Introduction

In 2020, colorectal cancer (CRC) accounted for over 1.9 million newly diagnosed cases, positioning it as the third most prevalent cancer globally. During the same period, CRC was responsible for approximately 0.9 million fatalities, rendering it the second leading cause of cancer-related mortality worldwide [1]. Significant geographical disparities have been documented concerning the incidence, mortality rates, temporal trends, and projected future burden of colorectal cancer across diverse countries and regions [2]. Concurrently, shifts in the age-specific incidence patterns of CRC have been observed, characterised by a rising incidence among younger individuals, particularly evident in developed nations [3]. Effective colorectal cancer prevention strategies involve two primary approaches: the identification and mitigation of modifiable risk factors, particularly those related to lifestyle (e.g. alcohol consumption, smoking, obesity, and an unhealthy diet), and the enhancement of protective factors (e.g. regular physical activity, adherence to specific chemo-preventive medications such as aspirin, and the adoption of a healthy dietary pattern) [4]. CRC screening, a form of secondary prevention, is recognised as an effective prophylactic measure within CRC control programs. Its primary objective is the early detection and subsequent removal of premalignant colorectal lesions [5]. Benign colorectal resections are undertaken to manage a diverse range of non-oncological conditions, notably including diverticulitis, inflammatory bowel disease (IBD), various forms of polyposis coli, select functional bowel disorders, and instances of colorectal endometriosis [6]. Although the fundamental surgical procedure largely parallels that employed in oncological resections, a key differentiating factor in these non-oncological cases is the deliberate preservation of a more extensive segment of the mesentery [7]. Bowel dysfunction encompasses a heterogeneous constellation of symptoms, including, but not limited to, faecal urgency, constipation, faecal incontinence, and/or abdominal pain. Each distinct symptomatic presentation necessitates a tailored and specific management strategy [8]. Recent investigations indicate that 80% of patients experience persistent residual symptoms following colorectal surgery. Of these individuals, 70% report improvement in their symptom profiles after therapeutic intervention [9]. It is important to note that many benign colorectal conditions are frequently associated with pre-existing functional bowel disorders, such as functional constipation, faecal incontinence, or abdominal pain, even before surgical resection. These pre-existing functional aspects contribute to a complex interplay of symptoms [10]. Furthermore, neurochemical alterations within the innervation of colonic blood vessels in patients afflicted with IBD may contribute to the characteristic abdominal pain and the altered bowel habit frequently observed in the context of this condition [11].

Aim

This study aims to evaluate the prevalence of psychiatric morbidities after colorectal surgical procedures, identify associated risk factors for their development, and determine whether improved access to psychological therapies would benefit this patient population.

Material and methods

Between January 2019 and December 2023, a total of 603 patients with a diagnosis of colorectal disease underwent elective colorectal operations in our institution and were considered for this retrospective study. Informed consent or approval by the local Ethics Committee was not obtained due to the observational nature of the study. Data were collected from medical and operating theatre records as well as from the hospital-coded database. Patient data were primarily analysed for the incidence of colorectal diseases such as colorectal cancer, diverticulitis, and inflammatory bowel disease. Secondary variables include patient characteristics (age at operation, gender), length of hospital stay, and operative parameters (time and type). All patients were subjected to clinical examination, blood and urine tests, and colonoscopy, before the operation. Computed tomography (CT) of the abdomen was performed in selected patients to ensure the diagnosis. Patients undergoing laparoscopic conversion to laparotomy were excluded from the study. Colectomies (open or laparoscopic) were performed by a team of 2 surgeons. The operative technique was determined by the preference of the consultant who was responsible for the procedure.

Results

During the 5-year study period, a total of 603 records of patients operated on for colorectal disease in our institution were retrieved from the computer database (Table I). A total of 498 (83%) colectomies were performed using the open method, and 104 (17%) were performed using the laparoscopic technique. Among patients undergoing colorectal operation in our institution, 126 (20,1%) had a psychiatric disorder in the 1-year postoperative follow-up. Patients’ information, such as gender, mean age, hospitalisation, and duration of surgery according to the patient’s group, is included in Table I.

The most common type of mental disorder was mood disorder, which appeared in 26 patients (Table II).

Discussion

The surgical community increasingly acknowledges survivorship as a pivotal outcome measure after major surgical interventions. This construct of survivorship encompasses the comprehensive health status and quality of life of a patient in the post-treatment phase, critically including the late effects of the therapeutic modality [12]. While the physical sequelae of surgery and their influence on quality of life are increasingly recognised, the psychological consequences experienced by patients remain largely underexplored. Common mental health conditions, including anxiety, depression, and post-traumatic stress disorder (PTSD), not only engender considerable distress but also directly impede physical recovery and social reintegration [13]. Evidence suggests that risk factors contributing to the development of these psychological conditions include feelings of vulnerability, the perceived threat of mortality, and an absence of adequate social support [14]. Prior investigations have consistently demonstrated that patients undergoing oncological treatment exhibit a heightened susceptibility to anxiety and depression. Reported incidence rates for these conditions range from 6.8% to 44% for anxiety and 5.2% to 50% for depression, respectively [15, 16]. PTSD has similarly demonstrated a high prevalence following major surgical procedures and interventions for oncological conditions. Incidence rates have been reported between 19% and 32% after major surgery for benign conditions (e.g. cardiac, spinal, and aortic surgeries) [17], and between 14% and 34% following cancer-related surgeries (e.g. gynaecological, prostate, and breast cancers) [18]. Data on the psychological sequelae following colorectal resections are limited. Nevertheless, all patients undergoing colonic resection experience a major surgical event, inherently placing them at risk for complications. The considerable physiological and psychological stress associated with such surgery could plausibly precipitate conditions such as anxiety, depression, or even PTSD [13]. Patients living with a stoma, regardless of the underlying medical condition, face an elevated risk of developing anxiety and depression. This vulnerability stems from complex adjustment challenges related to altered body image, sexual function, and the broader sociocultural or religious implications concerning faecal management [18]. Patients with colorectal cancer often experience increased anxiety and depressive symptoms even 1 year after surgery, and these conditions are more prevalent than in the general population [19]. Pre-existing psychiatric conditions, female gender, and a low level of social support are identified risk factors for developing depression following colorectal surgery [20]. Furthermore, patients with a history of depression tend to have worse postoperative outcomes, including a longer hospital stay and a higher likelihood of requiring skilled nursing assistance after discharge [21]. The psychological impact is not limited to cancer patients; individuals with IBD also face an increased risk of depression after surgery compared to other surgical patients, and for those with ulcerative colitis there is a higher risk of anxiety [22]. The prevalence of psychological problems like anxiety, depression, and PTSD is higher in patients who have undergone colorectal surgery compared to the general population, with younger patients and women being particularly vulnerable [23]. Due to the high incidence of colorectal diseases, it is very important to emphasise new technologies for their detection, as well as the search for biomarkers to reduce the complications of the disease. Both artificial intelligence and the Internet of Things (IoT) have contributed significantly to this [24–30].

Conclusions

This retrospective study aimed to evaluate the prevalence of psychiatric morbidities following colorectal surgical procedures, identify associated risk factors, and determine the potential benefit of improved access to psychological therapies for this patient population. After analysing data from 603 patients who underwent elective colorectal operations between January 2019 and December 2023, our findings indicate that the surgical technique of colectomy (open versus laparoscopic) does not significantly influence the incidence of psychiatric disorders post-operatively. Therefore, our findings highlight a critical need for further investigation. We strongly advocate for a prospective randomised controlled trial involving a larger and more diverse cohort of participants. Such a trial would enable a more rigorous and standardised assessment of psychiatric morbidities both pre- and post-surgery, facilitate the robust identification of modifiable and non-modifiable risk factors, and allow for the controlled evaluation of targeted psychological interventions.