Background: The "watch and wait" (W&W) strategy for rectal cancer offers organ preservation to patients achieving aclinical complete response (cCR) after neoadjuvant therapy. While oncologically safe, its adoption across the UK varies drastically due to non-standardised pathways, a lack of structured training, and clinician anxiety regarding local regrowth. With the rise of Total Neoadjuvant Treatment (TNT) and NICE-approved contact brachytherapy (Papillon), a shift toward "intentional" organ preservation is projected to exponentially increase service demands on multidisciplinary teams (MDTs). Aim: This protocol outlines the development of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) Position Statement. The initiative aims to mitigate MDT hesitation, standardise clinical pathways, and optimise the delivery of W&W care across the UK and Ireland. Methods: A 30-member multidisciplinary Task Force—comprising colorectal surgeons, oncologists, radiologists, trainees, andpatients—will undertake a rapid, single-round Delphi consensus process. The panel will evaluate approximately 30 statements spanning eight core domains, including response timing, endpoint definitions, service organisation, training, and follow-up. Consensus is defined as 70% or greater agreement, with any remaining disparities resolved via virtual nominal group meetings. Scope and Significance: The position statement focuses strictly on the clinical implementation of W&W following a cCR. Excluded from the scope are near-cCR management, salvage surgery, and trial frameworks. Scheduled for publication in mid-2026, this statement will provide a crucial framework to guide MDTs through an emerging clinical paradigm shift, with the aim of improving patient selection and resource allocation.

Objectives The ‘tumour, node, metastasis’ (TNM) classification of colorectal cancer (CRC) predicts prognosis and so is vital to consider in analyses of patterns and outcomes of care when using electronic health records. Unfortunately, it is often only available in free-text reports. This study aimed to develop regex-based text-processing algorithms that identify the reports describing CRC and extract the TNM staging at a low computational cost.Methods The CRC and TNM extraction algorithms were iteratively developed using 58 634 imaging and pathology reports of patients with CRC from the Oxford University Hospitals (OUH) and Royal Marsden (RMH) NHS Foundation Trusts (FT), with additional input from Imperial College Healthcare and Christie NHS FTs. The algorithms were evaluated on a stratified random sample of 400 OUH development data reports and 400 newer ‘unseen’ OUH reports. The reports were annotated with the help of two clinicians.Results The CRC algorithm achieved at least 93.0% positive predictive value (PPV), 72.1% sensitivity, 64.0% negative predictive value (NPV) and 90.1% specificity for primary CRC on pathology reports. On imaging reports, it demonstrated at least 78.0% PPV, 91.8% sensitivity, 93.0% NPV and 80.9% specificity. For the main T/N/M categories, the TNM algorithm achieved PPVs of at least 93.9% (T), 97.7% (N) and 97.2% (M), and sensitivities of 63.6% (T), 89.6% (N) and 64.8% (M). NPVs were at least 45.0% (T), 91.1% (N), 88.4% (M), and specificities 95.7% (T), 98.1% (N), 99.3% (M). Reductions in performance were mostly due to implicit staging. For extracting explicit TNM stages, current or historical, the algorithm made no errors on 400 pathology reports and six errors on 400 imaging reports.Conclusion The TNM algorithm accurately extracts explicit TNM staging, but other methods are needed for retrieving implicit stages. The CRC algorithm is accurate on non-supplementary reports, but outputs need additional review if higher precision is required.

Spatial biology has the potential to unlock information about the disrupted cellular ecosystems that define human disease. Quantitative analysis of spatially-resolved cell interactions allows mapping of tissue self-organisation and assessment of why cells interact differently in physiological and pathological contexts. However, the complexity of mammalian tissues, that occur across a spectrum of length scales, presents significant challenges for spatial analysis, increasing the gap between our capacity to generate and biologically interpret these datasets. Here, we have adapted a range of mathematical tools to develop a suite of spatial descriptors, and deployed them to determine how cell interactions change as colorectal cancer progresses from benign precursors. We demonstrate that combining mathematical analyses permits insightful examination of tissue organisational structures and identifies variable cell-interaction pathways that underpin disease progression. Mathematical tool triangulation can cross-corroborate spatial biology findings, facilitating development of analysis pipelines that are robust to individual method limitations. ### Competing Interest Statement The authors have declared no competing interest.

Abstract Exosomes are secreted vesicles made intracellularly in the endosomal system. We have previously shown that exosomes are not only made in late endosomes, but also in recycling endosomes marked by the monomeric G‐protein Rab11a. These vesicles, termed Rab11a‐exosomes, are preferentially secreted under nutrient stress from several cancer cell types, including HCT116 colorectal cancer (CRC) cells. HCT116 Rab11a‐exosomes have particularly potent signalling activities, some mediated by the epidermal growth factor receptor (EGFR) ligand, amphiregulin (AREG). Mutant activating forms of KRAS, a downstream target of EGFR, are often found in advanced CRC. When absent, monoclonal antibodies, such as cetuximab, which target the EGFR and block the effects of EGFR ligands, such as AREG, can be administered. Patients, however, inevitably develop resistance to cetuximab, either by acquiring KRAS mutations or via non‐genetic microenvironmental changes. Here we show that nutrient stress in several CRC cell lines causes the release of AREG‐carrying Rab11a‐exosomes. We demonstrate that while soluble AREG has no effect, much lower levels of AREG bound to Rab11a‐exosomes from cetuximab‐resistant KRAS‐mutant HCT116 cells, can suppress the effects of cetuximab on KRAS‐wild type Caco‐2 CRC cells. Using neutralising anti‐AREG antibodies and an intracellular EGFR kinase inhibitor, we show that this effect is mediated via AREG activation of EGFR, and not transfer of activated KRAS. Therefore, presentation of AREG on Rab11a‐exosomes affects its ability to compete with cetuximab. We propose that this Rab11a‐exosome‐mediated mechanism contributes to the establishment of resistance in cetuximab‐sensitive cells and may explain why in cetuximab‐resistant tumours only some cells carry mutant KRAS.

Abstract Introduction Extracellular vesicles (EVs) are nanoized vesicles, which deliver bioactive cargoes to target cells. Our lab has shown that metabolic stress leads to changes in the trafficking and also the cargo and functions of EVs secreted from colorectal cancer (CRC) cells: a so-called “EV switch”. Proteomic analysis revealed that switched EVs carry increased levels of the EGFR-ligand Amphiregulin (AREG). The aim of this work was to investigate the pro-tumorigenic properties of switched EVs in vitro and in vivo. Methods Size exclusion chromatography was used to isolate EVs from HCT116 and Caco-2 CRC cells grown under glutamine-replete and -depleted conditions, and their effect on recipient cell growth measured using the IncuCyte Live Cell Imager. Co-incubation assays with an AREG-neutralising antibody were undertaken to test the role of switched EVs. The in vivo role of switched EVs were investigated using a novel chick embryo model. In addition, we tested whether the growth inhibitory effects of cetuximab could be reversed by co-treatment with switched EVs. Results Switched EVs from HCT116 and Caco-2 cells contain increased levels of AREG and promote EGFR-ERK dependent growth in recipient cells in vitro and in vivo. These effects were inhibited by co-treatment with an AREG neutralising antibody. Caco-2 (KRAS-wild type), but not HCT116 (KRAS-mutant), cell growth was inhibited by cetuximab, which was partially reversed by co-treatment with switched EVs. AREG neutralisation reversed this EV-induced cetuximab rescue. Conclusion Switched EVs mediate CRC cell growth and cetuximab resistance, and could serve as novel biomarkers to predict treatment response.

The aim of this work was to assess the relationship between pelvic pain and rectal prolapse both before prolapse surgery and in the long term after ventral mesh rectopexy (VMR). Patients undergoing VMR between 2004 and 2017 were contacted. Outcomes including the severity of pelvic pain were recorded using a numeric rating scale. Four hundred and seventy eight of the 749 patients (64%) were successfully contacted. Of these, 39% reported pre-existing pelvic pain prior to VMR (group A) and 61% were pain free (group B). The median follow-up time was 8.0 years (interquartile range 5.0–10.0 years). Symptoms of obstructed defaecation were significantly more common ( p  = 0.002) in group A (91/187, 49%) than in group B (101/291, 35%). In contrast, faecal incontinence was more common ( p  = 0.007) in group B (75/291, 26%) than in group A (29/187, 15%). In group A, 76% showed improvement in pelvic pain after VMR: 61% were pain free and 39% had partial improvement in their pre-existing pelvic pain. Patients with persistent pelvic pain were younger ( p  = 0.01) and more likely to have revisional surgery after VMR ( p  = 0.0003), but there was no relation to the indication for surgery ( p  = 0.59). In group B, 15% reported de novo pelvic pain after VMR, and this was more common in women under 50 years old ( p  = 0.001), when obstructed defaecation was the indication ( p  = 0.03), in mesh erosion ( p  = <0.05) and when associated with revisional surgery ( p  = 0.005). Pelvic pain is common (39%) in patients undergoing prolapse surgery, and VMR improves this pain in most patients (76%). However, a significant number of patients fail to improve (12%), experience worsening of pain (12%) or develop de novo pelvic pain (15%).

Aim: The aim of this work was to assess the relationship between pelvic pain and rectal prolapse both before prolapse surgery and in the long term after ventral mesh rectopexy (VMR). Method: Patients undergoing VMR between 2004 and 2017 were contacted. Outcomes including the severity of pelvic pain were recorded using a numeric rating scale. Results: Four hundred and seventy eight of the 749 patients (64%) were successfully contacted. Of these, 39% reported pre-existing pelvic pain prior to VMR (group A) and 61% were pain free (group B). The median follow-up time was 8.0 years (interquartile range 5.0-10.0 years). Symptoms of obstructed defaecation were significantly more common (p = 0.002) in group A (91/187, 49%) than in group B (101/291, 35%). In contrast, faecal incontinence was more common (p = 0.007) in group B (75/291, 26%) than in group A (29/187, 15%). In group A, 76% showed improvement in pelvic pain after VMR: 61% were pain free and 39% had partial improvement in their pre-existing pelvic pain. Patients with persistent pelvic pain were younger (p = 0.01) and more likely to have revisional surgery after VMR (p = 0.0003), but there was no relation to the indication for surgery (p = 0.59). In group B, 15% reported de novo pelvic pain after VMR, and this was more common in women under 50 years old (p = 0.001), when obstructed defaecation was the indication (p = 0.03), in mesh erosion (p = <0.05) and when associated with revisional surgery (p = 0.005). Conclusion: Pelvic pain is common (39%) in patients undergoing prolapse surgery, and VMR improves this pain in most patients (76%). However, a significant number of patients fail to improve (12%), experience worsening of pain (12%) or develop de novo pelvic pain (15%).

Rectal prolapse is a debilitating disorder of the pelvic floor, and treatment outcomes are variable. Previous studies have identified underlying benign joint hypermobility syndrome (BJHS) in some patients. We sought to determine the outcomes of these patients after undergoing ventral rectopexy surgery (VMR). All consecutive patients who were referred to the pelvic floor unit at our institution between February 2010 and December 2011 were considered for recruitment into the study. Following recruitment, they were assessed using the Beighton criteria to determine the presence or absence of benign joint hypermobility syndrome. Both groups underwent similar surgical interventions and were then followed up. The need for revisional surgery was recorded in both groups. Fifty-two patients [34 normal; M:F, 1:6; median age 61 (range 22–84) years; 18 BJHS; M:F, 0:1; median age 52 (range 25–79) years] were recruited. A total of 42 patients completed the full 1-year follow-up (26 normal, 16 benign joint hypermobility syndrome). Patients with benign joint hypermobility syndrome were significantly younger (median age 52 versus 61 years, p < 0.001) with male to female ratio of 0:1 versus 1:6, respectively. In addition, they were significantly more likely to require revisional surgery than those without the condition (31

ANZ Journal of SurgeryEarly View LETTER TO THE EDITOR Pelvic floor retraining in patients with high-grade internal rectal prolapse Edward A. Cooper BSc(Adv), MBBS, MS, FRACS, Corresponding Author Edward A. Cooper BSc(Adv), MBBS, MS, FRACS [email protected] orcid.org/0000-0001-8184-2012 Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK Correspondence Dr Edward A. Cooper, Department of Colorectal Surgery, Churchill Hospital, Oxford, UK Email: [email protected]Search for more papers by this authorChris Cunningham BSc(Hons), MBChB, MD, FRCSEd, Chris Cunningham BSc(Hons), MBChB, MD, FRCSEd Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UKSearch for more papers by this authorIan Lindsey MBBS, FRACS, Ian Lindsey MBBS, FRACS orcid.org/0000-0002-5959-0143 Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UKSearch for more papers by this author Edward A. Cooper BSc(Adv), MBBS, MS, FRACS, Corresponding Author Edward A. Cooper BSc(Adv), MBBS, MS, FRACS [email protected] orcid.org/0000-0001-8184-2012 Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK Correspondence Dr Edward A. Cooper, Department of Colorectal Surgery, Churchill Hospital, Oxford, UK Email: [email protected]Search for more papers by this authorChris Cunningham BSc(Hons), MBChB, MD, FRCSEd, Chris Cunningham BSc(Hons), MBChB, MD, FRCSEd Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UKSearch for more papers by this authorIan Lindsey MBBS, FRACS, Ian Lindsey MBBS, FRACS orcid.org/0000-0002-5959-0143 Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UKSearch for more papers by this author First published: 28 July 2023 https://doi.org/10.1111/ans.18636Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Albayati S, Bhai D, Descallar J, Turner CE, Berney C, Morgan MJ. Pelvic floor training improves faecal incontinence and obstructed defaecation despite the presence of rectal intussusception. ANZ J. Surg. 2022; 93: 1253–1256. 2Adusumilli S, Gosselink MP, Fourie S et al. Does the presence of a high grade internal rectal prolapse affect the outcome of pelvic floor retraining in patients with faecal incontinence or obstructed defaecation? Colorectal Dis. 2013; 15: e680–e685. Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

Abstract Background Conflicting findings in recent literature question the significance of traditional coagulation variables in predicting bleeding associated with central venous catheter (CVC) removal. This audit evaluates the necessity and compliance of conducting same-day coagulation screens at Churchill Hospital. The study assesses the practice's relevance, compliance rates, and associated costs, offering implications for clinical decision-making, resource utilization, and potential modifications to current practices. The findings may lead to the adoption of new predictive factors or a targeted approach to coagulation testing, optimizing patient care and resource allocation in CVC removals. Methods This retrospective audit focused on surgical patients in the upper gastrointestinal, hepatobiliary and pancreatic, lower gastrointestinal, and transplant surgery departments at the Churchill Hospital. The study encompassed all instances of central venous catheter (CVC) removal that occurred between January 1st, 2022, and December 31st, 2022. Data retrieval was conducted using electronic patient records, and coagulation test results were interpreted utilizing the reference ranges available in the electronic patient record system (INR 0.9-1.2, PT 9-12, APTT 20-30). Results 78 patients had an average age of 53 years and a mean hospital stay of 35 days. The average duration of CVC in-situ was 8.9 days. Patients underwent an average of 5.07 coagulation tests per stay, equivalent to 0.28 tests per admission day. Among the audited patients (n=67), 41.8% had same-day coagulation screens, 17.9% had the screen one day prior to CVC removal, and 40.3% had the screen more than one day before removal. Analysis showed that 88% had normal INR values, with only eight patients having abnormal values. Furthermore, 74.6% and 58.2% had normal PT and APTT values, respectively. Conclusions This retrospective audit of CVC removals in surgical patients at Churchill Hospital revealed a concerning in-compliance rate of 44% with coagulation screens during CVC removals. Most patients had normal coagulation parameters, questioning the need for same-day screens. Delays and high costs (£64.76 per patient, £12.95 per screen) were incurred. Individualized risk-based approach, considering bleeding history, could be more efficient. Implementing targeted coagulation testing saves costs and optimizes resource utilization. Further evaluation required to improve patient care and resource allocation in CVC removals, reducing reliance on routine same-day screens.

OBJECTIVE:The aim of this study to describe a new international dataset for pathology reporting of colorectal cancer surgical specimens, produced under the auspices of the International Collaboration on Cancer Reporting (ICCR).BACKGROUND:Quality of pathology reporting and mutual understanding between colorectal surgeon, pathologist and oncologist are vital to patient management. Some pathology parameters are prone to variable interpretation, resulting in differing positions adopted by existing national datasets.METHODS:The ICCR, a global alliance of major pathology institutions with links to international cancer organizations, has developed and ratified a rigorous and efficient process for the development of evidence-based, structured datasets for pathology reporting of common cancers. Here we describe the production of a dataset for colorectal cancer resection specimens by a multidisciplinary panel of internationally recognized experts.RESULTS:The agreed dataset comprises eighteen core (essential) and seven non-core (recommended) elements identified from a review of current evidence. Areas of contention are addressed, some highly relevant to surgical practice, with the aim of standardizing multidisciplinary discussion. The summation of all core elements is considered to be the minimum reporting standard for individual cases. Commentary is provided, explaining each element's clinical relevance, definitions to be applied where appropriate for the agreed list of value options and the rationale for considering the element as core or non-core.CONCLUSIONS:This first internationally agreed dataset for colorectal cancer pathology reporting promotes standardization of pathology reporting and enhanced clinicopathological communication. Widespread adoption will facilitate international comparisons, multinational clinical trials and help to improve the management of colorectal cancer globally.

Objective Colorectal cancer is a common cause of death and morbidity. A significant amount of data are routinely collected during patient treatment, but they are not generally available for research. The National Institute for Health Research Health Informatics Collaborative in the UK is developing infrastructure to enable routinely collected data to be used for collaborative, cross-centre research. This paper presents an overview of the process for collating colorectal cancer data and explores the potential of using this data source. Methods Clinical data were collected from three pilot Trusts, standardised and collated. Not all data were collected in a readily extractable format for research. Natural language processing (NLP) was used to extract relevant information from pseudonymised imaging and histopathology reports. Combining data from many sources allowed reconstruction of longitudinal histories for each patient that could be presented graphically. Results Three pilot Trusts submitted data, covering 12 903 patients with a diagnosis of colorectal cancer since 2012, with NLP implemented for 4150 patients. Timelines showing individual patient longitudinal history can be grouped into common treatment patterns, visually presenting clusters and outliers for analysis. Difficulties and gaps in data sources have been identified and addressed. Discussion Algorithms for analysing routinely collected data from a wide range of sites and sources have been developed and refined to provide a rich data set that will be used to better understand the natural history, treatment variation and optimal management of colorectal cancer. Conclusion The data set has great potential to facilitate research into colorectal cancer.

Background: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes. Methods: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias. Results: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively. Conclusion: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable. (c) 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Data sharing is not applicable to this article as no new data were created or analysed in this study. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Objective: To examine the impact of The National Training Program for Lapco on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training. Summary of Background Data: Lapco provided competency-based supervised clinical training for specialist colorectal surgeons in England. Methods: We compared the rate of laparoscopic surgery, mortality, and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively. Results: One hundred eight Lapco delegates performed 4586 elective colo-rectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72,930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% [95% confidence interval (CI), 18.5–23.3, P < 0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, P = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, P = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56%, respectively. Conclusions: Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training.

Purpose Neoadjuvant radiotherapy is commonly used in rectal cancer. When used prior to radical surgery in locally advanced disease, up to one-quarter of patients have no residual cancer at surgery suggesting that radical surgery was unnecessary; those with complete clinical response may be managed on a rectal-preserving 'watch-and-wait' pathway. In those receiving radiotherapy for early stage cancer, local excision of small volume residual or recurrent tumour is possible, but its value is unclear. Methods Data were collected from two institutions (UK and Denmark) which maintain prospective databases on all patients undergoing local excision by transanal endoscopic microsurgery (TEM). The study group was all patients who had TEM after neoadjuvant radiation for rectal cancer over an 11-year period. Results Forty-five patients had TEM after neoadjuvant radiation, 18 after short course radiotherapy (SCRT) and 27 after chemoradiotherapy (CRT). Local recurrence occurred in 13 (29%) and distant metastases in 11 (24%). Complete pathological response was noted in 10 (22%), 28% after SCRT and 19% after CRT, p = 0.02. However, local recurrence still occurred in 60% of those with ypT0 after SCRT. The recurrence rate may be higher in those with residual disease at TEM compared with complete responders (40 vs 30%). Conclusion If complete response can be determined clinically, local excision of the scar does not confer benefit, but follow-up should be maintained. If there is regrowth or residual tumour at TEM, further recurrence is common, and the benefits of TEM may not outweigh the risks, except in those unsuitable for radical surgery.

Aim Cancer surgery in the COVID-19 pandemic presents many new challenges. For each patient, the risk of contracting COVID-19 during the perioperative period, with the potential for life-threatening sequelae (1), has to be weighed against the risk of delaying treatment. We assessed the response and short-term outcomes from elective colorectal cancer surgery during the pandemic at our institution. Method We report a prospective cohort study of all elective colorectal surgery cases performed at our Trust during the 11 weeks following the national UK lockdown on 23rd March 2020, compared with the same time period in 2019. Results Eighty-five colorectal operations were performed during the 2020 (COVID) time period, and 179 performed in the 2019 (non-COVID) time period. A significantly higher proportion of cases during the COVID period were cancer-related (66% vs 26%, p < 0.00001). There was no difference in length of hospital stay, complications or readmissions. There were no mortalities in either cohort. Among the cancer patients, there were no differences in TMN staging, R1 resection rate or lymph node yields. No elective patient tested positive for COVID-19 during the perioperative period. Conclusion At the height of the COVID pandemic, we maintained delivery the of high-quality elective colorectal cancer surgery, with no worsening of short-term outcomes and no compromise in the quality of cancer resections. Ongoing monitoring of this cohort is essential. The risks associated with COVID-19 will continue for some time, necessitating adaptive responses to maintain high-quality cancer services.

Accurate preoperative staging of colorectal cancers is critical in selecting patients for neoadjuvant therapy prior to resection. Inaccurate staging, particularly understaging, may lead to involved resection margins and poor oncological outcomes. Our aim is to determine preoperative imaging accuracy of colorectal cancers compared to histopathology and define the effect of inaccurate staging on patient selection for neoadjuvant treatment(NT). Staging and treatment were determined for patients undergoing colorectal resections for adenocarcinomas in a single tertiary centre(2016-2020). Data were obtained for 948 patients. The staging was correct for both T and N stage in 19.68% of colon cancer patients. T stage was under-staged in 18.58%. At resection, 23 patients (3.36%) had involved pathological margins; only 7 of which had been predicted by pre-operative staging. However, the staging was correct for both T and N stage in 53.85% of rectal cancer patients. T stage was understaged in 26.89%. Thirteen patients had involved(R1)margins; T4 had been accurately predicted in all of these cases. There was a general trend in understaging both the tumor and lymphonodal involvement (T p < 0.00001 N p < 0.00001) causing a failure in administrating NT in 0.1% of patients with colon tumor, but not with rectal cancer. Preoperative radiological staging tended to understage both colonic and rectal cancers. In colonic tumours this may lead to a misled opportunity to treat with neoadjuvant therapy, resulting in involved margins at resection.

The optimal management of a polyp cancer that has been removed endoscopically is unclear. Further local excision is often advocated to remove the polyp stalk or scar or to ensure clear margins, but the benefit of this is unclear. The aim of this paper is to determine whether the indications for further local excision can be better defined.