income and the diagnostic interval. We described diagnostic pathways by neighborhood income and investigated the association between income and the diagnostic interval. METHODS: This was a retrospective cohort study of colon cancer patients diagnosed 2007-2019 in Ontario using routinely collected data. The diagnostic interval was defined as the number of days from the first colon cancer encounter to diagnosis. Asymptomatic pathways were defined as first encounter with a colonoscopy or guaiac fecal occult blood test not occurring in the emergency department and were examined separately from symptomatic pathways. Quantile regression was used to determine the association between neighborhood income quintile and the conditional 50th and 90th percentile diagnostic interval controlling for age, sex, rural residence, and year of diagnosis. RESULTS: A total of 64,303 colon cancer patients were included. Patients residing in the lowest income neighborhoods were more likely to be diagnosed through symptomatic pathways and in the emergency department. Living in low-income neighborhoods was associated with longer 50th and 90th-percentile symptomatic diagnostic intervals compared to patients living in the highest income neighborhoods. For example, the 90th percentile diagnostic interval was 15 days (95% CI 6-23) longer in patients living in the lowest income neighborhoods compared to the highest. CONCLUSION: These findings reveal income inequities during the diagnostic phase of colon cancer. Future work should determine pathways to reducing inequalities along the diagnostic interval and evaluate screening and diagnostic assessment programs from an equity perspective.

Surgical options in retrosternal oesophageal reconstruction.

BACKGROUND: Retrosternal oesophageal reconstructions with collar anastomoses can become necessary when the stomach is either unavailable for oesophageal replacement, or orthotopic reconstruction is deemed impractical. Our aim was to analyse our results regarding technical approaches and outcomes. MATERIALS AND METHODS: All patients undergoing primary and secondary oesophageal retrosternal reconstructions with collar anastomoses at our centre (2019-2023) were retrospectively analysed and individual surgical reconstruction options were presented. RESULTS: Overall, twelve patients received primary (n = 5; 42.7%) or secondary (n = 7; 58.3%) reconstructions; ten with colonic interposition and two with gastric pull-up. Male/female ratio was 4:8; median age 66 years (30-87). Charlson-Comorbidity-Score (CCS) was 5 (1-7); 8/12 patients (67%) had ASA-classification score ≥ 3. We observed no conduit necrosis, but one patient (8.3%) with a leakage of the oesophago-colonostomy which was successfully treated by endoscopic vacuum therapy. Four patients (33.3%) acquired nosocomial pneumonia. Additional drainages for pleural fluid collections were necessary in three patients (25%). Overall comprehensive-complication-index (CCI) was 26.2 (0-44.9). Length-of-stay (LOS) was 22 days median (15-40). There was no 90-days mortality. Overall, CCI during the follow-up (FU) period at median 26 months (16-50) was 33.7 (0-100). 10 out of 12 patients were on sufficient oral nutrition at 12 months FU. CONCLUSION: Primary and secondary oesophageal retrosternal reconstructions encompass diverse entities and typically requires tailored decision-making. These procedures, though rare, are feasible with acceptable complication rates and positive functional outcomes when performed in experienced hands.

Treatment Differences for Splenic Flexure Cancers in Saudi Arabia: A Cross-Sectional Study.

Backgrounds Colorectal surgeons worldwide have differing opinions on the best way to handle rare cases of splenic flexure colon cancers (SFCs). Although the majority of reviews indicate no significant variation in oncological outcomes among the three different procedure types used to treat SFCs, surgeons still exhibit diversity in their practices. This study determined the treatment preferences of colorectal surgeons in Saudi Arabia. Methods A descriptive cross-sectional study evaluated the management of colorectal surgeons in handling SFC cases. We utilized a validated questionnaire developed by Manceau et al., consisting of 14 questions. Emails and phone numbers of members of the Saudi Society of Colorectal Surgery (SSCRS) were gathered. Google Forms surveys were administered from October 1-30, 2023. Results A response rate of 66% (58/88) was obtained among questioned colorectal surgeons. Their responses revealed that there was no consensus regarding the preferred procedure to treat SFCs. The most common treatment reported was segmental colectomy (SC) 21/58 (36.2%), followed by subtotal colectomy (STC) (19/58, 32.8%) and left hemicolectomy (LHC) (18/58, 31%). There was a strong consensus of 96% (56/58) of the respondents in favor of using stapler anastomosis rather than hand sewing. The frequency of performing SC, STC, and LHC in France was 70%, 13%, and 17%, respectively, compared to 36.2%, 32.8%, and 31% in Saudi Arabia, with a p-value of 0.001. The surgeons' preferred approaches to managing SFCs utilizing laparoscopic, open, or hand-aided in France versus Saudi Arabia were 63%, 31%, and 11%, respectively, compared to 84.5%, 8.6%, and 6.9%, with a p-value of 0.001. Conclusion A significant disparity exists regarding the treatment of SFCs between colorectal surgeons in France and Saudi Arabia. Furthermore, there is a lack of consensus among colorectal surgeons in Saudi Arabia regarding the surgical management of SFCs. Hence, it is imperative for the SCRSS to assemble a panel of experts to reach a consensus for the most appropriate and effective treatment of SFCs.

Low-grade appendiceal mucinous neoplasm penetrating sigmoid colon: A case report.

Low-grade appendiceal mucinous neoplasm (LAMN) is principally characterized by low-grade cytology without evidence of invasion to other organs. We report a LAMN surgical case whose appendiceal tumor penetrated the sigmoid colon wall. An 87-year-old man was referred for endoscopic resection (ER) of a colon polyp. Despite four ERs over 5 years, the polyp recurred at the same site. Laparoscopic surgery revealed a dilated appendix firmly attached to the sigmoid colon. We performed en bloc resection of both the sigmoid colon and appendix without tumor exposure. The histopathological evaluation showed that the LAMN had penetrated the sigmoid colon wall, forming two polyps on the colonic mucosa. In cases where the appendiceal-colonic fistula is suspected, en bloc resection of the appendix and colon wall should be considered.

[Colonic interposition with vascular anastomosis for upper digestive tract reconstruction after surgery for hypopharyngeal cancer with esophageal cancer].

Objective: To investigate the feasibility, safety and effectiveness of colonic interposition with vascular anastomosis in reconstructing the entire esophagus and hypopharynx after resection of hypopharyngeal cancer with esophageal cancer. Methods: We conducted a retrospective analysis of 4 male patients with simultaneous multiple primary cancers of the hypopharynx and esophagus, aged 47 to 58, treated in the Department of Head and Neck Surgery at the Hunan Cancer Hospital from February to August 2019. All cases underwent total hypopharyngectomy and total esophagectomy, of whom, three cases presented with total laryngectomy and one case with larynx preservation. Colonic interposition was performed using the left colic artery as a pedicle, with an average colonic length of 48.5 cm. The colon was elevated through the esophageal bed to the neck, and the branch of the colonic mesenteric artery was anastomosed to one of the neck arteries, including the inferior thyroid artery in one case, the transverse cervical artery in two cases, and the superior thyroid artery in one case, and all venous anastomoses were performed with the internal jugular veins. Results: The postoperative neck and abdominal wounds healed well without anastomotic leakage, and all patients were able to resume a regular oral diet within 21-30 days postoperatively. During the follow-up of 48-52 months, two cases died due to tumor recurrence, while the remaining two cases were disease-free survivals. Conclusion: Colonic interposition with vascular anastomosis is a safe and reliable reconstruction method suitable for repairing long-segment upper digestive tract defects after resection of hypopharyngeal cancer with esophageal cancer.

Colonic stenting: is the bridge to surgery worth its cost? A cost-effectiveness analysis at a single Asian institution.

Purpose: In patients with acute left-sided colonic obstruction, stenting can convert an emergency operation into a semi-elective procedure. However, its use continues to be debated. We performed a cost-effective analysis using our institution's experiences. Methods: Endoscopic, surgical, and financial details were prospectively collected for patients who presented with acute colonic obstruction and underwent stenting between 2019 and 2022. Outcomes were defined as technical/clinical success and successful surgical resection. The financial cost of stenting was compared with the expected cost without stenting. Results: Forty patients were included, with 29 undergoing definitive resection. The most common pathology was primary colon cancer (27 patients, 93%). Endoscopic stenting had high technical (90%) and clinical (83%) success rates, with low rates of complications such as perforation (2 patients, 7%) and migration (0 patients, 0%). As a bridge to surgery, the median procedure time was 226 minutes and the surgical outcomes also showed a low rate of complications (3 patients, 11%), such as anastomotic leakage (0 patients, 0%), intraabdominal abscesses (2 patients, 7%), and 30-day postoperative mortality (0 patients, 0%). The cumulative costs with colonic stenting were $32,900, while the expected costs with emergency surgery, including stoma reversal, were $40,700 (healthcare cost-savings of $7,800 per person). The difference was mainly due to the avoidance of upfront emergency surgery. The incremental cost-effectiveness ratio was 0.81, favoring colonic stenting over upfront emergency surgery. Conclusion: Colonic stenting as a bridge to surgery is safe and cost-effective for treating left-sided colonic obstruction with high success rates and low complication rates.

Selection of endoscopic resection technique for large colorectal lesion treatment.

PURPOSE OF REVIEW: Large nonpedunculated colorectal polyps ≥ 20 mm (LNPCPs) comprise 1% of all colorectal lesions. LNPCPs are more likely to contain advanced histology such as high-grade dysplasia and submucosal invasive cancer (SMIC). Endoscopic resection is the first-line approach for management of these lesions. Endoscopic resection options include endoscopic mucosal resection (EMR), cold-snare EMR (EMR), endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR). This review aimed to critically evaluate current endoscopic resection techniques. RECENT FINDINGS: Evidence-based selective resection algorithms should inform the most appropriate endoscopic resection technique. Most LNPCPs are removed by conventional EMR but there has been a trend toward C-EMR for endoscopic resection of LNPCPs. More high-quality trials are required to better define the limitations of C-EMR. Advances in our understanding of ESD technique, has clarified its role within the colorectum. More recently, the development of a full thickness resection device (FTRD) has allowed the curative endoscopic resection of select lesions. SUMMARY: Endoscopic resection should be regarded as the principle approach for all LNPCPs. Underpinned by high-quality research, endoscopic resection has become more nuanced, leading to improved patient outcomes.

Feasibility of initiating robotic surgery during the early stages of gastrointestinal surgery education.

PURPOSE: Minimally invasive surgery for gastrointestinal cancers is rapidly advancing; therefore, surgical education must be changed. This study aimed to examine the feasibility of early initiation of robotic surgery education for surgical residents. METHODS: The ability of staff physicians and residents to handle robotic surgical instruments was assessed using the da Vinci® skills simulator (DVSS). The short-term outcomes of 32 patients with colon cancer who underwent robot-assisted colectomy (RAC) by staff physicians and residents, supervised by a dual console system, between August 2022 and March 2024 were compared. RESULTS: The performances of four basic exercises were assessed after implementation of the DVSS. Residents required less time to complete these exercises and achieved a higher overall score than staff physicians. There were no significant differences in the short-term outcomes, operative time, blood loss, incidence of postoperative complications, and length of the postoperative hospital stay of the two surgeon groups. CONCLUSION: Based on the evaluation involving the DVSS and RAC results, it appears feasible to begin robotic surgery training at an early stage of surgical education using a dual console system.

The Value of Preoperative C-Reactive Protein to Albumin Ratio as a Prognostic Biomarker in Colon Cancer Patients.

Inflammatory acute phase proteins have been reported to play a crucial role in cancer progression. Various hematologic and inflammatory markers and scores, such as the lymphocyte-to-monocyte ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, systemic inflammation score (SIS), prognostic nutritional index (PNI), Glasgow prognostic score, and, more recently, the Naples prognostic score, have been reported as significant prognostic markers. The aim of this prospective study was to evaluate the prognostic significance of the C reactive protein-to-albumin ratio (CAR) in patients with colon cancer. Materials and Methods: We conducted a prospective observational study on a series of patients who underwent curative surgery for colon cancer. The C reactive protein-to-albumin ratio was determined preoperatively, and we evaluated the correlations between the CAR and various clinical and pathological parameters, as well as the correlation with Overall and Relapse-free survival. Furthermore, we compared the accuracy of the CAR with that of the Naples score. Results: One hundred and ten patients were included in the study. We set 0.4927 as the cut-off value for the CAR according to a receiver operating characteristic curve analysis. Based on the cut-off value, patients were divided into a low CAR group and a high CAR group. The preoperative CAR exhibited statistically significant correlation with tumor volume, T and N stage, number of positive lymph nodes, and grade of tumor differentiation. We also demonstrated a positive correlation between high CAR values and a higher Naples score (p = 0.0005), even when a subgroup analysis was performed for each group individually. Conclusions: The preoperative CAR is a useful prognostic marker in patients with colon cancer. These results may help to design strategies to personalize targeted management approaches among colon cancer patients.

Clinical Outcomes after Intracorporeal versus Extracorporeal Anastomosis in Patients Undergoing Laparoscopic Right Hemicolectomy for Colon Cancer.

Background and Objectives: Laparoscopic right hemicolectomy (LRHC) is commonly performed for patients with colon cancer, selecting between intracorporeal anastomosis (ICA) or extracorporeal anastomosis (ECA). However, the impact of ICA versus ECA on patient outcomes remains debatable. The varying levels of experience among surgeons may influence the outcomes. Therefore, this study sought to compare the short- and long-term outcomes of LRHC using ICA versus ECA. Materials and Methods: This retrospective study extracted patient data from the medical records database of Changhua Christian Hospital, Taiwan, from 2017 to 2020. Patients with colon cancer who underwent LRHC with either ICA or ECA were included. Primary outcomes were post-surgical outcomes and secondary outcomes were recurrence rate, overall survival (OS), and cancer-specific survival (CSS). Between-group differences were compared using chi-square, t-tests, and Fisher's exact tests and Mann-Whitney U tests. Associations between study variables, OS, and CSS were determined using Cox analyses. Results: Data of 240 patients (61 of ICA and 179 of ECA) with a mean age of 65.0 years and median follow-up of 49.3 months were collected. No recognized difference was found in patient characteristics between these two groups. The ICA group had a significantly shorter operation duration (median (IQR): 120 (110-155) vs. 150 (130-180) min) and less blood loss (median (IQR): 30 (10-30) vs. 30 (30-50) mL) than the ECA group (p < 0.001). No significant differences were found in 30-day readmission (ICA vs. ECA: 1.6% vs. 2.2%, p > 0.999) or recurrence (18.0% vs. 13.4%, p = 0.377) between the two groups. Multivariable analyses revealed no significant differences in OS (adjusted hazard ratio (aHR): 0.65; 95% confidence interval (CI): 0.25-1.44) or CSS (adjusted sub-hazard ratio (aSHR): 0.41, 95% CI: 0.10-1.66) between groups. Conclusions: Both ICA and ECA in LRHC for colon cancer had similar outcomes without statistically significant differences in post-surgical complications, 30-day readmission rates, recurrence rate, and long-term survival outcomes. However, ICA may offer two advantages in terms of a shorter operative duration and reduced blood loss.

Risk factors for esophageal anastomotic stricture after esophagectomy: a meta-analysis.

BACKGROUND: The aim of this study was to assess the risk factors for anastomotic stricture in esophageal cancer patients undergoing esophagectomy. Esophageal anastomotic stricture is the most common long-term complication for esophagectomy. The risk factors for esophageal anastomotic stricture still remain controversial. METHODS: MEDLINE, Cochrane Library, and EMBASE were searched to identify observational studies reporting the risk factors for esophageal anastomotic stricture after esophagectomy. A meta-analysis was conducted to investigate the impact of various risk factors on esophageal anastomotic stricture. The GRADE [Grading of Recommendations Assessment, Development and Evaluation] approach was used for quality assessment of evidence on outcome levels. RESULTS: This review included 14 studies evaluating 5987 patients.The meta-analysis found that anastomotic leakage (odds ratio [OR]: 2.75; 95% confidence interval[CI]:2.16-3.49), cardiovascular disease [OR:1.62; 95% CI: 1.22-2.16],diabete [OR: 1.62; 95% CI: 1.20-2.19] may be risk factors for esophageal anastomotic stricture.There were no association between neoadjuvant therapy [OR: 0.78; 95% CI:0.62-0.97], wide gastric conduit [OR:0.98; 95% CI: 0.37-2.56],mechanical anastomosis [OR: 0.84; 95% CI:0.47-1.48],colonic interposition[OR:0.20; 95% CI: 0.12-0.35],and transhiatal approach[OR:1.16; 95% CI:0.81-1.64],with the risk of esophageal anastomotic stricture. CONCLUSIONS: This meta-analysis provides some evidence that anastomotic leakage,cardiovascular disease and diabete may be associated with higher rates of esophageal anastomotic stricture.Knowledge about those risk factors may influence treatment and procedure-related decisions,and possibly reduce the anastomotic stricture rate.

Comparing cranial-caudal-medial and medial-lateral approaches for laparoscopic right hemicolectomy: a propensity score-matched analysis.

BACKGROUND: The cranial-caudal-medial approach (CCMA) has been proposed for laparoscopic right hemicolectomy nowadays. This study aimed to investigate the safety and oncological efficacy of CCMA in the treatment of right-sided colon cancer compared to the medial-lateral approach (MLA). METHODS: Patients diagnosed with right-sided colon cancer were included from February 2015 to June 2018, retrospectively, dividing into the CCMA group and the MLA group. We compared the basic characteristics and the short-term and long-term outcomes in two groups. RESULTS: Two hundred and ninety-six patients were included in this study. The baseline characteristics were similar in two groups. Compared with MLA group, CCMA group exhibited shorter operation time (136.3 ± 25.3 min vs. 151.6 ± 21.5 min, P < 0.001), lower estimated blood loss (44.1 ± 15.2 ml vs. 51.4 ± 26.9 min, P = 0.010), and more harvested lymph nodes (18.5 ± 7.1 vs. 16.5 ± 5.7, P = 0.021). The 5-year overall survival (OS) rate for the CCMA group was 76.5%, and the 5-year disease-free survival (DFS) rate was 72.3%, both of which were not inferior to the MLA group. No significant difference was found between two groups in terms of other clinical parameters. CONCLUSION: The CCMA in laparoscopic right hemicolectomy is safe and feasible, making the anatomical plane clearer. This approach can shorten the operation time, reduce intraoperative blood loss, harvest more lymph nodes, and yield satisfactory oncological outcomes.

Minimally invasive left colectomy with total intracorporeal anastomosis versus extracorporeal anastomosis. A single center cohort study. Stage 2b IDEAL framework for evaluating surgical innovation.

PURPOSE: Performing intracorporeal anastomoses in minimally invasive colon surgery appears to provide better short-term outcomes for patients with colon cancer. The aim of the study is to compare surgical aspects and short-term outcomes between intracorporeal and extracorporeal techniques in left colectomies with both laparoscopic and robotic approaches and evaluate advantages and disadvantages of intracorporeal anastomosis according to IDEAL framework (Exploration, stage 2b). METHODS: This is a single center, ambispective cohort study comparing total intracorporeal anastomosis (TIA) and standard surgery with extracorporeal anastomosis (EA). Patients with colon cancer treated by left colectomy, sigmoidectomy and high anterior resection by total intracorporeal anastomosis between May 2020 and January 2023 without exclusion criteria were prospectively included in a standardized database. Short-term outcomes in the group undergoing TIA were compared with a historical EA cohort. The main assessment outcomes were intraoperative complications, postoperative morbidity according to the Clavien-Dindo scale and the comparison of pathological. We conducted a preliminary comparative study within the TIA group between approaches, a primary analysis between the two anastomotic techniques, and a propensity score matched analysis including only the laparoscopic approach, between both anastomotic techniques. RESULTS: Two hundred and forty-six patients were included: 103 who underwent TIA, 35 of them with laparoscopic approach and 68 with robotic approach, and a comparison group comprising another 103 eligible consecutive patients who underwent laparoscopic EA. There were no statistically significant differences between the two groups in terms of demographic variables. No statistically significant differences were observed in anastomotic dehiscence. Intraoperative complications are fewer in the TIA group, with a higher C-Reactive Protein levels. Relevant anastomotic bleeding and the number of retrieved lymph nodes were higher in EA group. Nevertheless, no differences were observed in terms of overall morbidity. CONCLUSION: Minimally invasive left colectomy with intracorporeal resection and anastomosis is technically feasible and safe suing either a laparoscopic or a robotic approach. Clinical data from this cohort demonstrate outcomes comparable to those achieved through the conventional EA procedure in relation to postoperative morbidity and oncological efficacy, with indications suggesting that the utilization of robotic-assisted techniques may play a contributing role in enhancing overall treatment outcomes.

Modified Rosi-Cahill technique after left extended colectomy for splenic flexure advanced tumors.

Advanced splenic flexure tumors are uncommon and have a higher risk of relapse. To ensure that the resection includes the entire area of lymphatic drainage with a complete mesocolic excision (CME), a left extended colectomy is needed. In peritoneal carcinomatosis, there is often extensive involvement of the sigma and splenic flexure of the colon. In many instances, total colectomies are chosen for these patients, even when a significant portion of the colon could be preserved. The potential impact on quality of life after splenic flexure colon resection is discussed, as well as the importance of anatomical knowledge and expertise in performing this type of surgery. Overall, this work presents a modified technique that aims to improve the outcomes and quality of life for patients with splenic flexure colon cancer. Creating a tension-free anastomosis after extended left-sided colorectal resection is challenging. There is a negative impact on quality of life when an ileorectal anastomosis is created. The colorectal anastomosis performed after modified Rosi-Cahill or Deloyers' technique allows reduced small bowel bacterial overgrowth, achieves better water and sodium absorption, and altogether permits improved stool consistency. There are potential advantages of the Rosi-Cahill technique over other popular options such as Deloyers' procedure as there is no torsion of the ileocolic vessels and no mesenteric windows. A video was recorded showing a potential pitfall during Deloyers' technique resulting in the creation of a mesenteric window. The proper rotation of the colon during the modified Rosi-Cahill procedure was also filmed. Overall, this work presents a modified technique for reconstruction after left extended colectomy that aims to improve the outcomes and quality of life for patients with splenic flexure colon cancer.

Large non-pedunculated colorectal polyp management: The elephant in the room.

Minimally invasive innovations have transformed coloproctology. Specific to colorectal cancer (CRC), there has been a shift towards less invasive surgical techniques and use of endoscopic resection as an alternative for low risk T1 CRC. The role of endoscopic resection is however much more extensive: It is now considered the first line management strategy for most large (≥ 20 mm) non-pedunculated colorectal polyps, the majority of which are benign. This is due to the well-established efficacy, safety, and cost-effectiveness of endoscopic techniques compared to surgery. Multiple endoscopic modalities now exist with distinct risk-benefit profiles and their outcomes are further improved by site-specific technical modifications, auxiliary techniques, and adverse event mitigation strategies. Endoscopic capacity continues to evolve with emerging endoscopic techniques and expanding applications, particularly in the confines of a multi-disciplinary setting.

Tumor Budding as a Prognostic Marker in Primary Colon Cancer - A Single Center Experience.

Introduction: Tumor budding (TB) is considered to be a morphological and prognostic factor relevant to colon cancer (CC). The aim of our study is to assess the TB and to evaluate its relationship to clinicopathological findings within stage II and III CC patients as a single center experience. Materials and methods: A total of 120 CC patients operated between 2018 and 2021 at the University Clinic of Digestive Surgery in Skopje, the Republic of North Macedonia were included in this retrospective, single center study. TB was evaluated by the magnification of 200x along the invasive front of the primary tumor on H&E and CKAE1/AE3 immunohistochemically stained sections. Two grades were used: low grade (TB1, 0-4 TBs) and high-grade, which includes intermediate (TB2, 5-9 TBs) and high grade (TB3 ≥10TBs) of TBs. Results: A statistically significant correlation has been identified between high-grade TB and age (p=0.05) of the patients. There was also a significantly higher occurrence of high-grade TB in patients within stage III CC. Statistically significant correlations were also found in lymph node status (p<0.01), vascular invasion (p<0.05), lymphatic invasion (p<0.01), postoperative relapse (p<0.01), and death (p<0.01). Tumor relapse and death were significantly more frequent in patients with high-grade TB than those with low-grade TB. Patients with registered high-grade TB demonstrated significantly lower relapse-free survival (RFS) and overall survival (OS) rates than patients with low-grade TB over the observation period (RFS: 53.8% vs. 98.5%, p<0.001; OS: 65.4% vs. 97.1%, p<0.001, respectively). Patients with lung and liver postoperative relapses had higher percentage of cases with high-grade TB (94.1%). Conclusion: Our results are highly suggestive that TB should be included as a histological biomarker in the pathology report of patients with stage II and stage III CC, because of its prognostic value.