Comparison of emergency and elective surgeries in left colon cancers

Authors

Abstract

AimWe aimed to compare emergency and elective surgical approaches in tumors of the left colon at a tertiary center, with a focus on perioperative characteristics.
MethodsWe retrospectively reviewed patients who underwent surgical treatment for left colon tumors (splenic flexure, descending colon, and sigmoid colon) over the past 10 years. Rectosigmoid tumors were excluded. Patients were divided into Group 1 (Emergency) and Group 2 (Elective). Demographic and clinical characteristics, perioperative parameters, stoma status, complications, and survival were compared.
ResultsA total of 110 patients were included; 25 in Group 1 and 85 in Group 2. The male gender was predominant in both groups. Mean age (65 vs. 59, p=0.275) and carcinoembryonic antigen (CEA) levels (4.28 vs. 3.46, p=0.336) were similar. Laparoscopic approach was more common in Group 2 (8% vs. 50.8%, p < 0.001). Stoma rate was higher in Group 1 but not statistically significant (60% vs. 11%, p=0.073). Surgical site infections were more frequent in Group 1 (72% vs. 31.7%, p < 0.005). Other complications were similar. Median lymph nodes removed (13 vs. 16, p=0.364) and pathological stage (p=0.8688) were similar. No significant survival difference was observed (79.6% vs. 92.3%, p=0.191).
ConclusionPostoperative parameters were comparable between groups. Except for a higher incidence of surgical site infection in emergency patients, we did not observe a statistically significant difference between the groups in most evaluated outcomes.

Keywords

Introduction

Colorectal cancer (CRC) remains a significant cause of morbidity and mortality worldwide. According to 2022 data, it is the third most common cancer globally and the second leading cause of death.¹ Approximately 26% of colorectal cancer presentations—including obstruction, perforation, and bleeding—are of an emergency nature, and a considerable proportion of cases require emergency surgery.²
Despite active screening efforts, the incidence of emergency presentations in colon cancer remains constant.³ Regardless of the mode of presentation, surgery is the only potentially curative treatment option for colon cancer. However, emergency surgical treatment is associated with higher complication and mortality rates compared to elective surgery.⁴ The management of colon cancer under emergency conditions is particularly challenging due to the patient's poor general condition, limited information about the cancer stage, and comorbidities.
In terms of long-term oncological outcomes, several studies have identified emergency surgery as a negative prognostic factor for recurrence and survival in CRC patients.⁵ However, this association was not consistently observed after adjusting for initial tumor stages.6 Further investigation is required to clarify the relationship between emergency surgical intervention for colon cancer and oncological outcomes.
In this study, we aimed to compare the emergency and elective approaches of a tertiary center in tumors located in the left colon with their perioperative period characteristics.

Materials and Methods

We planned a single-center retrospective cross-sectional study. The study was conducted in accordance with the Declaration of Helsinki. Patients with colorectal cancer who underwent surgical treatment at our clinic between 2012 and 2022 were included in the study. Patients were selected based on tumor localization in the splenic flexure, descending colon, and sigmoid colon. Those with tumors in the right colon, transverse colon, rectosigmoid, and rectum, non-adenocarcinoma pathology results, or incomplete medical records were excluded from the study. Patient electronic files, pathology data, and observation files were used to create a prospectively designed dataset for analysis.
Patients were divided into two groups based on their mode of presentation: Group 1 (Emergency) and Group 2 (Elective). In these groups, we compared demographic and clinical characteristics, preoperative laboratory values, type of operation, stoma status, length of hospital stay, postoperative complications including surgical site infection, intra-abdominal abscess, bleeding, and ileus, the number of dissected lymph nodes, pathological stage, and average survival.
Routine preoperative evaluations consisted of physical examination, colonoscopy, and chest-abdomen-pelvis computed tomography (CT). Pathological staging was performed according to the seventh and eighth editions of the tumor, node, metastasis (TNM) Classification.^7,8 Patients who were taken to surgery without standard preoperative preparation due to acute symptoms were considered to be in emergency status. The type of surgery was selected based on the surgeon's decision and preference.
Survival was defined as the period from the date of surgical resection to the date of death.
Ethical ApprovalThe study was approved by the Ethics Committee of Balıkesir University Health Sciences Research Ethics Committee (Date: 06.05.2025, Decision No: 2025/179).
Statistical AnalysisStatistical analysis was performed using the SPSS v22 software package. Categorical data were presented as percentages (number). The normality of distribution for numerical data was assessed using the Kolmogorov-Smirnov test. Parameters that conformed to a normal distribution were presented as mean ± standard deviation, while those that did not were presented as median (interquartile range). The chi-square test was used to compare categorical data. For numerical data that followed a normal distribution, the t-test was employed, while the Mann-Whitney U test was used for data not conforming to normal distribution. Results with a p-value of less than 0.05 were considered statistically significant.
Reporting GuidelinesThis study is reported in accordance with the STROBE guidelines for observational studies.

Results

A total of 110 patients were included in our study, with 25 in Group 1 and 85 in Group 2. The male gender was predominant in both groups. The age (p=0.275) and body mass index (BMI) (p=0.351) averages were similar. The hemoglobin (Hgb) levels at presentation (12.6 vs 12.5, p=0.724) and carcinoembryonic antigen (CEA) levels (4.28 vs 3.46, p=0.336) were also similar (Table 1).
The laparoscopic approach was more frequent in Group 2 (8% vs 50.8%, p<0.001). Although the stoma rate was higher in Group 1, it was not statistically significant (60% vs 11%, p=0.073). Surgical site infections were higher in Group 1 (72% vs 31.7%, p<0.005). Other complications were similar. The median number of lymph nodes removed (13 vs 16, p=0.364) and pathological stage (p=0.8688) were similar. No significant difference was found in survival between the groups (79.6% vs 92.3%, p=0.191; Supplementary Table 1).

Discussion

In this study comparing emergency and elective approaches in tumors located in the left colon at a tertiary center, we found similar postoperative parameters in patients with similar demographic characteristics. Except for a higher incidence of surgical site infection in emergency patients, we did not observe a statistically significant difference between the groups in most evaluated outcomes.
Emergency surgeries inherently carry certain risks. The insufficient preoperative preparations and the surgical stress induced by emergency surgery are associated with high postoperative morbidity. Zhou et al., in their recent meta-analysis involving 10 studies, compared the incidence of postoperative complications between emergency and elective surgeries for CRC. They found a higher risk of postoperative complications in emergency surgeries. Specifically, they observed higher incidences of sepsis (OR: 1.79, 95% CI: 1.07–3.00, p=0.027; I² = 8.4%), surgical site infection (OR: 1.57, 95% CI: 1.15–2.15, p=0.005; I² = 55.2%), postoperative ileus (OR: 1.50, 95% CI: 1.01–2.21, p=0.043; I² = 27.2%), and anastomotic leakage (OR: 1.53, 95% CI: 1.16–2.02, p=0.003; I² = 48.3) in patients undergoing emergency surgery. This increased complication rate also led to a longer hospital stay by 4.48 days compared to elective surgery (WMD: 4.48, 95% CI: 2.32–6.64, p<0.001; I² = 59.4).4 Similarly, Sücülü et al. found a higher postoperative mortality rate in the emergency group (21.2% vs 4.8%, p=0.003), with increased rates of postoperative cardiac (21.2% vs 5.9%; p=0.001) and respiratory complications (28.8% vs 5.9%; p < 0.001), surgical site infection (42.4% vs 24.2%; p=0.005), and abscess formation (15.2% vs 3.8%; p=0.003).⁹ Beuran et al. also found significantly higher 30-day complication and mortality rates in emergency patients in their study, including left colon cancer (p<0.05). Emergency surgery was associated with a higher rate of reoperation (p=0.018).¹⁰ In our series, we found a higher incidence of surgical site infections in the emergency group, attributed to the presence of tumor perforations in these cases. These increased surgical site complications did not affect the length of hospital stay.
Studies in the literature have shown conflicting results regarding short-term and long-term survival in CRC patients presenting with emergencies. Traiki et al. found significantly lower three-year survival rates in the emergency group for colon cancer (50%) compared to the elective group (66.2%, p=0.026).¹¹ In the study by Lavanchy et al., long-term outcomes of patients undergoing emergency and elective resections for CRC were investigated, revealing no significant difference in 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) between emergency and elective surgery patients. However, in-hospital mortality was significantly higher in emergency CRC cases compared to elective ones (8.4% vs 3%, p=0.023).⁶ Similarly, Antony et al.'s study, using multivariable Cox regression and propensity score analyses, demonstrated no significant disadvantage in overall, disease-specific, or relative survival in patients with colon cancer alone undergoing emergency oncological resection after risk adjustment.¹² Esswein et al. showed that even after adjusting for 90-day mortality, there was a decrease in tumor-specific and overall survival rates in patients undergoing emergency resection for colorectal cancer, independent of age, gender, and tumor stage, compared to those undergoing elective resection.¹³ Zhou et al.'s recent meta-analysis compared long-term outcomes of emergency and elective operations in colorectal cancer. In a meta-analysis of 28 studies, emergency surgery patients showed worse overall survival compared to elective surgery (HR: 1.60, 95% CI: 1.47–1.73, p<0.001; I² = 63.4%). Subgroup analysis revealed this difference to be consistent regardless of whether the cancer was colon cancer (HR: 1.73, 95% CI: 1.52–1.96, p<0.001; I² = 21.2) or colorectal cancer (HR: 1.52, 95% CI: 1.38–1.67, p<0.001; I² = 46.5), indicating that emergency surgery was associated with decreased survival.4 Beuran et al. found significantly worse overall survival in emergency patients in their study, including left colon cancer; OR 1.702 (95% CI 1.373 to 2.109), with patients having perforated tumors showing worse overall survival.¹⁰
These adverse oncological outcomes can be attributed to various tumor-related and patient-related factors. Analyzing these studies individually, we see different patient groups with different tumor stages. It wouldn't be incorrect to assume that emergency approaches are applied to more advanced-stage tumors and lead to delayed adjuvant treatments due to increased postoperative morbidity. Our series, consisting of similar-stage patient groups with similar postoperative morbidity, did not show differences in long-term survival durations.

Limitations

Our study's limitations were its single-center and retrospective nature. Additionally, only patients from a tertiary healthcare institution were included in this study. Therefore, to generalize these findings, larger multi-center studies with bigger sample sizes are needed.

Conclusion

In conclusion, our data demonstrated that patients undergoing emergency resection for obstructive left colon tumors exhibited similar postoperative periods and survival durations compared to elective patients. These findings could be associated with various factors. We believe that increasing awareness of CRC and initiating a national colon cancer screening program would lead to earlier diagnosis of the disease and, consequently, reduce the need for emergency resections.

Declarations

Abbreviations

ANOVA: analysis of variance
BMI: body mass index
CEA: carcinoembryonic antigen
CI: confidence interval
CRC: colorectal cancer
CT: computed tomography
Hgb: hemoglobin
OR: odds ratio
SPSS: statistical package for the social sciences
STROBE: strengthening the reporting of observational studies in epidemiology
TNM: tumor, node, metastasis

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About This Article

Received:

April 19, 2026

Accepted:

May 17, 2026

Published Online:

May 7, 2026