BACKGROUND: Early-onset colorectal cancer is now the leading cause of cancer death among adults under 50, with delays in diagnosis cited as a potential contributor to patients being diagnosed more frequently at advanced stages than their older counterparts. Despite this, few studies have comprehensively evaluated factors associated with diagnostic delays among patients with early-onset colorectal cancer in the United States. OBJECTIVE: To synthesize factors contributing to early-onset colorectal cancer diagnostic delays in the United States using the Model of Pathways to Treatment to guide interventions that reduce diagnostic delays. DATA SOURCES: Two electronic databases were queried: Embase and MEDLINE. STUDY SELECTION: Both qualitative and quantitative studies were included if they had early-onset colorectal cancer participants and a discussion of factors contributing to delays in diagnosis. Studies conducted outside of the United States, not peer-reviewed, and lacking primary data were excluded. MAIN OUTCOME MEASURES: Patient, provider, and system-level factors contributing to delays in diagnosis across the appraisal, help-seeking, and diagnostic intervals. RESULTS: Among 35 included studies, only 8 utilized qualitative methods. Most studies examined broader trends in early-onset colorectal cancer instead of evaluating a specific interval, using stage at diagnosis as a proxy for delays. Additionally, many factors affected multiple intervals, highlighting that factors are crosscutting. LIMITATIONS: Findings may not be generalizable outside the United States, given differences in healthcare financing, access, and screening practices. Using late-stage diagnosis as a proxy for delays is also debated and could confound stage-based inferences about delay. Few studies capture the subjective experiences of younger patients or the clinical reasoning and constraints providers face when evaluating symptoms. CONCLUSIONS: Diagnostic delays in early-onset colorectal cancer are difficult to confine to a single interval and require system-level interventions to support earlier detection. More qualitative inquiry is necessary to identify effective interventions, including interviews that elicit patient and provider experiences of barriers.
BACKGROUND:Higher procedure volume correlates with improved surgical outcomes, yet recent literature has questioned whether this relationship persists in modern times. Reports of an attenuated volume-outcome association may reflect the limitations of a single, static, cutoff rather than true weakening of the underlying relationships. Stratum-specific likelihood ratios generate multiple empirically derived volume strata that may detect persistent gradients that are obscured by binary threshold approaches. OBJECTIVES:(1) To define hospital-level volume thresholds for colorectal cancer resections using stratum-specific likelihood ratios, (2) assess these thresholds across multiple outcome measures, procedure types, and tumor locations, and (3) examine whether the volume-outcome relationships persist across temporal cohorts. DESIGN:Retrospective cohort study. SETTING:National Cancer Database from 2004-2020. PATIENTS:Patients undergoing colorectal resection for cancer. Patients with metastatic disease were excluded. MAIN OUTCOME MEASURES:Primary outcome was 90-day mortality. Secondary outcomes included 30-day mortality and textbook outcome (length of stay ≤7 days, negative surgical margin, survival >90 days, and no 30-day readmission). RESULTS:Overall, 1,052,875 patients underwent colorectal resection at 1344 hospitals. Stratum-specific likelihood ratios identified 6 volume strata (≤42, 43-70, 71-108, 109-280, 281-439, and ≥440 colorectal resections per year) with progressively decreasing 90-day mortality across groups (≤42: 5.9% to ≥440: 0.6%). The threshold of 71 resections per year was identified as the optimal threshold. Consistent gradients were also observed across 30-day mortality and textbook outcome and persisted across procedure types and tumor locations. Volume-outcome associations remained significant across all temporal cohorts, including the most recent period (2016-2020; p <0.001). LIMITATIONS:Limited to Commission on Cancer facilities, lacks granular hospital characteristics, restricted to malignant indications. CONCLUSIONS:Stratum-specific likelihood ratios reveal persistent volume-outcome associations for colorectal cancer resections across multiple strata, even in contemporary data. These findings suggest that the reports of an attenuated volume-outcome relationship may reflect limitations of a single, static volume cutoff, rather than weakening of this association. See Video Abstract.
BACKGROUND:Minimally invasive surgery and Enhanced Recovery After Surgery protocols enable discharge within 1 to 3 days after colon surgery. However, despite accumulating evidence, routine implementation of discharge within 24 to 72 hour remains variable and often limited outside specialized pathways. To address this, our center implemented a clinically guided Day-1 discharge pathway, in which Day 1 discharge was the default target for all eligible patients. OBJECTIVE:To evaluate the feasibility and safety of a clinically guided Day-1 discharge pathway for all eligible patients undergoing minimally invasive colon surgery. DESIGN:Prospective cohort study from March 2020 to December 2024. SETTINGS:Tertiary colorectal center. PATIENTS:All adult patients who underwent minimally invasive colon resection surgery without stoma formation were included. INTERVENTION:A clinically guided Day 1 discharge pathway was implemented in March 2020, in which Day 1 discharge was the default target for all eligible patients, with discharge pursued when predefined clinical criteria and patient willingness were met. MAIN OUTCOME MEASURES:Primary outcome was safety and feasibility of standardized Day 1 discharge, assessed through Day 1 discharge rates in conjunction with 30-day readmissions, severe complications (Clavien-Dindo ≥IIIb), and failure to rescue. Secondary outcomes included changes in discharge practices over time and factors associated with readmissions, severe complications, or Day 1 discharge. RESULTS:A total of 549 patients were included (33.2% aged ≥ 75 years). Median length of stay decreased from 3.0 to 1.0days (p < 0.001). Day 1 discharge increased from 4.6 to 65.0% (p < 0.001), with no significant changes in 30-day readmission (p = 0.43) or severe complication rates (p = 0.91). No preventable failure to rescue after discharge was identified. No patient characteristics were associated with increased readmissions or severe complications. Day 1 discharge rates increased steadily over time and were sustained, with discharge decisions progressively guided by individual postoperative recovery rather than fixed patient characteristics. LIMITATIONS:Single-center, non-randomized design limits causal inference and generalizability. Low event rates reduced power for subgroup analyses. CONCLUSIONS:Standardized Day 1 discharge is feasible and safe for patients undergoing elective minimally invasive colon surgery without stoma formation. See Video Abstract.
BACKGROUND: Locally advanced rectal cancer is treated with total neoadjuvant therapy which consists of neoadjuvant chemotherapy, radiation, and surgery. The comparative efficacy of long and short course radiotherapy within total neoadjuvant therapy remains uncertain. OBJECTIVE: Compare overall survival and pathological outcomes between patients treated with long or short course radiation as components of total neoadjuvant therapy. DESIGN: Retrospective cohort study. SETTINGS: National Cancer Database, 2018 to 2023. PATIENTS: Adults with clinical Stage II or III rectal adenocarcinoma treated with neoadjuvant chemotherapy and radiation followed by radical surgical resection. MAIN OUTCOME MEASURES: Overall survival and pathological outcomes in a propensity score matched cohort comparing long and short course radiation. RESULTS: A total of 12,462 patients met inclusion criteria; 10,740 (86.2%) received long course radiation and 1,722 (13.8%) received short course radiation. After 1:1 propensity score matching, 1,721 per group were identified. Overall survival at 48 months did not differ (log rank p = 0.397). There were no differences in pathological complete response rate, pathological tumor stage, tumor downstaging, or pathological nodal stage. The long course radiotherapy group had higher nodal downstaging (66.5 vs 62.7%, p = 0.023) and a nonsignificant trend towards lower nodal disease (N0 73.9 vs 70.7%, N1 21.5 vs 23.3%, and N2 4.6 vs 6.0%, respectively, p = 0.062). LIMITATIONS: Residual confounding from unmeasured clinical and treatment details is possible. This cohort was restricted to patients who underwent resection. CONCLUSIONS: Among locally advanced rectal cancer patients treated with total neoadjuvant therapy and radical resection, long and short course radiotherapy had similar overall survival, but long course radiotherapy patients had higher rates of nodal downstaging. These findings support the use of either long or short course radiotherapy regimens when planned resection is intended, but the clinical significance of differences in nodal downstaging remain uncertain. See Video Abstract.
BACKGROUND:Liver enzyme biomarkers are known to contribute to the onset and progression of colorectal cancer. OBJECTIVE:To develop a novel oxidative stress index score integrating γ-glutamyl transferase and total bilirubin, evaluate its prognostic value in locally advanced rectal cancer patients receiving neoadjuvant therapy, and construct and validate machine learning-based survival prediction models incorporating oxidative stress index score. DESIGN:A novel liver enzyme indicator - oxidative stress index score was established by integrating γ-glutamyl transferase and total bilirubin. Machine learning models were constructed based on oxidative stress index score and clinicopathological characteristics to predict survival. The predictive performance of these models was evaluated and interpreted and further validated in the validation cohort. Using these models, patients were stratified into low risk and high-risk groups for both disease-free survival and overall survival, respectively. SETTINGS:Data were collected from Sun Yat-Sen University Cancer Center between May 2007 and August 2018. PATIENTS:We enrolled locally advanced rectal cancer patients who had undergone either total neoadjuvant therapy (as the training cohort) or neoadjuvant chemoradiotherapy (as the validation cohort), followed by total mesorectal excision with or without adjuvant chemotherapy. MAIN OUTCOME MEASURES:Disease-free survival and overall survival in the training and validation cohort. RESULTS:A total of 970 locally advanced rectal cancer patients were allocated to a training cohort (n = 521) and a validation cohort (n = 449). Among 5 machine learning models, random survival forests demonstrated optimal predictive efficiency. Thus, the random survival forests model was constructed based on oxidative stress index score. The random survival forests models outperformed ypstage in prediction efficiency significantly across both cohorts. In both cohorts, low-risk groups exhibited significantly higher disease-free survival and overall survival rates compared to high-risk groups (all p < 0.000 1). A free online random survival forests calculator has been developed (https://zhuoliworkroom.shinyapps.io/new_shiny/). LIMITATIONS:Our study has inherent limitations of retrospective and single-center studies. CONCLUSIONS:A higher oxidative stress index score was significantly associated with worse prognostic outcomes. Collectively, these random survival forests models exhibit superior predictive performance compared to conventional ypstage indicators. See Video Abstract.
Thirty-five-year-old female presents with a history of chronic constipation, gastroparesis, chronic lower abdominal pain, and anxiety. She is diagnosed with colonic inertia and undergoes a total abdominal colectomy with ileorectal anastomosis. She initially does well with resolution of her constipation; however, she continues to complain of persistent lower abdominal pain, debilitating enough to keep her from working at full capacity.
BACKGROUND:Achieving R0 resection in pelvic solid malignancies significantly prolongs survival. However, when these tumors involve the high sacrum (S2 and below), the procedure is often deemed contraindicated due to technical complexity and substantial perioperative risks. OBJECTIVE:To describe a standardized three-step posterior sacral resection technique for high sacrectomy and evaluate its perioperative and oncological outcomes. DESIGN:Retrospective cohort study. SETTINGS:Department of Abdominal and Pelvic Tumor Surgery, The First Affiliated Hospital of Zhengzhou University, and Department of General Surgery, Henan Cancer Hospital. PATIENTS:A total of 47 patients with pelvic solid malignancies (recurrent rectal cancer, chordoma, or presacral malignant teratoma) invading the high sacrum (S2 and below) who underwent surgery between January 2018 and December 2024. INTERVENTION:All patients underwent a standardized three-step posterior sacral resection: (1) posterior exposure and anatomical localization of the sacral level; (2) curvilinear osteotomy using a broad-bladed osteotome with preservation of the presacral venous plexus; (3) neurovascular identification, hemostasis, and pelvic floor reconstruction (e.g., gluteus maximus flap). MAIN OUTCOME MEASURES:Total operative time, duration of sacral resection, intraoperative blood loss, R0 resection rate, postoperative complications (assessed via Neurogenic Bladder Symptom Score), and 5-year recurrence rates. RESULTS:The median total operative time was 245 minutes (IQR, 210-285). The median sacral resection time was 40 minutes (IQR, 35-50), with a median blood loss of 150 mL (IQR, 100-250). All 47 patients (100%) achieved R0 resection. The 30-day and 90-day mortality were 0%. Major complications (Clavien-Dindo ≥ IIIb) were absent. Voiding dysfunction was common but transient: 7 patients (Neurogenic Bladder Symptom Score <20) recovered immediately; 15 (Neurogenic Bladder Symptom Score 20-40) recovered by 3 months; 20 (Neurogenic Bladder Symptom Score 40-60) recovered by 6 months; 5 (Neurogenic Bladder Symptom Score >60) recovered by 12 months. Superficial wound infection occurred in 8 patients (17.0%) and pelvic collection requiring drainage in 5 (10.6%). The median length of hospital stay was 19 days. LIMITATIONS:Single-region study with moderate sample size; lack of a control group for direct comparison with conventional approaches. CONCLUSIONS:This standardized three-step transperineal technique enables rapid, safe, and effective high sacrectomy with high R0 rates and acceptable morbidity, offering a promising option for patients with pelvic malignancies invading the high sacrum. See Video Abstract.
BACKGROUND: Anastomotic leakage remains a critical complication in colorectal surgery. OBJECTIVE: This study compared the efficacy of three-row versus two-row circular staplers in reducing anastomotic leakage rates. DESIGN: Prospective, randomized, single-center, non-inferiority trial. SETTINGS: Clinic of Colorectal and Minimally Invasive Surgery, University Hospital Nº 2, Sechenov University. PATIENTS: The trial included patients who underwent low anterior resection with total mesorectal excision. INTERVENTIONS: Patients were randomized 1:1 to 2-row or 3-row stapler group using centralized, computer-generated randomization. Outcome adjudicators, data collectors, and data analysts were blinded. MAIN OUTCOME MEASURES: Anastomotic leakage incidence; intra- and postoperative anastomotic bleeding; 30-day complications; low anterior resection syndrome; anastomotic stenosis; adverse events; time to and permanence of stoma; and 5-year overall survival. RESULTS: Among 154 patients included in the study, the anastomotic leakage rate was 16.9% (13/77) in the 3-row group compared to 15.6% (12/77) in the 2-row group ( p = 0.8). The observed difference between groups was 1.3%, with a one-sided 95% confidence interval bounded below by -8.47%. The rates of anastomotic stricture were 1.4% (n = 2) in the two-row group and 0.7% (n = 1) in the 3-row group ( p = 1). No patients experienced anastomotic hemorrhage. Stoma closure was successfully performed in 147 patients (95.5%). The 5-year overall survival was 80.2% (95% confidence interval, 69.4-92.8) in the 3-row group versus 83.8% (95% confidence interval, 75.6-92.3) in the 2-row group ( p = 0.80). LIMITATIONS: Routine postoperative proctography was not performed, clinically silent (Grade A) leaks may have been missed; the study was underpowered because the assumed 12% anastomotic leakage difference for sample-size estimation was optimistic; neoadjuvant regimen heterogeneity may have influenced outcomes; and the single-center design may limit generalizability. CONCLUSIONS: The three-row stapler was not non-inferior to the 2-row stapler in preventing anastomotic leakage. See Video Abstract . Clinical trial registration number: NCT03910699
BACKGROUND:Natural orifice specimen extraction surgery has been increasingly adopted in rectal cancer surgery, but comparative evidence across natural orifice specimen extraction surgery, laparoscopic surgery, and open surgery remains limited, especially regarding functional and long-term oncological outcomes. OBJECTIVE:To compare short-term recovery, 6-month functional outcomes, and long-term survival among natural orifice specimen extraction surgery, laparoscopic surgery, and open surgery for rectal cancer within a uniform treatment period. DESIGN:Multicenter retrospective analysis of prospectively collected real-world data using inverse probability of treatment weighting. SETTINGS:Four tertiary colorectal cancer centers in China. PATIENTS:A total of 3,385 patients underwent curative-intent resection for rectal adenocarcinoma between 2017 and 2019, including 1379 treated with open surgery, 1520 with laparoscopic surgery, and 486 with natural orifice specimen extraction surgery. MAIN OUTCOME MEASURES:Short-term postoperative recovery, complications, 6-month bowel and urinary function assessed using the low anterior resection syndrome score and the International Prostate Symptom Score, and long-term disease-free survival and overall survival. RESULTS:After weighting, baseline characteristics were well balanced (standardized mean differences < 0.1). Natural orifice specimen extraction surgery showed the fastest short-term recovery among the 3 groups, with significantly shorter time to gastrointestinal recovery, lower pain scores, and fewer wound-related complications compared with both laparoscopic surgery and open surgery. Functional outcomes favored minimally invasive approaches: both natural orifice specimen extraction surgery and laparoscopy surgery showed significantly lower low anterior resection syndrome score and International Prostate Symptom Score than open surgery, with no differences between the 2 minimally invasive approaches. Long-term oncological outcomes were comparable across groups; 5-year disease-free survival was 62.2% for laparoscopic surgery, 63.4% for natural orifice specimen extraction surgery, and 60.5% for open surgery, and 5-year overall survival was 72.2, 74.5, and 73.5%, respectively (all p > 0.05). LIMITATIONS:Retrospective design and potential residual confounding despite weighting. CONCLUSIONS:The short-term recovery advantage of natural orifice specimen extraction surgery was most evident compared with open surgery and more modest relative to laparoscopy surgery, while functional and long-term oncological outcomes remained comparable. When performed under standardized oncological principles, natural orifice specimen extraction surgery is a safe and effective minimally invasive option for selected rectal cancer patients. See Video Abstract.
BACKGROUND:Globally, the disease burden of colorectal cancer has been gradually increasing. Radical resection is the cornerstone treatment for colorectal cancer, but postoperative gastrointestinal dysfunction has been a potential complication. Current therapies are unsatisfactory. Acupuncture has the merits of inexpensive and easy-operative and has the potential to be a promising strategy. OBJECTIVE:This study aimed to observe the effect and safety of electroacupuncture in facilitating the postoperative recovery of colorectal cancer patients. DESIGN:Randomized controlled study. SETTING:Prospective, single-center study. PATIENTS:Patients over 18 years old who undergone radical resection of colorectal cancer. INTERVENTIONS:Electroacupuncture or sham electroacupuncture at 2h after surgery and on the morning of the first 2 days after surgery, with 30 minutes each session. OUTCOMES:The primary outcome was first flatus time. Secondary outcomes included first oral feeding time, bowel sound recovery time, length of postoperative hospitalization, adverse events, serum inflammatory cytokine indicators and heart rate variability indicators. RESULTS:One hundred fifteen patients met the inclusion criteria and 101 patients completed the treatment and were enrolled into statistical analysis. There was no statistically significant difference (p > 0.05) in baselines. First flatus time, first oral feeding time, bowel sound recovery time were improved in electroacupuncture group (p < 0.05). Length of postoperative hospitalization was not significantly different. On postoperative day 1, interleukin-1β was lower in electroacupuncture group (p < 0.05); On postoperative day 3, interleukin -1 β, and interleukin -6 were lower in electroacupuncture group (p < 0.05). Percentage of difference between adjacent normal RR intervals exceeding 50ms and high frequency were higher in electroacupuncture group (p < 0.05). Kaplan-Meier curve analysis, multiple linear regression and correlation analysis secured the stability of the main results. LIMITATIONS:This is a single-center trial with a small sample size and long-term follow-up was absent. No blank control group was set. CONCLUSIONS:EA facilitated postoperative recovery without increasing the incidence of complications. This effect was hypothesized to be related to lower IL-1β/IL-6 levels and the rebalance of autonomic nervous system. See Video Abstract.Clinical trial registration: The trial has been registered at chictr.org.cn (ChiCTR2100050660 https://www.chictr.org.cn/hvshowproject.html?id=167502&v=1.9).
BACKGROUND:Ileal pouch anal anastomosis can be performed via 2- and 3-stage techniques, with similar short- and long-term clinical outcomes. 2-stage ileal pouch anal anastomosis became the predominant approach in the 2000s; whether this trend has continued remains unknown. OBJECTIVE:To compare trends in the utilization of 3-stage, traditional 2-stage, and modified 2-stage IPAA for ulcerative colitis as well as markers of disease severity over time. DESIGN:Retrospective cohort. SETTING:Privately insured patients from an administrative database. PATIENTS:Non-elderly adults with a diagnosis of ulcerative colitis who underwent ileal pouch anal anastomosis between 2007 and 2023 and remained enrolled in their insurance plan for ≥ 6 months after surgery. MAIN OUTCOME MEASURES:Proportion of patients undergoing 3-stage, traditional 2-stage, and modified 2-stage ileal pouch anal anastomosis; annualized change in disease severity at the time of ileal pouch anal anastomosis creation. RESULTS:Four thousand thirty-nine patients underwent IPAA during the study period (2,179 traditional 2-stage; 1,107 3-stage; and 753 modified 2-stage). The proportion of patients undergoing a traditional 2-stage IPAAs decreased steadily (1.3% points per year [95% CI -1.7 to -0.9]) with a commensurate rise in both 3-stage (0.3% points per year [95% CI -0.02-0.7]) and modified 2-stage operations (0.9% points per year [95% CI 0.6-1.2]). Patients undergoing 3-stage or modified 2-stage IPAA had a more rapid increase in exposure to advanced therapies in the year before surgery (+ 2.9 vs + 2.0% points). Limitations: potential misclassification, generalizability. CONCLUSIONS:More patients are undergoing 3-stage and modified 2-stage operations than traditional 2-stage ileal pouch anal anastomosis. This shift parallels an increase in multiple markers of disease severity at IPAA creation, especially exposure to advanced therapies. See Video Abstract.
BACKGROUND: Large-scale evidence on the role of endoscopy alone as the assessment tool to identify complete response after neoadjuvant therapy in locally advanced rectal cancer, particularly across different neoadjuvant therapy regimens, is scarce. OBJECTIVE: This study aims to evaluate the diagnostic accuracy of endoscopy for predicting luminal complete response after neoadjuvant therapy and compare its performance between patients receiving neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy. DESIGN: Retrospective cohort study. SETTINGS: The study was conducted at a teaching hospital. PATIENTS: A total of 349 locally advanced rectal cancer patients (223 neoadjuvant chemotherapy, 126 neoadjuvant chemoradiotherapy) who underwent neoadjuvant therapy and restaging endoscopy were included. INTERVENTIONS: Three reviewers assessed endoscopic images independently to determine the occurrence of endoscopic complete response. MAIN OUTCOME MEASURES: The diagnostic accuracy for predicting pathological luminal complete response (ypT0) was calculated. RESULTS: The overall accuracy of endoscopy for predicting complete response was 92.0% (321/349), with a positive predictive value of 69.6%, sensitivity of 69.6% and specificity of 95.4%. A flat scar was the most predictive feature (positive predictive value = 70.3%). The sensitivity of endoscopic performance was significantly higher in the neoadjuvant chemoradiotherapy group compared to the neoadjuvant chemotherapy group (90.0% vs. 53.8%, p = 0.008), despite comparable overall accuracy and area under the curve. The addition of biopsy did not significantly improve diagnostic ability. Inter-reviewer agreement was substantial to excellent (κ=0.754-0.883). LIMITATIONS: No video or artificial intelligence was involved. CONCLUSIONS: Endoscopy is an optional tool for identifying luminal complete response after neoadjuvant therapy. Its sensitivity is lower after neoadjuvant chemotherapy than after neoadjuvant chemoradiotherapy, warranting caution against missed diagnoses. Beyond the flat scar, other features like small flat ulcers also have a non-negligible complete response rate. The role of routine biopsy still needs further exploration. See Video Abstract.
BACKGROUND:The incidence of rectal adenocarcinoma is rising in patients < 50 years old compared to those > 50. Nonoperative management and active surveillance have become a standard of care in rectal cancer treatment for those who achieve a complete response to neoadjuvant therapy; however, the use, safety and efficacy of this approach in different age groups has not been well described. OBJECTIVE:Examine oncological outcomes in patients with rectal adenocarcinoma managed by nonoperative management according to patient age. DESIGN:Retrospective cohort study. SETTING:Comprehensive cancer center in New York. PATIENTS:Patients with rectal adenocarcinoma diagnosed between January 2006 and December 2020. MAIN OUTCOME MEASURES:Local regrowth, recurrence-free survival, distant metastasis-free survival, overall survival rates. RESULTS:A cohort of 430 patients with rectal adenocarcinoma who were treated with neoadjuvant therapy and entered watch-and-wait were included. Patients were divided into 3 groups according to age at diagnosis: early-onset (age < 50, n = 98), middle-aged (50-64, n = 163), and late-onset (65+, n = 169). No differences were noted in tumor distance from the anal verge (p = 0.345) between groups. More patients in the early-onset cohort received induction chemotherapy with chemoradiation than late-onset patients, who more often received chemoradiation alone and had clinical stage I disease (p = 0.015). Median follow-up time was 4.0years (IQR 2.6-5.5). The 3-year local regrowth rates in each group were 23.8% (95% CI: 15.2-32.4), 33.0% (95% CI: 25.6-40.4), and 26.1% (95% CI: 19.4-32.8) in the early, middle-aged, and late-onset patients, respectively (p = 0.395). No associated differences in 5-year distant metastasis-free or recurrence-free survival rates were noted between the 3 age groups. The early-onset cohort had an associated superior disease-specific survival from the late-onset cohort. LIMITATIONS:Retrospective nature. CONCLUSIONS:Early-onset rectal cancer patients have at least similar oncological outcomes compared to those in older age groups when treated non-operatively. These data provide reassurance when offering a watch-and-wait approach to patients with early-onset rectal cancer. See Video Abstract.
BACKGROUND: Patients with early-onset colorectal cancer (age < 50) are vulnerable to unique psychosocial consequences given their developmental stage in life. Younger adults are often establishing their careers and families, and a cancer diagnosis can contribute to financial and professional instability. However, the lived experiences of patients with early-onset colorectal cancer have largely been underexplored. OBJECTIVE: To characterize the financial and professional experiences of patients with early-onset colorectal cancer. DESIGN: Semistructured interviews with patients with early-onset colorectal cancer. SETTINGS: Multicenter study across 7 academic medical centers. PATIENTS: Patients diagnosed with colon or rectal cancer before aged 50years. MAIN OUTCOME MEASURES: Thematic analysis of financial and professional impacts from early-onset colorectal cancer. Exploration of risk factors and drivers of these effects. RESULTS: Participants described a range of lasting impacts related to professional and financial impacts following early-onset colorectal cancer, from minimal to severe. Financial impacts included treatment costs, indirect expenses, income loss, reduced assets, and debt. Professional impacts included physical, cognitive, psychologic challenges, and career disruptions. Certain protective factors like supportive work environments or good insurance appeared to mitigate the severity the impacts experienced. LIMITATIONS: Limitations include recall, negativity, and survivorship biases. CONCLUSIONS: Survivors of early-onset colorectal cancer face persistent financial and professional effects. Many younger adults have variable access to paid leave and public assistance programs, exacerbating the strain of early-onset colorectal cancer. Protective factors, such as a supportive workplace, access to paid time off, and flexible accommodations, must be strengthened and expanded to better care for the growing population of younger adult cancer survivors. See Video Abstract.
Background: High-complexity pelvic exenteration requires extensive lateral dissection and often en bloc resection of the internal iliac vessels to secure margins. However, achieving safe, precise access to the distal pelvic sidewall through a confined operative field is technically demanding and hazardous. Impact of innovation: We developed a transperineal coccygeal muscle-guided endoscopic approach primarily to establish a reliable, anatomically guided pathway to the lateral pelvic compartments. Using the coccygeal muscle as a landmark facilitates precise identification of the distal internal iliac vessels and lumbosacral trunk, enabling safer sidewall dissection and facilitating an early distal vessel ligation strategy. Technology Materials and Methods: Following identification of the coccygeal bone, the coccygeal muscle is mobilized off the levator ani fascia. A targeted division of the levator ani at its lateral margin exposes the distal internal iliac vessels for early ligation under direct vision. This access clearly unroofs the lumbosacral trunk and sciatic nerve, permitting precise lateral pelvic sidewall dissection. Preliminary Results: In 11 consecutive patients with locally advanced or recurrent rectal cancer underwent pelvic exenteration with combined resection of the main trunk of internal iliac vein between January 2023 and December 2025, this method yielded acceptable operative time (median 918 min; 579 min until completion of resection), blood loss (median 991 ml; 374 ml until completion of resection), an R0 resection rate of 91%, and severe morbidity of 18%, comparable to published benchmarks. Conclusions and Future Directions: The transpenieal coccygeal muscle-guided route provides a practical, anatomically grounded method for accessing the distal pelvic sidewall. It represents a technically feasible strategy for managing the complex anatomy of high-complexity exenterations, though larger studies are required to confirm its impact on operative hemodynamics and long-term outcomes. See New Technology Report Video.
