SP 6.15 Evaluating Quality of Colorectal Cancer Surgery Across Elective and Emergency Health Systems: A Secondary Analysis of Prospective Cohort Studies in 95 Countries
NIHR Global Health Research Unit on Global SurgeryAbstract
Background
We aimed to understand differences in surgical quality between patients with potentially curative colorectal cancer undergoing emergency or elective resection.
Methods
This pre-planned secondary analysis included patients undergoing only curative-intent surgery for colorectal cancer from three contemporary global prospective cohort studies (GlobalSurg-3, n=5506; CovidSurg-Cancer, n=6719; APOLLO, n=876). Hierarchical multilevel logistic regression models quantified associations between urgency of surgery (elective vs emergency) and surgical quality, measured by margin-positive resection, adjusting for patient-, disease- and health-system factors. Bootstrap multivariable simulations evaluated effect modification by country income, cancer stage and location.
Results
We included 13,101 patients across 95 countries. Overall, 678 (5.4%) had margin-positive resections, with higher rates in emergency than elective surgery (13.7% vs 4.5%; p<0.0001). In adjusted models, emergency surgery was associated with increased odds of margin-positive resections (adjusted odds ratio 2.45, 95% CI 1.86-3.22), consistent across all country income groups and robust to alternate health-system indicators. Bootstrap-derived absolute risk differences revealed the greatest disparities in patients with stage III-IV rectal cancers; absolute differences of 12.6% (95% CI 10.2-15.7) in high-income countries, 19.0% (95% CI 13.6-23.9) in upper-middle-income countries, and 14.1% (95% CI 10.9-16.5) in lower-middle- and low-income countries.
Conclusion
Emergency surgery conferred a two-to-three-fold increased risk of margin-positive resections globally, independent of resource availability, exposing a neglected area of global surgical practice. For patients presenting as an emergency with potentially curative disease, enhanced decision-making around resectability, ensuring specialist surgeon availability, and developing bridge-to-surgery pathways represent immediate, low-cost strategies to improve global cancer outcomes.