BACKGROUND:Anal squamous cell carcinoma is increasingly prevalent among men who have sex with men (MSM) living with HIV, related to anal dysplasia associated with persistent Human Papillomavirus (HPV) infection. While high-resolution-anoscopy (HRA), using colposcopy and a rigid anoscope, is the diagnostic standard, it is resource-intensive and not widely available. This study evaluates flexible endoscopy compared to cytology and anal HPV for detecting high-grade squamous intraepithelial lesions (HSIL) in a structured screening protocol. PATIENTS AND METHODS:HIV-positive MSM (n = 304) were consecutively recruited during routine HIV monitoring. Anal samples were collected for cytology and HPV testing. Participants underwent high-resolution flexible endoscopy of the anal canal (HR-FEA), with endoscopic resection of suspected lesions and histopathological follow-up. RESULTS:Of 304 participants, 286 underwent HR-FEA where lesions were found in 80%. After 12 additional dropouts, 218/274 underwent resections. HSIL was found in 67/274 (24%) and LSIL in 61/274 (22%). Resected lesions were dysplastic in 59%. HPV testing showed 64% sensitivity and 72% specificity for HSIL; cytology had 15% sensitivity and 96% specificity. Combined testing (cytology/HPV) improved overall dysplasia detection but not HSIL beyond HPV alone. Both methods missed many HSILs found by endoscopy. Tolerability was high; 99% would repeat. CONCLUSIONS:This study assessed HR-FEA for HSIL screening in MSM living with HIV, comparing its diagnostic performance to anal cytology and HPV, and evaluating acceptability. HPV showed higher sensitivity, cytology higher specificity, while both tests missed many lesions compared to HR-FEA. Although specificity in HR-FEA was related to frequently occurring non-dysplastic lesions, HR-FEA was effective and well-tolerated.

T-cell activation may be contributing to severe psychiatric disorders. Soluble CD27 (sCD27) - a marker for T-cell activation and disease activity in several autoimmune diseases - was evaluated as a tool for distinguishing T-cell activity in selected patients with severe psychiatric disorders, multiple sclerosis (MS), and controls. We hypothesise that elevated sCD27 levels will be associated with comorbid autoimmune disease (AID). sCD27 was measured in cerebrospinal fluid (CSF) and blood from a population enriched for suspected immunological comorbidity: the Immunopsychiatry Cohort (IP; n=115) and patients with MS (n=37), where levels in both groups were higher when compared with age matched controls undergoing surgery (n=154). Positive sCD27 (sCD27+), was defined as values >97.5% of controls. In IP, 23% were CSF sCD27+ and 15% blood sCD27+, compared to patients with MS where 88% were CSF sCD27+ and 22% were blood sCD27+. CSF-sCD27+ was confirmed as a sensitive marker for MS. In IP, CSF-sCD27+ was associated with comorbid AID (X2=4.847, p =0.028;) and AID disease activity (OR=5.14, p=0.029). Associations with AID were stronger when CSF and/or blood sCD27+ were combined (X2=8.559, p=0.003). CSF-sCD27+ in IP was also associated with pleocytosis, CSF-Total-tau, and CSF-NfL. In patients with severe psychiatric disorders, the sCD27+ cases were more likely to have comorbid AID and established markers for neuroinflammation in CSF. Combining analyses of CSF and blood improved sensitivity and specificity for AID suggesting compartmentalized T-cell activation. Psychiatric symptoms may precede somatic symptoms - or be the prominent symptom - of AID and sCD27 is a candidate marker for identification of this subgroup.

INTRODUCTION:Lynch syndrome (LS) carriers have a 20-46% lifetime risk of colorectal cancer (CRC) due to mismatch repair gene variants. Mesalamine (5-ASA, 5-aminosalicylic acid), used safely in patients with ulcerative colitis, may reduce CRC risk in LS by decreasing microsatellite instability, a key driver of LS-related cancer. This study evaluates 5-ASA's efficacy as a tolerable chemopreventive drug, aiming to improve long-term CRC prevention in LS. METHODS AND ANALYSIS:This multicentre, multinational, randomised, double-blind, two-arm, phase II clinical study will compare the effects of a 2-year daily intake of 5-ASA (2000 mg) to placebo in LS carriers. The primary objective is to assess whether mesalamine reduces colorectal neoplasia, both benign and malignant, compared with placebo in LS carriers, as detected by colonoscopy at the end of the treatment period (24 months±1 month) and on study completion. Secondary objectives include evaluating whether 5-ASA reduces neoplasia/tumour multiplicity and progression compared with placebo at specified time points, examining variations in the effects of 5-ASA versus placebo based on cancer history, sex and age (<45 years vs ≥45 years), and assessing the safety of 5-ASA in LS carriers. ETHICS AND DISSEMINATION:The trial is currently open for enrolment, having received ethical approval from the Regional Ethical Review Board in Stockholm and funding from the Swedish Research Council. The study protocol is the finalised V.10.0 (11 April 2024), transitioned to the European Clinical Trials Information System. LS remains underdiagnosed, which may limit recruitment. The results are of global interest and will be published in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION NUMBER:ClinicalTrials.gov: NCT04920149. EudraCT: 2019-003011-55. EU CT:2024-514765-19-01.

BACKGROUND:Whether uncomplicated diverticulosis gives rise to symptoms is controversial. Diary-based studies of abdominal pain and stool habits in general populations are scarce, and we therefore investigated symptom patterns in diverticulosis from prospectively collected symptom diaries in a random sample of the general population who completed a research colonoscopy. METHODS:In the Swedish population-based colonoscopy (PopCol) study, 745 individuals from the general population underwent a colonoscopy of which 130 had diverticulosis, and none had diverticulitis. Seven-day symptom diaries were completed by 258 participants (age 54, women 64%) of which 50 had diverticulosis. The frequency and location of abdominal pain, bowel habit and other gastrointestinal symptoms were compared between individuals with and without diverticulosis using logistic regression. KEY RESULTS:Diverticulosis was not associated with abdominal pain (OR 1.24, CI 0.61-2.55) or left lower quadrant (LLQ) abdominal pain (OR 1.59, CI 0.73-3.49). Pain duration and severity were not associated with diverticulosis. When individuals with diverticulosis had pain, it was more often in the LLQ (OR 2.45, CI 1.02-5.86) compared with those without diverticulosis. Diverticulosis was not linked to altered bowel habits. Irritable bowel syndrome prevalence was 16% in the diverticulosis group and 19% in the non-diverticulosis group. CONCLUSIONS AND INFERENCES:Participants with diverticulosis did not report more abdominal pain or more LLQ abdominal pain than participants without diverticulosis. Bowel habit was not abnormal in diverticulosis. Our results do not support that uncomplicated diverticulosis cause symptoms in individuals without a history of acute diverticulitis.

Colonoscopy is the primary method for examination, detection, and removal of polyps. However, challenges such as variations among the endoscopists' skills, bowel quality preparation, and the complex nature of the large intestine contribute to high polyp miss-rate. These missed polyps can develop into cancer later, underscoring the importance of improving the detection methods. To address this gap of lack of publicly available, multi-center large and diverse datasets for developing automatic methods for polyp detection and segmentation, we introduce PolypDB, a large scale publicly available dataset that contains 3934 still polyp images and their corresponding ground truth from real colonoscopy videos. PolypDB comprises images from five modalities: Blue Light Imaging (BLI), Flexible Imaging Color Enhancement (FICE), Linked Color Imaging (LCI), Narrow Band Imaging (NBI), and White Light Imaging (WLI) from three medical centers in Norway, Sweden, and Vietnam. We provide a benchmark on each modality and center, including federated learning settings using popular segmentation and detection benchmarks. PolypDB is public and can be downloaded at . More information about the dataset, segmentation, detection, federated learning benchmark and train-test split can be found at .

PURPOSE:The Swedish National Patient Register (SNPR) is frequently used in studies of colonic diverticular disease (DD). Despite this, the validity of the coding for this specific disease in the register has not been studied. METHODS:From SNPR, 650 admissions were randomly identified encoded with ICD 10, K572-K579. From the years 2002 and 2010, 323 and 327 patients respectively were included in the validation study. Patients were excluded prior to, or up to 2 years after a diagnosis with IBD, Celiac disease, IBS, all forms of colorectal cancer (primary and secondary), and anal cancer. Medical records were collected and data on clinical findings with assessments, X-ray examinations, endoscopies and laboratory results were reviewed. The basis of coding was compared with internationally accepted definitions for colonic diverticular disease. Positive predictive values (PPV) were calculated. RESULTS:The overall PPV for all diagnoses and both years was 95% (95% CI: 93-96). The PPV for the year 2010 was slightly higher 98% (95% CI: 95-99) than in the year 2002, 91% (95% CI: (87-94) which may be due to the increasing use of computed tomography (CT). CONCLUSION:The validity of DD in SNPR is high, making the SNPR a good source for population-based studies on DD.

BackgroundAnal squamous intraepithelial lesions (ASILs) correspond to premalignant changes preceding the development of anal squamous cell carcinoma.ObjectiveTo describe a new endoscopic technique to detect and remove ASILs in non-anesthetized patients and compare it with standard surgical treatment.MethodsFor endoscopic treatment, high resolution (HR) flexible endoscopes with a distal attachment were used. Underwater inspection of the anal canal was performed in near-focus mode with white light and narrow-band imaging. Detected lesions were resected with a diathermia snare after local injection of xylocaine/adrenaline. We did a retrospective comparison of all patients who underwent endoscopic or standard surgical treatment for ASILs at Ersta hospital in Stockholm between 2018 and 2020. Patient files were reviewed for number of lesions, treatments until macroscopic radicality, degree of dysplasia, bleeding, pain and other complications.ResultsEndoscopic (n = 37) and surgical (n = 43) treatment displayed comparable number of lesions per patient (p = .37). The number of procedures until macroscopic radicality was higher for endoscopy than surgery (p = .04). However, in endoscopic follow up of 12 of the surgically treated patients, residual ASIL was found in 10 cases. Post-procedural bleeding requiring healthcare occurred in two endoscopy patients and one surgically treated patient.ConclusionsUnderwater resection using a HR flexible endoscope in non-anesthetized is a new, feasible and well tolerated method for ASILs treatment. Its efficacy and risk of complications seem comparable to standard surgical treatment while avoiding general anesthesia. However, minor lesions might be overlooked at surgery.

Deep Learning has the ability to train on datasets created from videos. This facility makes deep learning algorithms suitable for detecting distinct objects in large sets of frames, particularly for delineating anomalies like precancerous lesions during surveillance colonoscopies of the large bowel. However, capturing subtle, diffuse characteristics in these videos’ frames can be a challenge.This paper presents a deep learning system that uses colour channel separation and recombination of images to improve the performance of an object detection model, to tackle this challenge. Using a dataset from surveillance colonoscopy videos to find precancerous and cancerous lesions in IBD patients, individual colour channels of RGB images in the dataset are separated and recombined to form different datasets which are later used to train YOLOv8x models. The object detection model that is trained and tested with only the blue channel component of the images in the dataset performs better and gives more accurate predictions than the object detection model that is trained and tested with the datasets containing the green and/or the red channel images, as well as the dataset containing the original RGB images.

Abstract Background The etiopathogenesis of diverticular disease is unknown. Objective To compare the fecal and mucosa-associated microbiota between participants with and without diverticulosis and participants who later developed diverticulitis versus those that did not from a population-based study. Methods The PopCol study, conducted in Stockholm, Sweden, invited a random sample of 3556 adults to participate, of which 745 underwent colonoscopy. Overall, 130 participants (17.5%) had diverticulosis. 16S rRNA gene sequencing was conducted on available sigmoid biopsy samples from 529 and fecal samples from 251 individuals. We identified individuals who subsequently developed acute diverticulitis up to 13 years after sample collection. In a case-control design matching for gender, age (+/−5 years), smoking and antibiotic exposure, we compared taxonomic composition, richness and diversity of the microbiota between participants with or without diverticulosis, and between participants who later developed acute diverticulitis versus those who did not. Results No differences in microbiota richness or diversity were observed between participants with or without diverticulosis, nor for those who developed diverticulitis compared with those who did not. No bacterial taxa were significantly different between participants with diverticulosis compared with those without diverticulosis. Individuals who later developed acute diverticulitis (2.8%) had a higher abundance of genus Comamonas than those who did not (p = .027). Conclusions In a population-based cohort study the only significant difference was that those who later develop diverticulitis had more abundance of genus Comamonas. The significance of Comamonas is unclear, suggesting a limited role for the gut microbiota in the etiopathogenesis of diverticular disease.

Background and Aims Inflammatory bowel disease may cause long-standing inflammation and fibrosis and may increase the risk of adverse events in colonoscopy. We evaluated whether inflammatory bowel disease and other potential risk factors are associated with bleeding or perforation in a nationwide, population-based, Swedish study. Methods Data from 969 532 colonoscopies, including 164 012 [17%] on inflammatory bowel disease patients, between 2003 and 2019, were retrieved from the National Patient Registers. ICD-10 codes for bleeding [T810] and perforation [T812] within 30 days of the colonoscopy were recorded. Multivariable logistic regression was used to test if inflammatory bowel disease status, inpatient setting, time period, general anaesthesia, age, sex, endoscopic procedures, and antithrombotic treatment were associated with higher odds for bleeding and perforation. Results Bleeding and perforation were reported in 0.19% and 0.11% of all colonoscopies, respectively. Bleeding [odds ratio 0.66, p <0.001] and perforation [odds ratio 0.79, p Conclusions Individuals with inflammatory bowel disease did not have more adverse events compared with individuals without inflammatory bowel disease status. However, the inpatient setting was associated with more adverse events, particularly in inflammatory bowel disease status. General anaesthesia was associated with a greater risk of perforation.

Objectives Long-standing inflammatory bowel disease (IBD) colitis is an indication for endoscopic surveillance. Postcolonoscopy colorectal cancer (PCCRC), cancer detected after a negative colonoscopy, is a quality indicator for colonoscopy. In analogy with PCCRC, we aimed to assess postendoscopy CRC (PECRC) in individuals with IBD who had undergone colectomy. Methods This register study included Swedish adults with an IBD diagnosis who had undergone colectomy and later were examined by either colonoscopy or sigmoidoscopy during 2001–2012. The final study population had a CRC diagnosis within 36 months of the index examination. Poisson regression was used to assess the relative risks (RR) of PECRC. Results A total of 33 individuals, 12 with an ileorectal anastomosis and 21 with a rectal remnant, had a CRC diagnosis within 36 months of the index endoscopy. Eleven cancers were detected as CRCs, and 22 (67%) were PECRCs. Compared with individuals aged >70 years, individuals aged <30 years had an RR of 3.1 ( P = 0.054) and individuals aged 30–50 years had a RR of 2.6 ( P = 0.030). A longer interval between colectomy and index endoscopy (>10 vs. <10 years) was associated with a lower risk of PCCRC (RR = 0.5; P = 0.007). There was no significant difference between the risk for Crohn’s disease vs. ulcerative colitis, or between ileorectal anastomosis and rectal remnant risks. Conclusions Continuous surveillance of IBD patients after colectomy is important. In the postcolectomy context, PECRC may be used as a quality indicator.

•In 2015, a multidisciplinary team at Uppsala University Hospital was established to evaluate and identify patients with underlying autoimmune disorders, or possible, probable and definite forms of an immunopsychiatric disease.•The model aims to improve knowledge and collaboration across medical specialties and provide a forum for ethical discussions and risk-benefit analysis for treatment and systematically collect clinical data to allow evaluation of treatment outcomes and quality of health care.•The structure coordinates university and hospital interests by integrating clinical care with infrastructure for research and development (biobanking, data bases, clinical trials) in order to develop novel tools for diagnostics and treatment in this patient population.

Histologic sections from patients with inflammatory bowel disease (IBD) usually exhibit crypts with architectural distortions and branching crypts. It has been postulated that crypt branching should be assessed only in well-oriented, upright crypts. However, those crypts are mostly found in sections from colectomy specimens and colon mucosectomies. Sections from endoscopic biopsies are fortuitously cut in a horizontal plane, a procedure mostly revealing cross-cut crypt rings. In endoscopic biopsies from UC patients we previously detected cross-cut crypts heralding the crest domain of branching crypts. Recently, the scrutiny of biopsies from IBD patients revealed that branching-crest domains concurred either with crypts in symmetric branching, typified by twin, amalgamating back-to-back isometrics crypt-rings, or with crypts in asymmetric branching, characterized by ≥2 amalgamating anisometric crypt-rings; both symmetric and asymmetric branching-crest domains were encased by a thin muscularis mucosae. Quantitative studies in biopsies from Swedish and German patients with IBD showed that crypts in asymmetric branching outnumbered those in symmetric branching. Because crypt-branching seldom occurs in the normal colon in adults and considering that colon crypts typically divide once or twice during a lifetime, the accruing of asymmetric branching crypts in IBD biopsies emerges as a significant histologic parameter. Although the biological significance of asymmetric crypt-branching in IBD remains at present elusive, their occurrence deserves to be further investigated. The future policy will be to include in our pathologic reports, the number of crypts in asymmetric branching, in order to monitor their frequency in prospective surveillance biopsies in patients with IBD.

Adequate bowel cleansing is essential for high-quality colonoscopy. Recently, a new very low-volume 1 litre (1L) polyethylene glycol (PEG) plus ascorbate solution (ASC) has been introduced. Our aims were to assess the effectiveness and tolerability of this product compared to low-volume 2L PEG-ASC and high-volume 4L PEG solutions, in a real-life setting. In six endoscopy units in Sweden, outpatients undergoing colonoscopy were either prescribed solutions according to local routines, or the very low-volume solution in split dose regimen. Bowel cleansing effectiveness and patient experience was assessed using the Boston Bowel preparation scale (BBPS) and a patient questionnaire. A total of 1098 patients (mean age 58 years, 52% women) were included. All subsegment and the total BBPS scores were significantly greater for 1L PEG-ASC in comparison to other solutions (p < 0.05 for 1L PEG-ASC and 4L PEG for transverse and left colon, otherwise p < 0.001). Nausea was more frequent with 1L PEG-ASC compared to 2L PEG-ASC (p < 0.001) and vomiting were more often reported compared to both other solutions (p < 0.01 and p < 0.05 for 2L PEG-ASC and 4L PEG, respectively). Smell, taste, and total experience was better for 1L PEG-ASC compared to 4L PEG (p < 0.001), and similar compared to the 2L PEG-ASC. In conclusion, 1L PEG-ASC leads to better bowel cleansing compared to 2L PEG-ASC or 4L PEG products, with similar or greater patient satisfaction.

Gastrointestinal (GI) pathologies are periodically screened, biopsied, and resected using surgical tools. Usually, the procedures and the treated or resected areas are not specifically tracked or analysed during or after colonoscopies. Information regarding disease borders, development and amount and size of the resected area get lost.This can lead to poor follow-up and bothersome reassessment difficulties post-treatment. To improve the current standard and also to foster more research on the topic we have released the "Kvasir-Instrument" dataset which consists of 590 annotated frames containing GI procedure tools such as snares, balloons and biopsy forceps, etc. Beside of the images, the dataset includes ground truth masks and bounding boxes and has been verified by two expert GI endoscopists. Additionally, we provide a baseline for the segmentation of the GI tools to promote research and algorithm development. We obtained a dice coefficient score of 0.9158 and a Jaccard index of 0.8578 using a classical U-Net architecture. A similar dice coefficient score was observed for DoubleUNet. The qualitative results showed that the model did not work for the images with specularity and the frames with multiple instruments, while the best result for both methods was observed on all other types of images. Both, qualitative and quantitative results show that the model performs reasonably good, but there is a large potential for further improvements. Benchmarking using the dataset provides an opportunity for researchers to contribute to the field of automatic endoscopic diagnostic and therapeutic tool segmentation for GI endoscopy.

Background Mortality in diverticulitis patients is poorly documented. Aims To determine short- and long-term mortality in diverticulitis patients compared to matched disease-free individuals. Methods By use of nation-wide registers, mortality among all individuals with a first-time hospital admission for diverticulitis 1990-2010 was compared to a disease-free cohort, matched for gender and age, with up to 21 years of follow-up. Hazard ratios (HR) for death within 0-100 days and 101 days–5 years from admission, respectively, were calculated using Cox regression, adjusting for prior comorbidity and social factors. Separate analyses were performed on diverticulitis treated conservatively and surgically. Results 83 461 diverticulitis and 812 942 disease-free individuals were included. Among all diverticulitis patients, mortality within 100 days was four times higher than in disease-free individuals, HR 4.44 (95% confidence interval 4.26-4.63), and in surgically treated patients, a HR of 12.13 (11.03-13.34) was observed. Within 100 days, 11.4% of patients receiving surgical treatment died, compared to 3.2% after conservative treatment. From day 101 to 5 years, the HR was 1.40 (1.32-1.47) after surgical treatment and 1.08 (1.05-1.10) after conservative treatment. Relative mortality within 100 days was slightly more pronounced in females than males, whereas in the 101 days–5 years interval, HRs were similar between genders. Conclusions In patients initially admitted for diverticulitis, survival is significantly reduced, both in the short and the long-term. This highlights the need of further efforts for prevention and optimised treatment.

Artificial intelligence (AI) is predicted to have profound effects on the future of video capsule endoscopy (VCE) technology. The potential lies in improving anomaly detection while reducing manual labour. Existing work demonstrates the promising benefits of AI-based computer-assisted diagnosis systems for VCE. They also show great potential for improvements to achieve even better results. Also, medical data is often sparse and unavailable to the research community, and qualified medical personnel rarely have time for the tedious labelling work. We present Kvasir-Capsule , a large VCE dataset collected from examinations at a Norwegian Hospital. Kvasir-Capsule consists of 117 videos which can be used to extract a total of 4,741,504 image frames. We have labelled and medically verified 47,238 frames with a bounding box around findings from 14 different classes. In addition to these labelled images, there are 4,694,266 unlabelled frames included in the dataset. The Kvasir-Capsule dataset can play a valuable role in developing better algorithms in order to reach true potential of VCE technology.

BACKGROUND:An individual's drive to seek medical help remains a complex behavioural process, incorporating psychological, social and symptom-specific factors. Within irritable bowel syndrome (IBS), gastrointestinal symptoms only predict a small portion of the high healthcare-seeking experienced.AIM:To examine the moderating role of quality of life (QoL) domains on this relationship to help explain the variance observed.METHODS:This is an analysis of a Swedish population-based prospective study of healthcare use over a 12-year period. At baseline, gastrointestinal symptoms were measured with the valid Gastrointestinal Symptom Rating Scale, and QoL via the SF-36. 1159 subjects (57% female; mean age 48.6 years) had their health records matched with the initial survey. 164 were classified as IBS by Rome II criteria. Negative binomial or logistic models were fit to evaluate the moderating effect of particular QoL domains on the relationship between gastrointestinal symptoms and prospective healthcare utilisation.RESULTS:Gastrointestinal symptoms were associated with prospective healthcare use, but moderation in this relationship by particular QoL domains was not supported; most models did not reach statistical significance. Furthermore, the impact of IBS status did not alter the moderation hypotheses.CONCLUSIONS:Particular QoL domains did not impact the relationship between gastrointestinal symptoms on prospective healthcare seeking. Future research should continue to examine other psychological, social and symptom variables to identify predictors of high healthcare consumers in IBS.

Background/Aim: We previously found crypts in symmetric fission (CSF) and in asymmetric fission (CAF) in colectomy-specimens with ulcerative colitis. We now analyzed CSF and CAF (CSAF) in biopsies from 80 patients with inflammatory bowel disease (IBD) without dysplasia or carcinoma. Patients and Methods: One unselected double-biopsy from affected endoscopic areas was investigated in the 80 cases. Results: A total of 353 crypts in fission were found. The median number of CAF/biopsy was 3.7 and for CSF/biopsy, 0.7 (p<0.00001). Conclusion: CSAF often occur in unselected biopsies from patients with IBD. Whereas the increased frequency of CSF might mirror a compensatory mechanism of crypt production in areas occupied by inflammation, CAF reflects a pathological aberration of cryptogenesis, probably generated by somatic mutations. The biological significance of CAF in IBD without dysplasia or carcinoma, deserves to be further investigated.

Besides clinical evaluation, all patients with rectal cancer must be examined with CT of the chest and abdomen to assess the presence of metastases, pelvic MRI to stage the tumour locally, and if possible, colonoscopy to detect synchronous lesions. The recommended treatment is then discussed at an MDT conference and neoadjuvant radio- or chemoradiotherapy given according to national guidelines. A new digital rectal examination (DRE) and proctoscopy, CT and pelvic MRI should be performed around six weeks after treatment. The purpose is to detect potential new metastases and to assess tumour response after treatment. It is crucial to do a second MDT with careful MRI evaluation to detect a possible clinical complete response. If the post-treatment MRI shows a complete or near complete response, corresponding to clinical findings on DRE and endoscopy, the patient should be offered a prospective watch and wait protocol in a dedicated institution. With proper management of patients with rectal cancer, 20-25 procent may be saved from a rectal resection and the potential risk of a permanent stoma.