Abstract
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.
Highlights
Colon cancer is the fourth most commonly diagnosed malignancy and the second leading cause of cancer related death worldwide [1]
This study found no differences between EM and EL surgery with respect to margin status, nodal yield, receipt of appropriate medical oncology referral, or time from operation to medical oncology referral
The importance of quality metrics in emergency surgery outside of the traditionally studied perioperative outcomes has been emphasized in recent literature: a Delphi expert consensus identified appropriate guideline directed follow-up and surveillance for patients undergoing emergency oncology operations as a metric of quality of care [12]
Summary
Colon cancer is the fourth most commonly diagnosed malignancy and the second leading cause of cancer related death worldwide [1]. 30% of colorectal cancer cases are diagnosed following emergency presentations, typically due to obstructing tumours or bowel perforation [2,3,4]. Emergency presentation itself has been identified as a poor prognostic factor, independent of disease stage [5]. The management of colon cancer, at its core, consists of surgical resection (for most patients), with the addition of adjuvant therapy for patients with nodal metastasis or high-risk tumour features [6]. High quality cancer care goes beyond this, and includes a host of additional components, including the pre-operative identification and histologic diagnosis of colon cancer, pre-operative staging computed tomography (CT) scanning, carcinoembryonic antigen (CEA) testing, pre-operative colonoscopy, pre-operative medical
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