Previous studies have suggested that CRCs that present with acute symptoms and require emergency surgery have more aggressive behavior and higher tumor stages [4, 8]. Consistent with those findings, our study found that CRC patients who underwent emergency surgery had a more advanced stage tumor, which may partly explain the poorer survival. In addition, unplanned emergency operations are inferior to elective surgeries in terms of inadequate control of any underlying co-morbidities. For these reasons, it could be expected that procedures done in an emergency setting post a higher risk of operative complications. Obstruction and perforation are common problems that bring CRC patients to an emergency surgery before their scheduled surgery [5, 7, 9]. The number of emergency surgeries in our series was relatively lower than other previous reports [4, 5, 7–9], which might be explained by the fact that we did not include cases who first presented with emergency conditions in our analysis.
Providing fast-track service for these higher risk CRC patients may help in reducing acute events that require emergency surgery and its related higher morbidity . Our study found that clinical symptoms alone were not adequate in determining such high-risk patients, especially when the tumor was situated on the right colon. The pre-operative colonoscopy is an objective study that should be performed in all cases suspected of CRC, as in addition to a tissue biopsy for histological confirmation of malignancy, severity of luminal obstruction can be evaluated. We also found that a luminal obstruction was associated with larger tumor size and T-stage, but not histological grade. Moreover, eOB was also correlated with poorer nutritional status in our cases, as evidenced by lower serum albumin and hemoglobin. Above all, the evidence of eOB was associated with required emergency surgery. Overall, the data from our study suggest that patients with eOB should be reevaluated carefully and considered for fast-track urgent surgery. The average surgical waiting time in the study CRC cases was 35 days. If all of our cases are considered as on the same elective list, 10% of cases with eOB and 2% of non-eOB cases required an emergency operation. However, if the patients with eOB had been scheduled for surgery within 2 weeks of their first hospital visit, the overall number of emergency surgeries would have been reduced to 5%.
Use of a self-expandible metallic stent as a bridge-to-surgery method has been recently proposed, not only as a time-buying strategy, but also to allow for more adequate pre-operative staging and bowel preparation . The stent procedure has one notable technical limitation, however, in that it can be applied only for an obstruction in the left colon and rectum. Although various retrospective case series have reported the benefits of this intervention [12–14], there are yet no good quality data to support its clinical advantage over emergency surgery.
In conclusion, our study found that a luminal obstruction detected by endoscopy was significantly associated with locally advanced tumor. This group of CRC patients had a higher risk of requiring an unplanned operation. The data suggest that this endoscopic finding should be regarded as an indication that these patients should be considered for fast-track surgical scheduling list.