Colorectal cancer surgery without preoperative histology does not compromise surgical quality-A nationwide cohort study.

Abstract

In colorectal cancer care, planned surgery is sometimes performed without preoperative histological confirmation of malignancy, raising concerns that diagnostic uncertainty may affect surgical quality. Do surgeons maintain high quality oncological resection practices when colorectal cancer is suspected yet not histologically confirmed? We conducted a nationwide retrospective cohort study using the Danish Colorectal Cancer Group database, including patients undergoing planned colorectal cancer surgery between 2016 and 2020. Patients were grouped according to whether malignancy was histologically confirmed prior to surgery. Surgical quality was assessed by lymph node harvest, resection margins and microradicality. Multivariable regression analyses adjusted for demographic, clinical and surgical factors. Among 12,260 included patients, 16.7% (n = 2053) underwent surgery without preoperative histological confirmation. Despite this, key indicators of oncological resection quality remained consistently high across both groups. Mean lymph node harvest approached 30 in both groups (29.3 vs. 29.6), and resection margins were comparable. Microradical resection was achieved in 91.8% of cases regardless of diagnostic status and although statistical adjustment identified a minor difference in microradicality, this was not considered clinically meaningful (regression coefficient - 0.22; number needed to treat = 63). Nearly one in six colorectal resections in Denmark is performed without definitive preoperative histology. Surgical quality, evaluated using established oncological criteria, did not differ between these two groups. This is likely the result of multidisciplinary assessment and standardized surgical protocols. These findings support the safety of proceeding directly to surgery when multidisciplinary evaluation indicates strong clinical and radiological suspicion of colorectal cancer, potentially avoiding delays and risks associated with repeat diagnostic procedures.