Long-term oncological outcomes following emergency resection of colon cancer

Quality of emergency oncological surgery: time for advanced oncological life support

OBJECTIVE

In the emergency care of cancer patients, in addition to cancer-related factors, two aspects influence the outcome: (1) where the patient is treated and (2) who will perform the surgery. In Brazil, a significant proportion of patients with surgical oncological emergencies will be operated on in general hospitals by surgeons without training in oncological surgery.

OBJECTIVE

The objective was to discuss quality indicators and propose the creation of an urgent oncological surgery advanced life support course.

METHODS

Review of articles on the topic.

RESULTS

Generally, nonelective resections are associated with higher rates of morbidity and mortality, as well as lower rates of cancer-specific survival. In comparison to elective procedures, the reduced number of harvested lymph nodes and the higher rate of positive margins suggest a compromised degree of radicality in the emergency scenario.

CONCLUSION

Among modifiable factors is the training of the emergency surgeon. Enhancing the practice of oncological surgery in emergency settings constitutes a formidable undertaking that entails collaboration across various medical specialties and warrants endorsement and support from medical societies and educational institutions. It is time to establish a national registry encompassing oncological emergencies, develop quality indicators tailored to the national context, and foster the establishment of specialized training programs aimed at enhancing the proficiency of physicians serving in emergency services catering to cancer patients.

Colorectal Oncologic Emergencies: Recognition, Management, and Outcomes

Colorectal cancer is the third most frequent type of malignancy in the United States, and the age at diagnosis is decreasing. Although the goal of screening is focused on prevention and early detection, a subset of patients inevitably presents as oncologic emergencies. Approximately 15% of patients with colorectal cancer will present as surgical emergencies, with the majority being due to either colonic perforation or obstruction. Patients presenting with colorectal emergencies are a challenging cohort, as they often present at an advanced stage with an increase in T stage, lymphovascular invasion, and metachronous liver disease.

Emergency resection is an independent risk factor for decreased long-term overall survival in colorectal cancer: a matched-pair analysis

BACKGROUND

Colorectal cancer is one of the most common malignant neoplasms worldwide. Up to 30% of the patients present in an emergency setting despite an established screening program. Emergency colorectal resection is associated with increased mortality and morbidity as well as worse oncological outcome. This study aims to analyze the impact on tumor recurrence and survival in patients with an emergency colorectal resection, independent of sex, age, and tumor stage.

METHODS

Patients, who underwent an oncological resection for colorectal cancer at the Medical University of Innsbruck, Department of Visceral, Transplant and Thoracic Surgery, between January 2003 and December 2018 were analyzed retrospectively and screened for emergency resections. Matched pairs were formed to analyze the impact of emergency operations on long-term outcomes, considering tumor stage, sex, and age, comparing it with elective patients.

RESULTS

In total, 4.5% out of 1297 patients underwent surgery in an emergency setting. These patients had higher UICC (Union internationale contre le cancer) stages than elective patients. After matching the patients for age, sex, and tumor stage, emergency patients still had higher mortality. The incidence of recurrence was higher (47.5% vs. 25.4%, p = 0.003) and the 5-year overall survival decreased (35.6% vs. 64.4%, p < 0.001) compared to the matched patients with elective resection. Correcting for 90-day mortality still a reduction in the 5-year overall survival was demonstrated (44% vs. 70%, p = 0,001). The left-sided colon tumors were more common in the emergency group (45.8% vs. 25.4%, p = 0.006) and the rectal tumors in the elective one (21.2% vs. 3.4%, p = 0.002).

CONCLUSION

Patients undergoing emergency resection for colorectal cancer have a decreased tumor-specific and overall survival compared to patients after elective resection, independent of age, sex, and tumor stage, even after correcting for 90-day mortality. These findings confirm the importance of colorectal cancer awareness and screening to reduce emergency resections.

Oncological outcomes of elective versus emergency surgery for colon cancer: A tertiary academic center experience

Background

In this study, we aimed to identify the oncological outcomes in colon cancer patients who underwent elective versus emergency curative resection.

Methods

All patients who underwent curative resection for colon cancer between July 2015 and December 2019 were retrospectively reviewed and analyzed. Patients were divided into two groups based on the presentation into elective and emergency groups.

Results

A total of 215 patients with colon cancer were admitted and underwent curative surgical resection. Of those, 145 patients (67.4%) were elective cases, and 70 (32.5%) were emergency cases. Family history of malignancy was positive in 44 patients (20.5%) and significantly more common in the emergency group (P = 0.016). The emergency group had higher T and TNM stages (P = 0.001). The 3-year survival rate was 60.9% and significantly less in the emergency group (P = 0.026). The mean duration from surgery to recurrence, 3-year disease-free survival, and overall survival were 1.19, 2.81, and 3.11, respectively.

Conclusion

Elective group was associated with better 3-year survival, longer overall, and 3-year disease-free survival compared to the emergency group. The disease recurrence rate was comparable in both groups, mainly in the first two years after curative resection.

Comparison of short-term surgical outcomes and long-term survival between emergency and elective surgery for colorectal cancer: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to summarize relevant data from previous reports and perform a meta-analysis to compare short-term surgical outcomes and long-term oncological outcomes between emergency and elective surgery for colorectal cancer (CRC).

METHODS

A systematic literature search was performed using PubMed and Embase databases, and relevant data were extracted. Postoperative morbidity, hospital mortality within 30 days, postoperative recovery, overall survival (OS), and relapse-free survival (RFS) were compared using a fixed or random-effect model.

RESULTS

A total of 28 studies involving 353,686 participants were enrolled for this systematic review and meta-analysis, and 23.5% (83,054/353,686) of CRC patients underwent emergency surgery. The incidence of emergency presentations in CRC patients ranged from 2.7 to 38.8%. The lymph node yield of emergency surgery was comparable to that of elective surgery (WMD:0.70, 95%CI: - 0.74,2.14, P = 0.340; I² = 80.6%). Emergency surgery had a higher risk of postoperative complications (OR:1.83, 95%CI:1.62-2.07, P < 0.001; I² = 10.6%) and hospital mortality within 30 days (OR:4.62, 95%CI:4.18-5.10, P < 0.001; I² = 42.9%) than elective surgery for CRC. In terms of long-term oncological outcomes, emergency surgery was significantly associated with poorer RFS (HR: 1.51, 95%CI:1.24-1.83, P < 0.001; I² = 58.9%) and OS(HR:1.60, 95%CI: 1.47-1.73, P < 0.001; I² = 63.4%) of CRC patients. In addition, the subgroup analysis for colon cancer patients revealed a pooled HR of 1.73 for OS (95%CI:1.52-1.96, P < 0.001), without the evidence of significant heterogeneity (I² = 21.2%).

CONCLUSION

Emergency surgery for CRC had an adverse impact on short-term surgical outcomes and long-term survival. A focus on early screening programs and health education was warranted to reduce emergency presentations of CRC patients.

A perforated sigmoid colon cancer initially diagnosed as a tubo-ovarian abscess: A teaching case

Given the wide range of differential diagnoses for adnexal masses, the key issue is the correct assessment of the initial location to rule out malignant or emergency cases. Here, we report a case of perforated sigmoid colon cancer initially diagnosed as a tubo-ovarian abscess.

Oncologic outcome of colon cancer with perforation and obstruction

Purpose

Perforation and obstruction in colorectal cancer are poor prognostic factors. We aimed to evaluate the oncological outcomes of patients with colon cancer presenting with perforation or obstruction.

Methods

A total of 260 patients underwent surgery for colon cancer between January 2015 and December 2017. Among them, 54 patients who underwent emergency surgery for perforated (n = 32) or obstructive (n = 22) colon cancer were included.

Results

The perforation (PG, n = 32) and obstruction groups (OG, n = 22) did not differ significantly in age (p = 0.486), sex (p = 0.821), tumor stage (p = 0.221), tumor location (p = 0.895), histologic grade (p = 0.173), or 3-year overall survival rate (55.6% vs. 50.0%, p = 0.784). However, the PG had a higher postoperative complication rate (44% vs. 17%, p = 0.025), longer intensive care unit stay (4.8 days vs. 0.8 days, p = 0.047), and lower 3-year recurrence-free survival (42.4% vs. 78.8%, p = 0.025) than the OG. In the multivariate analysis, perforation was significantly increased risk of recurrence (hazard ratio = 3.67, 95% confidence interval: 1.049–12.839, p = 0.042).

Conclusion

Patients with colon cancer initially presenting with perforation had poorer recurrence-free survival, higher postoperative complication rates, and longer ICU stays than those who had obstruction.

Determinants of emergency presentation in patients with colorectal cancer: a systematic review and meta-analysis

Colorectal cancer remains a significant cause of morbidity and mortality, even despite curative treatment. A significant proportion of patients present emergently and have poorer outcomes compared to elective presentations, independent of TNM stage. In this systematic review and meta-analysis, differences between elective/emergency presentations of colorectal cancer were examined to determine which factors were associated with emergency presentation. A literature search was carried out from 1990 to 2018 comparing elective and emergency presentations of colon and/or rectal cancer. All reported clinicopathological variables were extracted from identified studies. Variables were analysed through either systematic review or, if appropriate, meta-analysis. This study identified multiple differences between elective and emergency presentations of colorectal cancer. On meta-analysis, emergency presentations were associated with more advanced tumour stage, both overall (OR 2.05) and T/N/M/ subclassification (OR 2.56/1.59/1.75), more: lymphovascular invasion (OR 1.76), vascular invasion (OR 1.92), perineural invasion (OR 1.89), and ASA (OR 1.83). Emergencies were more likely to be of ethnic minority (OR 1.58). There are multiple tumour/host factors that differ between elective and emergency presentations of colorectal cancer. Further work is required to determine which of these factors are independently associated with emergency presentation and subsequently which factors have the most significant effect on outcomes.

Racial Disparities in the Management of Locoregional Colorectal Cancer

Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.

Quality of Colon Cancer Care in Patients Undergoing Emergency Surgery

Thirty percent of colon cancer diagnoses occur following emergency presentations, often with bowel obstruction or perforation requiring urgent surgery. We sought to compare cancer care quality between patients receiving emergency versus elective surgery. We conducted an institutional retrospective matched (46 elective:23 emergency; n = 69) case control study. Patients who underwent a colon cancer resection from January 2017 to February 2019 were matched by age, sex, and cancer stage. Data were collected through the National Surgical Quality Improvement Program and chart review. Process outcomes of interest included receipt of cross-sectional imaging, CEA testing, pre-operative cancer diagnosis, pre-operative colonoscopy, margin status, nodal yield, pathology reporting, and oncology referral. No differences were found between elective and emergency groups with respect to demographics, margin status, nodal yield, oncology referral times/rates, or time to pathology reporting. Patients undergoing emergency surgery were less likely to have CEA levels, CT staging, and colonoscopy (p = 0.004, p = 0.017, p < 0.001). Emergency cases were less likely to be approached laparoscopically (p = 0.03), and patients had a longer length of stay (p < 0.001) and 30-day readmission rate (p = 0.01). Patients undergoing emergency surgery receive high quality resections and timely post-operative referrals but receive inferior peri-operative workup. The adoption of a hybrid acute care surgery model including short-interval follow-up with a surgical oncologist or colorectal surgeon may improve the quality of care that patients with colon cancer receive after acute presentations. Surgeons treating patients with colon cancer emergently can improve their care quality by ensuring that appropriate and timely disease evaluation is completed.

Volume-outcome relationship in rectal cancer surgery

INTRODUCTION

Hospital centralization effect is reported to lower complications and mortality for high risk and complex surgery operations, including colorectal surgery. However, no linear relation between volume and outcome has been demonstrated. Aim of the study was to evaluate the increased surgical volume effect on early outcomes of patient undergoing laparoscopic restorative anterior rectal resection (ARR).

METHODS

A retrospective analysis of all consecutive patients undergoing ARR with primary anastomosis between November 2016 and December 2020 after centralization of rectal cancer cases in an academic Centre. Short-term outcomes are compared to those of patients operated in the same unit during the previous 10 years before service centralization. The primary outcome was estimated anastomotic leak rate. Mean operative time, need of conversion, postoperative use of blood transfusion, radicality, in-hospital stay, number and type of complications, readmission and reoperation rate, mortality and 1-year and stoma persistence rates were evaluated as secondary outcomes.

RESULTS

86 patients were operated in the study period and outcomes compared to those of 101 patients operated during the previous ten years. Difference in volume of surgery was significant between the two periods (p 0.019) and the estimated leak rate was significantly lower in the higher volume unit (p 0.047). Mean operative time, need of conversion, postoperative use of blood transfusion and in-hospital stay (p < 0.05) were also significantly reduced in Group A.

CONCLUSION

This study suggests that the shift toward higher volume in rectal cancer surgery is associated to decreased anastomotic leak rate. Potentiation of lower volume surgical units may yield optimal perioperative outcomes.

Increased long-term mortality after emergency colon resections

AIM

Emergency surgery is a known predictor for 30-day mortality. However, its relationship with long-term mortality is still a matter of debate. The aim of this study was to analyse the effect of emergency surgery compared with elective surgery on long-term survival.

METHOD

Data from the Dutch Colorectal Audit and the Dutch Cancer Centre registry of a large nonacademic teaching hospital were used to analyse outcomes of patients who underwent surgery for colon cancer from 2009 until 2017. Univariable and multivariable Cox regression were used to assess the effect of emergency surgery on long-term mortality with adjustment for patient, tumour and treatment characteristics.

RESULTS

A total of 1139 patients with a median follow-up of 40 months (interquartile range 23-65 months) were included. Emergency surgery was performed in 158 patients (14%). The 5-year survival after emergency surgery was 46% compared with 72% after elective surgery. After adjusting for baseline differences there was an independent and significant association between emergency surgery and increased long-term mortality (hazard ratio 1.79, 95% CI 1.28-2.51, P = 0.001).

CONCLUSION

Emergency surgery for colon cancer seems to lead to a significantly increased risk of long-term mortality compared with elective surgery. Detection and treatment of early symptoms that can lead to emergency surgery might be the way forward.

Recurrence Risk after Radical Colorectal Cancer Surgery-Less Than before, But How High Is It?

Simple Summary

Evidence indicates that recurrence risk after colon cancer today is less than it was when trials performed decades ago showed that adjuvant chemotherapy reduces the risk and prolong disease-free and overall survival. After rectal cancer surgery, local recurrence rates have decreased but it is unclear if systemic recurrences have. After a systematic review of available literature reporting recurrence risks after curative colorectal cancer surgery we report that the risks are lower today than they were in the past and that this risk reduction is not solely ascribed to the use of adjuvant therapy. Adjuvant therapy always means overtreatment of many patients, already cured by the surgery. Fewer recurrences mean that progress in the care of these patients has happened but also that the present guidelines giving recommendations based upon old data must be adjusted. The relative gains from adding chemotherapy are not altered, but the absolute number of patients gaining is less.

Abstract

Adjuvant chemotherapy aims at eradicating tumour cells sometimes present after radical surgery for a colorectal cancer (CRC) and thereby diminish the recurrence rate and prolong time to recurrence (TTR). Remaining tumour cells will lead to recurrent disease that is usually fatal. Adjuvant therapy is administered based upon the estimated recurrence risk, which in turn defines the need for this treatment. This systematic overview aims at describing whether the need has decreased since trials showing that adjuvant chemotherapy provides benefits in colon cancer were performed decades ago. Thanks to other improvements than the administration of adjuvant chemotherapy, such as better staging, improved surgery, the use of radiotherapy and more careful pathology, recurrence risks have decreased. Methodological difficulties including intertrial comparisons decades apart and the present selective use of adjuvant therapy prevent an accurate estimate of the magnitude of the decreased need. Furthermore, most trials do not report recurrence rates or TTR, only disease-free and overall survival (DFS/OS). Fewer colon cancer patients, particularly in stage II but also in stage III, today display a sufficient need for adjuvant treatment considering the burden of treatment, especially when oxaliplatin is added. In rectal cancer, neo-adjuvant treatment will be increasingly used, diminishing the need for adjuvant treatment.

Impact of the COVID-19 pandemic during Spain's state of emergency on the diagnosis of colorectal cancer

INTRODUCTION

We evaluate the impact of COVID-epidemic in colorectal cancer (CRC) diagnosis during Spain's state of emergency.

METHODS

We compared newly diagnosed patients with patients diagnosed in the same period of 2019.

RESULTS

A new diagnosis of CRC decreased 48% with a higher rate of patients diagnosed in the emergency setting (12.1% vs. 3.6%; p = .048) and a lower rate diagnosed in the screening program (5.2% vs. 33.3%; p = .000).

CONCLUSIONS

Fewer patients have been diagnosed with CRC, with a higher rate of patients diagnosed in an emergency setting.

A Systematic Review Comparing Emergency Resection and Staged Treatment for Curable Obstructing Right-Sided Colon Cancer

BACKGROUND

Treatment for obstructing colon cancer (OCC) is controversial because the outcome of acute resection is less favorable than for patients without obstruction. Few studies have investigated curable right-sided OCC, and patients with OCC usually undergo acute resection. This study aimed to better understand the outcome and best management of potentially curable right-sided OCC.

METHODS

A systematic review of studies was performed with a focus on differences in mortality and morbidity between emergency resection and staged treatment for patients with potentially curable right-sided OCC. In March 2019, the study searched Embase, Medline, Web of Science, Cochrane, and Google scholar databases according to PRISMA guidelines using search terms related to "colon tumour," "stenosis or obstruction and surgery," and "decompression or stents." All English-language studies reporting emergency or staged treatment for potentially curable right-sided OCC were included in the review. Emergency resection and staged resection were compared for mortality, morbidity, complications, and survival.

RESULTS

Nine studies were found to be eligible and comprised 600 patients treated with curative intent for their right-sided OCC by emergency resection or staged resection. The mean overall complication rate was 42% (range 19-54%) after emergency resection, and 30% (range 7-44%) after staged treatment. The average mortality rate was 7.2% (range 0-14.5%) after emergency resection and 1.2% (range 0-6.3%) after staged treatment. The 5-year disease-free and overall survival rates were comparable for the two treatments.

CONCLUSIONS

The patients who received staged treatment for right-sided OCC had lower mortality rates, fewer complications, and fewer anastomotic leaks and stoma creations than the patients who had emergency resection.

Time Trends in the Diagnosis of Colorectal Cancer With Obstruction, Perforation, and Emergency Admission After the Introduction of Population-Based Organized Screening

IMPORTANCE

Up to 30% of patients with a diagnosis of colorectal cancer (CRC) present as an emergency (an intestinal obstruction, perforation, or emergency hospital admission) (OPE). There are limited data about the association of organized, population-based colorectal cancer screening with the rate of emergency presentations.

OBJECTIVE

To examine the association of CRC screening with OPE at cancer diagnosis and time trends in the rate of OPE after the start of organized CRC screening using a highly sensitive fecal occult blood test.

DESIGN, SETTING, AND PARTICIPANTS

A historical cohort study was conducted among 1861 individuals 52 to 74 years of age with a diagnosis of CRC from January 1, 2007, to December 31, 2015, who lived in Winnipeg, Manitoba, a province with universal health care and an organized CRC screening program. Statistical analysis was performed from January 22, 2019, to February 26, 2020.

EXPOSURES

Variables included prior CRC screening, era of diagnosis, cancer stage at diagnosis, tumor site in the colon, area level mean household income, primary care continuity of care, and comorbidity.

MAIN OUTCOMES AND MEASURES

The primary outcomes were defined as an OPE. Logistic regression was used to evaluate factors associated with OPE at CRC diagnosis. Trends over time were calculated using Joinpoint Regression.

RESULTS

From 2007 to 2015, 1861 individuals 52 to 74 years of age (1133 men; median age, 65.1 years [interquartile range, 60.0-70.3 years]) received a diagnosis of CRC in Winnipeg. Most individuals had good continuity of care and moderate comorbidities. Overall, 345 individuals (18.5%) had an OPE. The rate of emergency hospital admissions decreased significantly from 2007 (the start of the organized, province-wide CRC screening program) to 2015 (annual change, -7.1%; 95% CI, -11.3% to -2.8%; P = .01). There was no change in the rate of obstructions or perforations or stage IV CRCs. Individuals who were up to date for CRC screening were significantly less likely to receive a diagnosis of an OPE (odds ratio, 0.38; 95% CI, 0.28-0.50; P < .001). The results were similar after adding emergency department visits and stage IV CRC at diagnosis to the outcome.

CONCLUSIONS AND RELEVANCE

This study suggests that the rate of emergency hospital admissions decreased over time for individuals who underwent CRC screening, but there was no change in the rate of obstructions and perforations. Individuals who were up to date for CRC screening were less likely to have a CRC diagnosis with an OPE.

Oncologic long-term outcomes of emergency versus elective resection for colorectal cancer

PURPOSE

Long-term outcomes in patients undergoing emergency versus elective resection for colorectal cancer (CRC) are discussed controversially. This study aims to assess long-term outcomes of emergency versus elective CRC surgery.

METHODS

Single-center retrospective cohort study. Patients undergoing emergency or elective CRC surgery from July 2002 to January 2013 were included. Primary outcome was 5-year survival, secondary outcomes were in-hospital mortality and local tumor recurrence.

RESULTS

Overall, 475 patients were included. Median age was 69.0 (IQR 59.0-77.0) years. A total of 141 patients (30%) were operated for rectal cancer and 334 patients (70%) for colon cancer. Median follow-up was 445 (IQR 67-1409) days. Emergency resection was performed in 105 patients (22%) due to obstruction, perforation, or bleeding. Stage IV tumors and ASA scores≥ 3 were significantly more frequent in the emergency than in the elective resection group (39.0% vs. 33.5%, p < 0.001; 75.5% vs. 61.3%, p = 0.003). The rate of patients with positive lymph nodes was similar in the two groups (46.2% vs. 46.3%, p = 1.000). In-hospital mortality was significantly higher in the emergency CRC versus the elective CRC group (8.4% vs. 3.0%, p = 0.023). Five-year survival (aHR 1.38; 95%CI 0.81-2.37, p = 0.237) or local tumor recurrence (aHR 1.48; 95%CI 0.47-4.66, p = 0.500) were not significantly different in patients undergoing emergency versus elective surgery for CRC.

CONCLUSION

In-hospital mortality was increased in emergency versus elective CRC resections. However, 5-year survival and local recurrence after surgery for CRC were determined by the tumor stage, and not by the emergency versus elective setting of surgical resection.

Histotype influences emergency presentation and prognosis in colon cancer surgery

AIM

To investigate whether differences in histotype in colon cancer correlate with clinical presentation and if they might influence oncological outcomes and survival.

METHODS

Data regarding colon cancer patients operated both electively or in emergency between 2009 and 2014 were retrospectively collected from a prospectively maintained database and analyzed for the purpose of this study. Rectal cancer was excluded from this analysis. Statistical univariate and multivariate analyses were performed to investigate possible significant variables influencing clinical presentation, as well as oncological outcomes and survival.

RESULTS

Data from 219 patients undergoing colorectal resection for cancer of the colon only were retrieved. One hundred seventy-four patients had an elective procedure and forty-five had an emergency colectomy. Emergency presentation was more likely to occur in mucinous (p < 0.05) and signet ring cell (p < 0.01) tumors. No definitive differences in 5-year overall (44.7% vs. 60.6%, p = 0.078) and disease-free (51.2% vs. 64.4%, p = 0.09) survival were found between the two groups as a whole, but the T3 emergency patients showed worse prognosis than the elective (p < 0.03). Lymph node invasion, laparoscopy, histology, and blood transfusions were independent variables found to influence survival. Distribution assessed for pTNM stage showed T3 cancers were more common in emergency (p < 0.01).

CONCLUSIONS AND DISCUSSION

Mucinous and signet ring cell tumors are related to emergency presentation, pT3 stage, poorest outcomes, and survival. Disease-free survival in patients who had emergency surgery for T3 colon cancer seems related to the histotype.