Emergency colorectal cancer surgery linked to poorer surgical outcomes, major global study finds

Patients undergoing emergency surgery for potentially curable colorectal cancer are more than twice as likely to receive an incomplete cancer resection compared with those having planned operations, according to a major international study led by researchers at the University of Birmingham.

Published in BJS Open, the study analysed data from 13,101 patients treated across 964 hospitals in 95 countries between 2018 and 2023. The research was conducted by the NIHR Global Health Research Unit on Global Surgery, led by the University of Birmingham's School of Health Sciences.

The study found that 13.7% of patients undergoing emergency colorectal cancer surgery experienced a margin-positive resection, compared with just 4.5% of patients receiving elective surgery. After accounting for factors including cancer stage, patient characteristics and health system differences, emergency surgery remained associated with over twice the increased risk of incomplete tumour removal.

A margin-positive resection occurs when cancer cells remain at or close to the edge of the tissue removed during surgery and is recognised internationally as a key measure of surgical quality. Patients who experience margin-positive resections face a greater risk of cancer recurrence and poorer long-term outcomes.

The increased risk associated with emergency surgery was observed across all income groups, from high-income to low-income countries, and remained consistent regardless of measures such as healthcare access, health expenditure and surgical workforce density. The greatest disparities were seen in patients with advanced rectal cancers, where the difference in risk between emergency and planned surgery was particularly pronounced.

The findings challenge the assumption that poorer outcomes in emergency colorectal cancer surgery are primarily due to patients presenting with more advanced disease; instead, the researchers suggest that modifiable factors, including surgical decision-making, access to specialist colorectal surgeons and the availability of "bridge-to-surgery" approaches, may play a significant role in improving outcomes. These approaches can include temporary stomas, stenting procedures and other interventions that allow patients to be stabilised before undergoing definitive cancer surgery.

Lead author Mr Sivesh Kamarajah, from the NIHR Global Health Research Unit on Global Surgery at the University of Birmingham, said:

"The findings matter as patients undergoing poor quality surgery are at risk of shorter survival. It highlights for a shift towards better decision making in the emergency setting, ensuring specialist surgeons are available to deliver these or enabling bridging options to allow for better planning.

We hope that these findings will make an impact into daily discussions surgical teams have around the world and develop plans in place within hospitals to ensure every patient, including those of a younger population, gets the best quality care for a cancer which is becoming more prevalent.”