Nonelective colon cancer resection: A continued public health concern

Interaction of Insurance and Neighborhood Income on Operative Colorectal Cancer Outcomes Within a National Database

INTRODUCTION

Sociodemographic disparities in colorectal cancer (CRC) surgical patients are known. Few studies, however, have examined the intersection of insurance type and median household income (MHI).

METHODS

In this retrospective analysis of the National Inpatient Sample from 2000 to 2019, all CRC surgery patients between 50 and 64 y old were included. Patients were further stratified based on insurance type (commercial, Medicaid, and uninsured) as well as county-level MHI quartiles. Outcomes included nonelective surgery (primary outcome), inpatient mortality, complications, and blood transfusions. Multivariate logistic regression adjusted for sociodemographic variables, medical comorbidities, and hospital-level factors.

RESULTS

Of 108,606 patients, 80.5% of patients had commercial insurance, while 5.8% were uninsured. On multivariate analysis, Medicaid or no insurance, especially when living in a lower-income community, were associated with significantly higher odds of nonelective surgery (ORs: 1.11-4.54). There was a stepwise effect on nonelective surgery by insurance type (uninsured with lower odds than insured) and MHI (each lower quartile had higher odds). There were similar trends for inpatient blood transfusions, but there were no significant differences in mortality or complications.

CONCLUSIONS

Especially when considered together, noncommercial insurance and lower MHI were associated with worse outcomes in CRC patients. Insurance was more protective than MHI against worse outcomes. These findings among a screening-aged cohort have policy planning implications for insurance expansions and healthcare funding allocations. Further research is needed to understand the complex underlying mechanisms that create this interaction between insurance and MHI.

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.

A qualitative analysis of patients' experiences with an emergency department diagnosis of gastrointestinal cancer

OBJECTIVES

Optimally, cancer is diagnosed through periodic screening or detection of early symptoms in primary care settings. However, an estimated 23%-52% of gastrointestinal (GI) cancers are diagnosed in the emergency department (ED). Cancer diagnosed in the ED has been associated with worse clinical and patient-reported outcomes even after adjustment for cancer stage. We sought to explore patients' accounts of patient and health care system factors related to their diagnosis in the ED and their lived experience of receiving a diagnosis in this setting.

METHODS

Patients with an ED visit during or within 30 days of their GI cancer diagnosis at an urban academic hospital serving a largely disadvantaged population were recruited. Interviews were coded in NVivo 12 and analyzed using a thematic analysis approach.

RESULTS

Patient-reported factors associated with their experiences included denial and avoidance of symptoms, mistrust of the health system, and lack of cancer screening knowledge. Health care system factors included misdiagnosis and delayed access to specialty care or tests. Experiences receiving a cancer diagnosis in the ED were overwhelmingly negative.

CONCLUSIONS

This study highlights the unmet needs in identifying and diagnosing patients who ultimately present to the ED for evaluation and eventual diagnosis of cancer. Our results shed light on several modifiable factors, including the need for increased public awareness of the asymptomatic nature of cancer and the importance of cancer screening. Additionally, health care systems modifications beyond the ED are needed to improve access to timely care when symptoms arise.

A Novel Clinical Nomogram for Predicting Overall Survival in Patients with Emergency Surgery for Colorectal Cancer

BACKGROUND

Long-term survival after emergency colorectal cancer surgery is low, and its estimation is most frequently neglected, with priority given to the immediate prognosis. This study aimed to propose an effective nomogram to predict overall survival in these patients.

MATERIALS AND METHODS

We retrospectively studied 437 patients who underwent emergency surgery for colorectal cancer between 2008 and 2019, in whom we analyzed the clinical, paraclinical, and surgical parameters.

RESULTS

Only 30 patients (6.86%) survived until the end of the study. We identified the risk factors through the univariate Cox regression analysis and a multivariate Cox regression model. The model included the following eight independent prognostic factors: age > 63 years, Charlson score > 4, revised cardiac risk index (RCRI), LMR (lymphocytes/neutrophils ratio), tumor site, macroscopic tumoral invasion, surgery type, and lymph node dissection (p < 0.05 for all), with an AUC (area under the curve) of 0.831, with an ideal agreement between the predicted and observed probabilities. On this basis, we constructed a nomogram for prediction of overall survival.

CONCLUSIONS

The nomogram created, on the basis of a multivariate logistic regression model, has a good individual prediction of overall survival for patients with emergency surgery for colon cancer and may support clinicians when informing patients about prognosis.

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.

Short-term Outcomes of Emergent Versus Elective Gastrectomy for Gastric Adenocarcinoma: A National Surgical Quality Improvement Program Study

BACKGROUND

Gastric adenocarcinoma is a leading cause of cancer death worldwide and in the United States, and can present emergently with upper GI hemorrhage, obstruction, or perforation. Few large studies have examined how emergency surgery for gastric cancer affects patient outcomes.

METHODS

All patients from National Surgical Quality Improvement Program with gastric adenocarcinoma from 2005 to 2017 were examined retrospectively. Univariate and multivariate analysis of patient factors and perioperative outcomes was performed. P-values < .05 were significant.

RESULTS

Of 4663 total patients, 115 had emergency surgery and 4548 had elective surgery. Emergency surgery patients were more likely to be non-white, underweight, higher ASA class, require a preoperative blood transfusion, and were less likely to be functionally independent. Multivariate analysis demonstrates an increased likelihood of unplanned intubation, prolonged ventilation, and deep vein thrombosis (DVT).

DISCUSSION

There are no significant differences in mortality, reoperation, or infection when comparing emergent surgery for gastric cancer and elective surgery; however, there is an increased risk of reintubation, prolonged intubation, and DVT in patients undergoing emergent surgery. Patients requiring emergent surgery have more comorbidities, higher blood transfusion requirements, and worse preoperative functional status, and this study demonstrates that they also have worse perioperative outcomes. Previous studies have shown that long-term oncologic outcomes are worse for patients undergoing urgent surgery, and this study shows that perioperative outcomes are also somewhat worse. Thus, definitive surgery performed on a patient who presents emergently with gastric cancer should be considered but may come at the cost of increased perioperative respiratory complications, DVTs, and worse oncologic outcomes.

Is robotic utilization associated with increased minimally invasive colorectal surgery rates? Surgeon-level evidence

Background

It is unclear whether robotic utilization has increased overall minimally invasive colorectal surgery rates or if robotics is being adopted instead of laparoscopy. The goal was to evaluate whether increasing robotic surgery utilization is associated with increased rates of overall colorectal minimally invasive surgery.

Methods

The Statewide Planning and Research Cooperative System (New York) was used to identify patients undergoing elective colectomy or proctectomy from 2009 to 2015. Individual surgeons were categorized as having increasing or non-increasing robotic utilization (IRU or non-IRU, respectively) based on the annual increase in the proportion of robotic surgery performed. The odds of surgical approach across the study period were evaluated with multinomial regression.

Results

Among 72,813 resections from 2009 to 2015, minimally invasive-surgery increased (47–61%, p < 0.0001). For colectomy, overall minimally invasive-surgery rates increased (54–66%, p < 0.0001), laparoscopic remained stable (53–54%), and robotics increased (1–12%). For proctectomy, overall minimally invasive-surgery rates increased (22–43%, p < 0.0001), laparoscopic remained stable (20–21%), and robotics increased (2–22%). Over the study period, 2487 surgeons performed colectomies. Among 156 surgeons with IRU for colectomies, robotics increased (2–29%), while laparoscopy decreased (67–44%), and open surgery decreased (31–27%). Overall, surgeons with IRU performed minimally invasive colectomies 73% of the time in 2015 versus 69% in 2009. Over the study period, 1131 surgeons performed proctectomies. Among 94 surgeons with IRU for proctectomies, robotics increased (3–42%), while laparoscopy decreased (25–15%), and open surgery decreased (73–44%). Overall, surgeons with IRU performed minimally invasive proctectomy 56% of the time in 2015 versus 27% in 2009. Patients in the latter study period had 57% greater odds of undergoing robotic surgery.

Conclusions

Overall, minimally invasive colorectal resections increased from 2009 to 2015 largely due to increasing robotic utilization, particularly for proctectomies.

Factors affecting short-term survival in patients older than 85 treated with resection for stage II and III colon cancer

BACKGROUND

Patients ≥85 years of age have high rates of colon cancer but disproportionately poor outcomes. Factors affecting short-term (90-day) survival in patients ≥85 undergoing surgery for stage II and III colon cancer were examined to identify potentially modifiable factors to improve outcomes.

METHODS

The New York State Cancer Registry and Statewide Planning Research and Cooperative System were queried for patients ≥85 years who underwent colectomy for stage II and III colon cancer between 2004 and 2012. Regression analyses were performed for factors associated with 90-day mortality and stratified by elective and nonelective surgery.

RESULTS

In total, 3,779 patients ≥85 years of age underwent colectomy between 2004 and 2012 for stage II or III colon cancer. Of these, 48.4% underwent nonelective colectomy, 79.9% had an open operation, and 90-day survival was 83.2%. Worse survival was associated with nonelective surgery (odds ratio = 3.81, 95% confidence interval = 3.03-4.89). Improved survival in the nonelective and overall groups was associated with a minimally invasive operation (nonelective group: odds ratio = 0.35, 95% confidence interval = 0.21-0.58; overall group: odds ratio = 0.50, 95% confidence interval = 0.36-0.73) and discharged to another health care facility (nonelective group: odds ratio = 0.30, 95% confidence interval = 0.22-0.39; overall group: odds ratio = 0.42, 95% confidence interval = 0.33-0.53). High surgeon annual operating volume was associated with improved survival in the elective and nonelective groups (P < .001).

CONCLUSION

Factors associated with greater odds of 90-day mortality in this population include nonelective surgery, preoperative weight loss, and multiple comorbidities, whereas a minimally invasive approach was associated with lower mortality. Potential areas to improve outcomes in this population include using a multidisciplinary team approach, addressing frailty preoperatively when possible, and potentially reconsidering screening guidelines for colorectal cancer to reduce rates of emergency operations.

Colonic Stents as a Bridge to Surgery Compared with Immediate Resection in Patients with Malignant Large Bowel Obstruction in a NY State Database

BACKGROUND

There is controversy surrounding the efficacy and safety of colonic stents as a bridge to surgery compared with immediate resection in patients presenting with an acute malignant large bowel obstruction.

METHODS

Retrospective longitudinal cohort study using the NYS SPARCS Database. Patients with acute malignant large bowel obstruction who either had stent followed by elective surgery within 3 weeks (bridge to surgery) or underwent immediate resection between October 2009 and June 2016 in the state of New York were included. The primary outcome was rate of stoma creation at index resection. Secondary outcomes were 90-day readmission, reoperation, procedural complications, and discharge disposition.

RESULTS

A total of 3059 patients were included, n = 2917 (95.4%) underwent an immediate resection and n = 142 (4.6%) underwent bridge to surgery. We analyzed 139 patients in propensity score-matched groups. Patients in the bridge to surgery group were less likely than those in the immediate resection group to get a stoma at the time of surgery (OR 0.33, 95% CI 0.18-0.60). They were also less likely to be discharged to a rehabilitation facility or require a home health aide upon discharge (OR 0.36, 95% CI 0.22-0.61). There were no differences in rates of 90-day readmission, reoperation, or procedural complications between groups.

DISCUSSION

Colonic stenting as a bridge to surgery leads to less stoma creation, a significant quality of life advantage, compared with immediate resection. Patients should be counseled regarding these potential benefits when the technology is available.

Enhanced recovery after surgery in emergency resection for obstructive colorectal cancer: a systematic review and meta-analysis

PURPOSE

Enhanced recovery after surgery (ERAS) improves outcomes after elective colorectal operations. Whether it is beneficial for emergency colorectal surgery is unclear. This study aimed to systematically review and summarize evidence from all studies comparing ERAS versus conventional care in patients having emergency colectomy and/or proctectomy for obstructive colorectal cancer.

METHODS

EMBASE, MEDLINE, and PUBMED from 1981 to December 2019 were systematically searched. Any studies comparing our primary outcome of interest (length of hospitalization) among patients having emergency resection for obstructive colorectal cancer who received ERAS versus conventional care were selected. Primary outcome was length of hospitalization. Secondary outcomes were gastrointestinal recovery, postoperative complication, 30-day readmission and mortality, and time to start adjuvant therapy.

RESULTS

Three cohort studies with 818 participants (418 received ERAS and 400 received conventional care) were included. Length of hospitalization (mean reduction 3.07 days; 95% CI, - 3.91 to - 2.23) and risk of overall complication (risk ratio 0.78; 95% CI, 0.63 to 0.97) were significantly lower in ERAS than in conventional care. ERAS was also associated with quicker time to gastrointestinal recovery, a lower incidence of ileus, and a shorter interval between operation and commence of adjuvant chemotherapy. There was no significant difference in the rates of anastomotic leakage, surgical site infection, reoperation, readmission, and mortality within 30 days after surgery between groups.

CONCLUSIONS

ERAS had advantages over conventional care in patients undergoing emergency resection for obstructive colorectal cancer-including a shorter length of hospitalization, a lower incidence of overall complication, and a quicker gastrointestinal recovery.

Diagnosis Setting and Colorectal Cancer Outcomes: The Impact of Cancer Diagnosis in the Emergency Department

BACKGROUND

The rate of diagnosis of colorectal cancer (CRC) in the emergency department (ED), its characteristics, and its effect on outcomes have been poorly described.

MATERIALS AND METHODS

Chart review was conducted to identify presenting clinical setting leading to diagnosis, symptoms, and history of colonoscopy for patients diagnosed with CRC at a single institution from 2012-2014. Patients diagnosed with CRC as a result of an ED visit (EDDx) were compared with those diagnosed after presentation to other settings (non-EDDx).

RESULTS

Of 638 patients meeting inclusion criteria, 271 (42.4%) were EDDx patients. These patients were more likely to be older than 80 y (29.89% versus 19.35%), have Medicare (59.78% versus 42.78%) or Medicaid (23.62% versus 12.81%) insurance, have stage IV cancer (45.02% versus 18.26%), and were symptomatic at the time of presentation (94.83% versus 64.03%). EDDx patients were less likely to ever have had a colonoscopy (21.77% versus 41.69%). In a model adjusted for patient demographics, cancer stage, presence of symptoms, and history of prior colonoscopy, EDDx was associated with increased mortality (hazard ratio, 1.89; 95% confidence interval, 1.3-2.8). On stratifying survival by stage, it was found that for all stages, EDDx was associated with decreased survival.

CONCLUSIONS

More than 40% of patients with CRC received their diagnosis through the ED. EDDx was associated with a nearly twofold mortality risk increase. EDDx should be considered a marker of poor outcomes for CRC and may be related to unaccounted patient-level or systems-level factors. Efforts should be made to identify modifiable risks of cancer diagnosis in the ED to improve cancer outcomes.

How Soon Should Patients With Colon Cancer Undergo Definitive Resection?

BACKGROUND

Timing of surgery has been shown to affect outcomes in many forms of cancer, but definitive national data do not exist to determine the effect of time to surgery on survival in colon cancer.

OBJECTIVE

This study aimed to determine whether a delay in definitive surgery in colon cancer significantly affects survival.

DATA SOURCES

A retrospective cohort study using 2 independent population-based databases, The Surveillance, Epidemiology, and End Results Medicare-linked database and the National Cancer Database, was performed.

STUDY SELECTION

All patients had American Joint Committee on Cancer stage 1 through 3 colon cancer. Patients were more than 18 years of age in the National Cancer Database cohort and older than 66 years of age in the Medicare cohort. Patients had a minimum of 3 years of follow-up.

MAIN OUTCOME MEASURES

The main outcome was overall survival as a function of time between diagnosis and surgery in 4 intervals (1-2, 3-4, 5-6, >6 weeks).

RESULTS

The Medicare cohort demonstrated an adjusted 5-year survival of 8% to 14% higher in patients with a surgical delay between 3 and 6 weeks, with significantly lower hazard ratios in that interval. The National Cancer Database cohort demonstrated an adjusted 5-year survival of 9% to 16% higher in patients with surgery 3 to 6 weeks after diagnosis, with comparatively similar improvements in survival hazard.

LIMITATIONS

Because this was a retrospective study of administrative databases, with Medicare data limited to billing data, the causality of outcomes must be interpreted with caution.

CONCLUSIONS

The ideal timing of definitive resection in colon cancer is between 3 and 6 weeks after initial diagnosis. All efforts should be made for patients to obtain definitive surgery within this interval to achieve a modest but significant improvement in overall survival. See Video Abstract at http://links.lww.com/DCR/B76. ¿CUÁNDO DEBEN SOMETERSE LOS PACIENTES CON CÁNCER DE COLON A UNA RESECCIÓN DEFINITIVA?: Se ha demostrado que el momento de la cirugía afecta los resultados en muchas formas de cáncer, pero no existen datos nacionales definitivos para determinar el efecto del tiempo hasta la cirugía en la supervivencia en el cáncer de colon.Determinar si un retraso en la cirugía definitiva en el cáncer de colon afecta significativamente la supervivencia.Un estudio de cohorte retrospectivo que utiliza dos bases de datos independientes basadas en la población; Se realizó la base de datos vinculada a la vigilancia, la epidemiología y los resultados finales y la base de datos nacional del cáncer.Pacientes con cáncer de colon en estadíos 1 a 3 del Comité Estadounidense Conjunto sobre el Cáncer. Los pacientes tenían más de 18 años en la cohorte de la National Cancer Database y más de 66 años en la cohorte de Medicare. Los pacientes tuvieron un mínimo de 3 años de seguimiento.El resultado principal fue la supervivencia general en función del tiempo entre el diagnóstico y la cirugía en 4 intervalos (1-2, 3-4, 5-6, y mas de 6 semanas).La cohorte de Medicare demostró una supervivencia ajustada de 5 años de 8 a 14% más en pacientes con un retraso quirúrgico entre 3 a 6 semanas, con razones de riesgo significativamente más bajas en ese intervalo. La cohorte de la National Cancer Database demostró una supervivencia ajustada a 5 años de 9 a 16% más en pacientes con cirugía de 3 a 6 semanas después del diagnóstico, con mejoras comparativamente similares en el riesgo de supervivencia.Dado que este fue un estudio retrospectivo de bases de datos administrativas, con datos de Medicare limitados a datos de facturación, la causalidad de los resultados debe interpretarse con precaución.El momento ideal para la resección definitiva en el cáncer de colon es entre tres y seis semanas después del diagnóstico inicial. Se deben hacer todos los esfuerzos para que los pacientes obtengan una cirugía definitiva dentro de este intervalo para lograr una mejora modesta pero significativa en la supervivencia general. Consulte Video Resumen en http://links.lww.com/DCR/B76.

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.

Nationwide cohort study of the impact of education, income and social isolation on survival after acute colorectal cancer surgery

Background

Acute colorectal cancer surgery has been associated with a high postoperative mortality. The primary aim of this study was to examine the association between socioeconomic position and the likelihood of undergoing acute versus elective colorectal cancer surgery. A secondary aim was to determine 1‐year survival among patients treated with acute surgery.

Methods

All patients who had undergone a surgical procedure according to the Danish Colorectal Cancer Group (DCCG.dk) database, or who were registered with stent or diverting stoma in the National Patient Register from 2007 to 2015, were reviewed. Socioeconomic position was determined by highest attained educational level, income, urbanicity and cohabitation status, obtained from administrative registries. Co‐variables included age, sex, year of surgery, Charlson Co‐morbidity Index score, smoking status, alcohol consumption, BMI, stage and tumour localization. Logistic regression analysis was performed to determine the likelihood of acute colorectal cancer surgery, and Kaplan–Meier and Cox proportional hazards regression methods were used for analysis of 1‐year overall survival.

Results

In total, 35 661 patients were included; 5310 (14·9 per cent) had acute surgery. Short and medium education in patients younger than 65 years (odds ratio (OR) 1·58, 95 per cent c.i. 1·32 to 1·91, and OR 1·34, 1·15 to 1·55 respectively), low income (OR 1·12, 1·01 to 1·24) and living alone (OR 1·35, 1·26 to 1·46) were associated with acute surgery. Overall, 40·7 per cent of patients died within 1 year of surgery. Short education (hazard ratio (HR) 1·18, 95 per cent c.i. 1·03 to 1·36), low income (HR 1·16, 1·01 to 1·34) and living alone (HR 1·25, 1·13 to 1·38) were associated with reduced 1‐year survival after acute surgery.

Conclusion

Low socioeconomic position was associated with an increased likelihood of undergoing acute colorectal cancer surgery, and with reduced 1‐year overall survival after acute surgery.

Effect of care continuity on mortality of patients readmitted after colorectal surgery

BACKGROUND

Postoperative readmission after colorectal resection is common. It is unknown whether patients who receive readmission care from the surgeon who performed the index surgery have improved mortality. This study evaluated whether postdischarge continuity of care, defined at the hospital and surgeon level, was associated with decreased mortality after colorectal surgery.

METHODS

The Statewide Planning and Research Cooperative System was queried for patients who had colorectal resections from 2004 to 2014, and were readmitted within 30 days of discharge. Propensity-adjusted logistic regression analysis was used to evaluate the association between 30-day mortality and readmission care continuity.

RESULTS

A total of 20 016 patients readmitted within 30 days of discharge were eligible for analysis. Some 39·5 per cent of readmitted patients experienced hospital and surgeon care continuity, 47·1 per cent hospital but not surgeon continuity, 1·0 per cent surgeon but not hospital continuity, and 12·4 per cent neither hospital nor surgeon care continuity. A total of 1349 patients (6·7 per cent) died within 30 days of readmission. Patients readmitted with absence of surgeon but not of hospital care continuity had 2·04 (95 per cent c.i. 1·72 to 2·42) times the risk of 30-day mortality compared with those who experienced surgeon and hospital continuity. Absence of both surgeon and hospital care continuity was associated with 2·65 (2·18 to 3·30) times the risk of death compared with presence of both.

CONCLUSION

Readmission after colorectal resection not under the care of the index operating surgeon is associated with an increased risk of 30-day mortality. Addressing processes of care that are affected by surgeon care continuity may decrease surgical deaths.

Outcomes of Elderly Patients Undergoing Emergency Surgery for Complicated Colorectal Cancer: A Retrospective Cohort Study

OBJECTIVE

Colorectal cancer is one of the most frequent types of malignant neoplasms. Age is a risk factor for this disease, with 75% of cases diagnosed in patients older than 65 years. Complications such as obstruction, hemorrhage, and perforation are present in more than one-third of cases and require emergency treatment. We aim to analyze the profile of elderly patients undergoing surgery for complicated colorectal cancer, and to evaluate factors related to worse short-term prognosis.

METHODS

A retrospective analysis of patients who underwent emergency surgical treatment for complicated colorectal cancer was performed. Demographics, clinical, radiological and histological data were collected.

RESULTS

Sixty-seven patients were analyzed. The median age was 72 years, and almost half (46%) of the patients were female. Obstruction was the most prevalent complication at initial presentation (72%). The most common sites of neoplasia were the left and sigmoid colon in 22 patients (32.8%), and the right colon in 17 patients (25.4%). Resection was performed in 88% of cases, followed by primary anastomosis in almost half. The most frequent clinical stages were II (48%) and III (22%). Forty-three patients (65.7%) had some form of postoperative complication. Clavien-Dindo grades 1, 2, and 4, were the most frequent. Complete oncologic resection was observed in 80% of the cases. The thirty-day mortality rate was 10.4%. Advanced age was associated with worse morbidity and mortality.

CONCLUSION

Elderly patients with complicated colorectal cancer undergoing emergency surgery have high morbidity and mortality rates. Advanced age is significantly associated with worse outcomes.

Mortality after emergency treatment of colorectal cancer and associated risk factors-a nationwide cohort study

PURPOSE

The aim of this study was to investigate if postoperative mortality after acute surgical treatment of colorectal cancer has decreased in Denmark during this period and to investigate risk factors associated with early death.

METHODS

This is a nationwide and population-based cohort study. From the Danish Colorectal Cancer Group database and National Patient Registry, we collected data on all patients operated with bowel resection, diverting stoma only, or placement of an endoscopic stent from 2005 to 2015. Year of surgery was the main exposure variable and 90-day postoperative mortality the primary outcome.

RESULTS

We included 6147 patients. The incidence of patients per year was stable during 2005-2015. The 90-day mortality decreased from 31% in 2005 to 24% in 2015 with a significant time trend (p < 0.0001). Other factors associated with postoperative mortality were increasing age, presence of comorbidity (measured as Charlson comorbidity index score ≥ 1), and stage IV disease. Insertion of self-expanding metallic stent was protective for 90-day postoperative mortality compared with other surgical procedures.

CONCLUSION

Ninety-day postoperative mortality from acute colorectal surgery has improved in Denmark from 2005 to 2015. Nevertheless, almost one out of four patients undergoing acute surgery for colorectal cancer dies within 90 days.