Emergency treatment of complicated colorectal cancer

Figures & data

Table 1 Demographics and basic clinical data

	Total	Umberto I University Hospital	Noble’s Hospital	p-value
Number of cases	131	60 (45.8%)	71 (54.2%)
Gender				0.495
M	70 (53.4%)	34 (56.7%)	36 (50.7%)
F	61 (46.6%)	26 (43.3%)	35 (49.3%)
Age (years)^a	73.5±12.6	73.3±11.7	73.7±13.3	0.862
	74 (35–97)	73.5 (43–94)	74 (35–97)
Presentation				0.480
Obstruction	108 (82.4%)	47 (78.3%)	61 (85.9%)
Perforation	15 (11.5%)	8 (13.3%)	7 (9.9%)
Bleeding	8 (6.1%)	5 (8.3%)	3 (4.2%)
Symptom onset to admission (days)^a	19.3±61.6	19.9±57.8	18.7±65.1	0.003
	2 (0–488)	4.5 (0–375)	1 (0–488)
Admission to first treatment (days)^a	4.1±11.3	3.0±13.0	5.2±9.3	0.006
	0 (0–99)	0 (0–99)	1 (0–37)
ASA				0.015
1	8 (6.1%)	0	8 (11.3%)
2	43 (32.8%)	18 (30.0%)	25 (35.2%)
3	55 (42.0%)	32 (53.3%)	23 (32.4%)
4	24 (18.3%)	9 (15.0%)	15 (21.1%)
5	1 (0.8%)	1 (1.7%)	0
T				0.395
2	2 (1.6%)	0	2 (2.9%)
3	59 (46.1%)	26 (44.8%)	33 (47.1%)
4	67 (52.3%)	32 (55.2%)	35 (50.0%)
(Missing)	3	2	1
N				0.343
0	50 (39.4%)	26 (45.6%)	24 (34.2%)
1	34 (26.8%)	16 (28.1%)	18 (25.7%)
2	42 (33.1%)	15 (26.3%)	27 (38.6%)
(Missing)	5	3	2
M				0.065
0	84 (65.6%)	43 (74.1%)	41 (58.6%)
1	44 (34.4%)	15 (25.9%)	29 (41.4%)
(Missing)	3	2	1
Location				0.020
Right colon	54 (41.2%)	17 (28.3%)	37 (52.1%)
Left colon	50 (38.2%)	27 (45.0%)	23 (32.4%)
Rectum	27 (20.6%)	16 (26.7%)	11 (15.5%)
Emergency treatment				0.000
Immediate resection	78 (59.5%)	48 (80.0%)	30 (42.3%)
DCS	11 (8.4%)	4 (6.7%)	7 (9.9%)
Palliative treatment	42 (32.1%)	8 (13.3%)	34 (47.9%)

Notes: National groups comparison (^amean ± standard deviation, median and range). Significant p-values are reported in bold.

Abbreviations: ASA, American Society of Anesthesiologists; DCS, damage control surgery.

Table 2 Emergency treatment

	Total	Umberto I University Hospital	Noble’s Hospital
Total	131	60 (45.8%)	71 (54.2%)
Radical resection	89	52 (58.4%) (86.7% within group)	37 (41.6%) (52.1% within group)
Immediate resection	78	48 (61.5%)	30 (38.5%)
Right colectomy	25 (32.1%)	9 (18.8%)	16 (53.3%)
Extended right colectomy	8 (10.3%)	5 (10.4%)	3 (10.0%)
Left colectomy	18 (23.1%)	15 (31.3%)	3 (16.7%)
Extended left colectomy	1 (1.3%)	0	1 (3.3%)
Hartmann’s	10 (12.8%)	7 (14.6%)	3 (10.0%)
Sigmoid colectomy	2 (6.7%)	0	2 (2.6%)
Anterior resection	1 (1.3%)	1 (2.1%)	0
Subtotal colectomy	3 (3.8%)	2 (4.2%)	1 (3.3%)
Total colectomy	10 (12.8%)	9 (18.8%)	1 (3.3%)
		p=0.012
Damage control	11	4 (36.4%)	7 (63.6%)
Loop colostomy	9 (81.8%)	2 (50.0%)	7 (100%)
Stent	2 (18.2%)	2 (50.0%)	0
		p=0.039
Palliative treatment	42	8 (19.0%)	34 (81.0%)
Terminal colostomy	1 (2.4%)	1 (12.5%)	0
Loop colostomy	7 (16.7%)	2 (25.0%)	5 (14.7%)
Terminal ileostomy	3 (7.1%)	3 (8.8%)	0
Loop ileostomy	8 (19.0%)	2 (25.0%)	6 (17.6%)
Ileotransverse bypass	3 (7.1%)	0	3 (8.8%)
Diagnostic laparoscopy	2 (4.8%)	0	2 (5.9%)
Exploratory laparotomy	3 (7.1%)	1 (12.5%)	2 (5.9%)
Stent	2 (4.8%)	1 (12.5%)	1 (2.9%)
Medical treatment	13 (31.0%)	1 (12.5%)	12 (35.3%)
		p=0.305
Colostomya	28 (21.4%)	12 (20.0%)	16 (22.5%)
Ileostomya	27 (20.6%)	16 (26.7%)	11 (15.5%)
No stoma	76 (58.0%)	32 (53.3%)	44 (62.0%)
		p=0.289
Laparotomy	89 (67.9%)	51 (85.0%)	38 (53.5%)
Laparoscopy	23 (17.6%)	3 (5.0%)	20 (28.2%)
Conversion lap-open	2 (1.5%)	2 (3.3%)	0
No operation	17 (13.0%)	4 (6.7%)	13 (18.3%)
		p=0.000
Emergency surgery <24 h	81 (61.8%)	47 (78.3%)	34 (47.9%)
Delayed surgery >24 h	37 (28.2%)	12 (20%)	25 (35.2%)
Medical treatment	13 (9.9%)	1 (1.7%)	12 (16.9%)
		p=0.001

Notes:

a Total number of ostomies, including protective stomas and palliative stomas. P-values of the comparison between the two series (Umberto I vs Noble’s) are reported in bold.

Table 3 Distribution of the emergency treatments by factors

	Immediate resection	Damage control	Palliative treatment	p-value
Total	78 (59.5%)	11 (8.4%)	42 (32.1%)
Gender				0.031
M	38 (54.3%)	10 (14.3%)	22 (31.4%)
F	40 (65.6%)	1 (1.6%)	20 (32.8%)
ASA				0.057
1	1 (12.5%)	2 (25.0%)	5 (62.5%)
2	23 (53.5%)	5 (11.6%)	15 (34.9%)
3	36 (65.5%)	4 (7.3%)	15 (27.3%)
4	18 (75.0%)	0	6 (25.0%)
5	0	0	1 (100%)
Presentation				0.043
Obstruction	63 (58.3%)	9 (8.3%)	36 (33.3%)
Perforation	13 (86.7%)	0	2 (13.3%)
Bleeding	2 (25.0%)	2 (25.0%)	4 (50.0%)
Location				0.000
Proximal colon	32 (59.3%)	0	22 (40.7%)
Distal colon	38 (76.0%)	3 (6.0%)	9 (18.0%)
Rectum	8 (29.6%)	8 (29.6%)	11 (40.7%)

Note: Significant p-values are reported in bold.

Abbreviation: ASA, American Society of Anaesthesiologists.

Table 4 Chemotherapy/radiotherapy

	Neoadjuvant radiochemotherapy	Adjuvant chemotherapy	Palliative chemotherapy	No radiotherapy or chemotherapy	p-value
Total	6 (4.6%)	42 (32.1%)	16 (12.2%)	67 (51.1%)
Umberto I	1 (1.7%)	23 (38.3%)	3 (5.0%)	33 (55.0%)	0.038
Noble’s	5 (7.0%)	19 (26.8%)	13 (18.3%)	34 (47.9%)
<70 y	5 (9.8%)	21 (41.2%)	8 (15.7%)	17 (33.3%)	0.004
≥70 y	1 (1.3%)	21 (26.3%)	8 (10.0%)	50 (62.5%)
ASA 1	1 (12.5%)	2 (25.0%)	1 (12.5%)	4 (50%)	0.317
ASA 2	3 (7.0%)	14 (32.6%)	9 (20.9%)	17 (39.5%)
ASA 3	2 (3.6%)	21 (38.2%)	5 (9.1%)	27 (49.1%)
ASA 4	0	5 (20.8%)	1 (4.2%)	18 (75.0%)
ASA 5	0	0	0	1 (100%)
Proximal colon	0	17 (31.5%)	10 (18.5%)	27 (50.0%)	0.000
Distal colon	0	20 (40.0%)	4 (8.0%)	26 (52.0%)
Rectum	6 (22.2%)	5 (18.5%)	2 (7.4%)	14 (51.9%)
Immediate resection	0	39 (50.0%)	0	39 (50.0%)	0.000
DCS + resection	5 (45.5%)	3 (27.3%)	0	3 (27.3%)
Palliative treat	1 (2.4%)	0	16 (38.1%)	25 (59.5%)
Laparotomy	3 (2.5%)	37 (31.4%)	16 (13.6%)	62 (52.5%)	0.004
Laparoscopy	3 (23.1%)	5 (38.5%)	0	5 (38.5%)

Note: Significant p-values are reported in bold.

Abbreviations: ASA, American Society of Anesthesiologists; DCS, damage control surgery; y, year.

Table 5 Elective resections after damage control

	Total	Umberto I University Hospital	Noble’s Hospital
Hartmann	2 (18.2%)	2 (50.0%)	0
Left colectomy	2 (18.2%)	1 (25.0%)	1 (14.3%)
Abdomino-perineal resection	1 (9.1%)	0	1 (9.1%)
Anterior resection	3 (27.3%)	1 (25.0%)	2 (27.3%)
Exenteration	1 (9.1%)	0	1 (9.1%)
Total proctocolectomy	1 (9.1%)	0	1 (9.1%)
Extended right colectomy	1 (9.1%)	0	1 (9.1%)
		p=0.428
Colostomy	3 (27.3%)	2 (50.0%)	1 (14.3%)
Ileostomy	4 (36.4%)	0	4 (57.1%)
Colostomy + urostomy	1 (9.1%)	0	1 (14.3%)
No stomia	3 (27.3%)	2 (50%)	1 (14.3%)
		p=0.155
Laparotomy	7 (63.6%)	4 (100%)	3 (42.9%)
Laparoscopy	4 (36.4%)	0	4 (57.1%)
		p=0.058

Note: Significant p-values are reported in bold.

Table 6 Univariate analysis on resected patients (89 cases)

	Mortality	Morbiditya	LOSb	Ostomy	Complementary treatment	LN analyzed	LN adequate clearance	R0
Total	12 (13.5%)	24 (27.0%)	16.8±19.8 10 (1–122)	37 (41.6%)	47 (52.8%)	16.4±9.1 14.5 (0–64)	65 (73.0%)	76 (85.4%)
Age (years)
<70	2 (5.7%)	7 (20.0%)	14.4±13.4 10 (4–79)	13 (37.1%)	25 (71.4%)	19.4±11.0 17.5 (5–64)	27 (77.1%)	28 (80.0%)
≥70	10 (18.5%)	17 (31.5%)	18.0±20.8 10.5 (1–122)	24 (44.4%)	22 (40.7%)	14.4±6.9 13 (0–33)	38 (70.4%)	48 (88.9%)
p	0.084	0.233	0.980c	0.495	0.005	0.030c	0.482	0.246
Presentation
Obstruction	9 (12.5%)	17 (23.6%)	15.4±17.5 10 (1–122)	26 (36.1%)	39 (54.2%)	17.2±9.7 15 (0–64)	53 (73.6%)	63 (87.5%)
Perforatation	2 (15.4%)	4 (30.8%)	19.3±21.6 10 (1–79)	9 (69.2%)	6 (46.2%)	12.7±3.9 14 (5–19)	10 (76.9%)	10 (76.9%)
Bleeding	1 (25.0%)	3 (75.0%)	29.3±18.8 28 (11–50)	2 (50.0%)	2 (50.0%)	12.0±3.6 11 (9–16)	2 (50.0%)	3 (75.0%)
p	0.758	0.075	0.140c	0.078	0.862	0.204c	0.552	0.509
Onset to admission	0.329d	0.351d	0.103d	0.553d	0.706d	0.569d	0.290d	0.125d
Admission to treatment	0.549d	Coeff 0.007 0.079d	Coeff 0.986 0.000d	0.335d	0.665d	0.751d	0.173d	0.102d
ASA
1	0	0	9.0±7.0 6 (4–17)	2 (66.7%)	3 (100%)	45.5±26.2 45.5 (27–64)	3 (100%)	2 (66.7%)
2	2 (7.1%)	5 (17.9%)	15.9±14.2 9 (6–64)	10 (35.7%)	17 (60.7%)	18.0±7.4 15.5 (2–33)	25 (89.3%)	23 (82.1%)
3	2 (5.0%)	9 (22.5%)	19.0±21.5 11 (1–122)	16 (40.0%)	22 (55.0%)	15.9±7.6 15 (0–34)	28 (70.0%)	37 (92.5%)
4	8 (44.4%)	10 (55.6%)	13.4±17.3 10.5 (1–79)	9 (50.0%)	5 (27.8%)	11.3±4.6 10 (5–19)	9 (50.0%)	14 (77.8%)
p	0.000	0.017	0.357c	0.628	0.046	0.002c	0.019	0.316
Location
Proximal colon	4 (12.5%)	7 (21.9%)	14.5±12.6 9.5 (3–53)	1 (3.1%)	17 (53.1%)	18.8±11.2 15 (5–64)	26 (81.3%)	25 (78.1%)
Distal colon	7 (17.1%)	11 (26.8%)	16.8±21.6 10 (1–122)	21 (51.2%)	20 (48.8%)	15.9±7.7 14 (0–33)	29 (70.7%)	36 (87.8%)
Rectum	1 (6.3%)	6 (37.5%)	20.1±18.9 12 (1–64)	15 (93.8%)	10 (62.5%)	12.4±5.4 12.5 (2–21)	10 (62.5%)	15 (93.8%)
p	0.550	0.516	0.714c	0.000	0.647	0.102c	0.348	0.295
Dukes
B	9 (20.5%)	17 (38.6%)	17.9±17.2 11 (1–79)	21 (47.7%)	18 (40.9%)	14.2±7.6 12.5 (0–34)	26 (59.1%)	39 (88.6%)
C	3 (10.0%)	4 (13.3%)	15.1±21.9 10 (1–122)	11 (36.7%)	20 (66.7%)	20.9±10.4 19 (9–64)	28 (93.3%)	26 (86.7%)
D	0	3 (20.0%)	15.5±13.4 10 (6–53)	5 (33.3%)	9 (60.0%)	14.6±7.7 12 (5–33)	11 (73.3%)	11 (73.3%)
p	0.106	0.044	0.764	0.496	0.077	0.002c	0.005	0.340
Treatment
Immediate resection	12 (15.4%)	21 (26.9%)	15.9±18.5 10 (1–122)	27 (34.6%)	39 (50.0%)	16.6±9.4 15 (0–64)	56 (71.8%)	66 (84.6%)
DCS + resection	0	3 (27.3%)	21.3±16.3 17 (4–50)	10 (90.9%)	8 (72.7%)	14.9±5.7 14 (8–27)	9 (81.8%)	10 (90.9%)
p	0.162	0.980	0.160c	0.000	0.157	0.701c	0.483	0.580
Approach
Open	12 (15.8%)	24 (31.6%)	18.0±19.3 11 (1–122)	33 (43.4%)	8 (61.5%)	15.7±7.8 14 (0–34)	53 (69.7%)	64 (84.2%)
Laparoscopy	0	0	8.1±4.6 7 (3–18)	4 (30.8%)	39 (51.3%)	20.0±13.9 19 (8–64)	12 (92.3%)	12 (92.3%)
p	0.123	0.018	0.009	0.392	0.495	0.265	0.090	0.445

Notes:

a Morbidity represents the total number of patients who had at least 1 complication during the whole surgical treatment, excluding neoadjuvant or adjuvant treatment.

b For patients with 2-stage treatment, LOS is the sum of the 2 admissions.

c Difference was estimated with the non-parametric Mann–Whitney U-test as distribution of this variable is not normal.

d Comparison between 2 continuous variables or between an independent continuous variable and a dependent nominal variable has been performed with a linear regression. When the 2 variables are somehow correlated, the correlation coefficient is shown, to demonstrate the direction of the correlation. Significant p-values are reported in bold.

Abbreviations: ASA, American Society of Anesthesiologists; DCS, damage control surgery; LN, lymph nodes; LOS, length of stay.

Table 7 Multivariate analysis on resected patients (89 cases)

Dependent variable	Independent prognostic factors	Correlation coefficient	p-value
Mortality	ASA	0.156	0.000
	Dukes	–0.115
Morbidity	ASA	0.170	0.000
	Dukes	–0.136
	Laparoscopic resection	–0.287
LOS	Admission to treatment	0.997	0.000
	Onset to admission	0.068
Ostomy	Distal cancer	0.458	0.000
Chemoradiotherapy	Age >70	–0.307	0.004
LN analyzed	ASA	–4.953	0.000
	Distal cancer	–3.164
LN adequate clearance	ASA	–0.197	0.000
	Dukes	0.140
R+	Laparoscopic resection	–0.231	0.000
	Onset to admission	0.001

Abbreviations: ASA, American Society of Anesthesiologists; LN, lymph nodes; LOS, length of stay.