Global variation in emergency colorectal cancer surgery: Results from the APOLLO prospective cohort study in 39 countries.

Abstract

Colorectal cancer is increasing in low- and middle-income countries, necessitating improved worldwide access to acute oncologic care. This study aimed to evaluate global outcomes of emergency surgery in acute colorectal cancer. The Acute Presentation of Colorectal Cancer-an International Snapshot study was a prospective international cohort study of adults acutely admitted with colorectal cancer (January-June 2023). Key outcomes included rates of urgent/immediate surgery, resection margin positivity (R1/R2), and surgeon specialization compared across high-income, upper- middle-income, and low- and middle-income countries. Risk-adjusted models analyzed 90-day complications and mortality. The study included 1,861 patients (high-income: 1,410 patients, 18 countries; upper- and middle-income: 277 patients, 11 countries; low- and middle-income: 174 patients, 10 countries). Urgent- or immediate-surgery rates were highest in low- and middle-income countries (high-income: 43.2%; upper- and middle-income: 47.7%; low- and middle-income: 56.3%; P = .001, adjusted odds ratio 2.18, 95% confidence interval 1.48-3.21). Low- and middle-income countries had higher R1/R2 resection rates (high-income: 23.5%; upper- and middle-income: 41.3%; low- and middle-income: 52.2%; P < .001) independent of cancer stage, and 38% of surgeries were performed by nonspecialist surgeons (high-income: 18%; P < .001). Adjusted 90-day complication rates were similar, but mortality was higher in low- and middle-income countries (27.6% vs 16.1% in high-income; P = .005, adjusted odds ratio 2.84, 95% confidence interval 1.17-6.92). Patients presenting with acute colorectal cancer in low- and middle-income countries are more likely to undergo urgent surgery, but have decreased access to specialized surgical care and hospital capacity to rescue. Urgent efforts are needed to empower the global health care workforce and facilitate equitable access to safe unplanned surgery.