eISSN: 1896-9151
ISSN: 1734-1922
Archives of Medical Science
Current issue Archive Manuscripts accepted About the journal Special issues Editorial board Abstracting and indexing Subscription Contact Instructions for authors
SCImago Journal & Country Rank
4/2018
vol. 14
 
Share:
Share:
more
 
 
Clinical research

Surgical outcome and clinicopathological characteristics of emergency presentation elective cases of colorectal cancer

Mojtaba Ahmadinejad, Seyyed Mohsen Pouryaghobi, Fatemeh Bayat, Ehsan Bolvardi, Niaz Mohammad Jafari Chokan, Babak Masoumi, Koorosh Ahmadi

Arch Med Sci 2018; 14, 4: 826–829
Article file
- surgical outcome.pdf  [0.07 MB]
Get citation
ENW
EndNote
BIB
JabRef, Mendeley
RIS
Papers, Reference Manager, RefWorks, Zotero
AMA
APA
Chicago
Harvard
MLA
Vancouver
 
 

Introduction

Colorectal cancer (CRC) is known as a preventable cancer worldwide with 850,000 annual new cases and 500,000 deaths annually [1, 2]. It has been reported that most patients have an advanced stage at the time of diagnosis and undergo surgery with curative intent. A high proportion of colorectal cancer patients may present as an emergency most often as obstruction or perforation.
It has been previously indicated that the high postoperative mortality rate and poor survival are correlated with emergency presentation [3–6], as well as low 5-year survival [7]. The symptoms that lead patients to present as emergency, including perforation, obstruction and intestinal bleeding, contribute to advanced disease. Furthermore, patients with emergency CRC may also present with cardiovascular, metabolic, respiratory or infectious emergencies that can be markedly associated with higher risk of mortality [8]. Previous investigations indicated that emergency surgery was correlated with poorer outcome compared with elective surgery [9].
The aim of this study was to evaluate the significance of clinicopathological characteristics of colorectal cancer patients undergoing emergency and elective surgery.

Material and methods

All participating patients signed the consent forms, and all protocols in the present study were conducted in accordance with the Declaration of Helsinki Guidelines. In total, 116 patients treated surgically for CRC at the four hospitals in Tehran and Tabriz between 2008 and 2013 were included in the present study. The tissues were confirmed by pathological evaluation. The data of patients were obtained from medical records and the individual surgeons after surgery. The data of 30-day mortality, intensive care unit (ICU) admission, and length of hospital stay were obtained in the study.
The patients who underwent emergency CRC surgery were assigned as emergency cases due to obstruction, perforation, or bleeding, and other patients were considered elective with abdominal pain, blood in stool, change in bowel habit, mass and weight loss.
Slides stained with hematoxylin and eosin (H + E) were obtained from the patients. The histopathology report was based on the World Health Organization (WHO) classification [10]. The clinicopathological characteristics of the patients are shown in Table I.

Statistical analysis

The 2 test was used to analyze the relationships among variables. The correlation between clinical and pathologic parameters and type of surgery were evaluated using the 2 test or Mann-Whitney U-test as appropriate. Statistical analysis was performed with the software SPSS version 16.0 for Windows (SPSS Inc, IL, USA). P-value < 0.05 was considered to be statistically significant.

Results

A total of 116 patients were included in the study; 61.20% (71) were elective and 38.79% (45) were emergency cases. The mean age of the patients was 65.4 years. Of the 116 patients, median age of patients who had emergency surgery was 60.23 years, while it was 58 years for elective cases (p > 0.05). Overall, 66 patients (56.89%) were male and 50 (43.10%) were female.
The tumors were located: in the right colon (33.62%; 39 cases), in the left colon (25.86%, 30 cases), or in the rectum (40.51%, 47 cases).
Among the emergency patients, 22 (48.8%) had obstruction, and perforation was observed in 16 (35.5%); the remaining cases were operated on for suspected acute appendicitis, incarcerated hernia or a gynecological condition. Perforations were observed at the tumor site in patients and close to the tumor in 13 patients. Furthermore, obstruction of the right colon was observed in 63.3% of patients and left-sided obstruction was observed in 36.3%.
The clinicopathological characteristics of the patients with elective and emergency presentations are shown in Table I. Our findings revealed that the emergency cases were significantly more likely to have an advanced TNM stage (p = 0.027) and histologic grade (p = 0.01) compared with the elective cases. Furthermore, the nature of surgery was significantly associated with vascular and perineural invasion (p = 0.021; p = 0.001).
On the other hand, we examined the association of clinicopathological parameters such as gender, age, and tumor location with surgical presentation. But no association was found between these parameters and the nature of surgery (Table I). Emergency was also correlated with greater length of hospital stay and higher rate of admission to the ICU. The mortality rate was 20% in emergency cases, while patients with elective surgery had 5.63% perioperative mortality (p = 0.001). The emergency patients had a higher rate of mortality (Table II).

Discussion

Emergency presentation has been shown to have worse outcomes when compared with elective resections in patients with colorectal cancer. The poor outcomes for emergency patients begin at their initial hospital stay and continue into their long-term survival [11, 12].
The aim of this study was to evaluate the significance of clinicopathological characteristics of colorectal cancer patients with emergency and elective admission. Our results indicated that the emergency cases were significantly more likely to have an advanced TNM stage and histologic grade compared with the elective patients, which is in agreement with previous studies [13, 14]. Ghazi et al. [15] reported that emergency cases generally show a more aggressive histopathologic profile and a more advanced stage than do elective cases. Previous studies indicated that emergency surgery cases tend to have more advanced cancers (AJCC stages III and IV), with more tumor (T)3 and T4 tumors and more node (N)1 and N2 cases as compared to elective surgery [13, 16]. Furthermore, the nature of surgery was significantly associated with vascular and perineural invasion. Vascular invasion was more common in the emergency patients in the present study. It seems that patients with emergency presentation can show a higher frequency of both vascular and perineural invasion. This evidence showed poor prognosis for patients with emergency surgery [13, 14, 16, 17]. We also evaluated the association of gender, age, and tumor location with the nature of surgical presentation. However, no association was found between other parameters and the nature of surgery, including age, and sex and tumor location.
Median age of patients who had emergency surgery was 60.23 years, while it was 58 years for elective cases (p > 0.05). Wong et al. reported that patients undergoing emergency surgery were older than elective surgery and both groups are in danger of having their symptoms ignored, albeit for different reasons [13]. Overall, the tumors were located: in the right colon (33.62%; 39 cases), in the left colon (25.86%, 30 cases), or in the rectum (40.51%, 47 cases). Left colon cancer is constrictive in nature. It has been shown that left-sided colon cancers may be associated with change in bowel habit, constipation and rectal bleeding tenesmus. Sigmoid cancers can mimic diverticulitis with pain, fever, and obstructive symptoms [17]. Previous studies reported an age-related shift toward the colon in CRC, and found that up to 40% of cancers were located in the right colon [18, 19].
In the present study, the emergency patients had a higher rate of mortality. Ascanelli et al. [20] demonstrated 27% morbidity and 12% mortality in patients with colorectal cancer subjected to emergency surgery. Sjo et al. [21] reported a mortality rate of 3.5% after elective and 10% after emergency operation with resection. A previous study showed morbidity and mortality of 41% and 15% in patients operated on for obstruction or perforation respectively [22]. Previous investigations have revealed that a high rate of mortality and shorter survival may be related to emergency admission [5, 6, 21]. These clinicopathological parameters were previously reported by different authors for various cancers [23–26].
In conclusion, our findings suggest that colorectal cancer patients undergoing emergency surgery showed an advanced stage. The emergency patients had a higher rate of mortality than elective cases.

Conflict of interest

The authors declare no conflict of interest.

References

1. Tan E, Tilney H, Thompson M, Smith J, Tekkis PP. The United Kingdom National Bowel Cancer Project – epidemiology and surgical risk in the elderly. Eur J Cancer 2007; 43: 2285-94.
2. Ries LAG, Eisner MP. SEER Cancer Statistics Review, 1973–1997. Bethesda, MD: National Cancer Institute 2000.
3. Brown SCW, Walsh S, Abraham JS, Sykes PA. Risk factors and operative mortality in surgery for colorectal cancer. Ann R Coll Surg Engl 1991; 73: 269-72.
4. Alvarez JA, Baldonedo RF, Bear IG, Truán N, Pire G, Alvarez P. Presentation, treatment, and multivariate analysis of risk factors for obstructive and perforative colorectal carcinoma. Am J Surg 2005; 190: 376-82.
5. McArdle CS, Anderson JH. Obstructing large bowel cancer. In: Colorectal Cancer. McArdle CS, Kerr DJ, Boyle P (eds). Isis Medical Media, Oxford 2000; 195-207.
6. Carraro PG, Segala M, Cesana BM, Tiberio G. Obstructing colonic cancer: failure and survival patterns over a ten-year follow-up after one-stage curative surgery. Dis Colon Rectum 2001; 44: 243-50.
7. McArdle CS, Hole DJ. Emergency presentation of colorectal cancer is associated with poor 5-year survival. Br J Surg 2004; 91: 605-9.
8. Lewis MA, Hendrickson AW, Moynihan TJ. Oncologic emergencies: pathophysiology, presentation, diagnosis, and treatment. CA Cancer J Clin 2011; 61: 287-314.
9. Ghazi S, Berg E, Lindblom A, Lindforss U. Clinicopathological analysis of colorectal cancer: a comparison between emergency and elective surgical cases. World J Surg Oncol 2013; 11: 133.
10. Bosman FT, Carneiro F, Hruban RH, Theise ND. WHO classification of tumours, vol. 3. IARC WHO Classification of Tumours, No. 3; 2010. Washington.
11. Tekkis PP, Prytherch DR, Kocher HM, et al. Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM). Br J Surg 2004; 91: 1174-82.
12. Metcalfe MS, Norwood MG, Miller AS, Hemingway D. Unreasonable expectations in emergency colorectal cancer surgery. Colorectal Dis 2005; 7: 275-8.
13. Wong SK, Jalaludin BB, Morgan MJ, et al. Tumor pathology and long-term survival in emergency colorectal cancer. Dis Colon Rectum 2008; 51: 223-30.
14. Metcalfe MS, Norwood MG, Miller AS, Hemingway D. Unreasonable expectations in emergency colorectal cancer surgery. Colorectal Dis 2005; 7: 275-8.
15. Ghazi S, Berg E, Lindblom A, Lindforss U. Clinicopathological analysis of colorectal cancer: a comparison between emergency and elective surgical cases. World J Surg Oncol 2013; 11: 133.
16. Bass G, Fleming C, Conneely J, Martin Z, Mealy K. Emergency first presentation of colorectal cancer predicts significantly poorer outcomes: a review of 356 consecutive Irish patients. Dis Colon Rectum 2009; 52: 678-68.
17. Kumar S, Kafle P, Patowary BN, et al. Surgical outcome and clinical profile of emergency versus elective cases of colorectal cancer in College of Medical Sciences. Nepal Journal of College of Medical Sciences-Nepal 2013; 9: 25-30.
18. Arai T, Takubo K, Sawabe M, Esaki Y. Pathologic characteristics of colorectal cancer in the elderly: a retrospective study of 947 surgical cases. J Clin Gastroenterol 2000; 31: 67-72.
19. Ikeda Y, Koyanagi N, Mori M, et al. Increased incidence of proximal colon cancer in the elderly. J Clin Gastoenterol 1996; 23: 105-8.
20. Ascanelli A, Navarra G, Tonini G, et al. Early and late outcome after surgery for colorectal cancer: elective versus emergency surgery. Tumori 2003; 89: 36-41.
21. Sjo OH, Larsen S, Lunde OC, Nesbakken A. Short term outcome after emergency and elective surgery for colon cancer. Colorectal Dis 2009; 11: 733-9.
22. Tobaruela E, Camuñas J, Navascúes JME, Díez M, Ratia T, Martin A. Medical factors in the morbidity and mortality associated with emergency colorectal cancer surgery. Rev Esp Enferm Dig 1997; 89: 13-22.
23. Mirghasemi A, Taheriazam A, Karbasy SH, Shakeri M, Yahaghi E, Mokarizadeh A. Down-regulation of miR-133a and miR-539 are associated with unfavorable prognosis in patients suffering from osteosarcoma. Cancer Cell Int 2015; 15: 86.
24. Tavasoly A, Gholami H, Rostami A, Touni SR, Khaleghian P, Mokarizadeh A. Clinico-histopathologic and outcome features of cutaneous infundibular keratinizing acanthoma: a case report and literature review. World J Surg Oncol 2014; 12: 173.
25. Manesh JY, Shafiee R, Pedram B, Javanbakht J, Mokarizadeh A, Khadivar F. Improving the diagnosis, treatment, and biology patterns of feline mammary intraepithelial lesions: a potential model for human breast masses with evidence from epidemiologic and cytohistopathologic studies. Tumour Biol 2014; 35: 12109-17.
26. Maghsoudi O, Mirjalili SH, Dolatabadi M, Joshaghani MF, Yahaghi E, Mokarizadeh A. Investigations of renal function using the level of neutrophil gelatinase-associated lipocalin associated with single-dose of cisplatin during chemotherapy. Diagn Pathol 2015; 10: 98.
Copyright: © 2016 Termedia & Banach. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
FEATURED PRODUCTS
Quick links
© 2018 Termedia Sp. z o.o. All rights reserved.
Developed by Bentus.
PayU - płatności internetowe