Emergency Colorectal Cancer Surgery Carries a Higher Risk of Incomplete Tumour Resection: BJS Open | August 2026

Introduction:

Approximately 30% of patients with colorectal cancer present as a surgical emergency, most commonly because of bowel obstruction or perforation. While poorer outcomes after emergency surgery are often attributed to more advanced disease, it remains unclear whether differences in surgical quality also contribute. This large international study evaluated whether emergency colorectal cancer surgery is associated with poorer oncological resection quality compared with elective surgery across diverse healthcare systems.

Why was this study needed?

Emergency colorectal cancer surgery is associated with higher morbidity and mortality.

It is uncertain whether poorer outcomes result solely from advanced disease or also from differences in surgical quality.

Margin-positive resection is a well-established marker of surgical quality and is strongly associated with recurrence and survival.

Global data comparing elective and emergency colorectal cancer surgery across different healthcare systems have been limited.

Identifying modifiable system-level factors could improve outcomes without major additional healthcare investment.

Results:

This secondary analysis included 13,101 patients undergoing curative-intent colorectal cancer surgery across 95 countries.

Margin-positive resections were significantly more common after emergency surgery than elective surgery (13.7% vs 4.5%).

After adjusting for patient characteristics, tumor stage, and healthcare system factors, emergency surgery remained associated with a more than twofold higher risk of incomplete tumor resection.

The increased risk was consistent across high-, middle-, and low-income countries, indicating that the problem extends beyond resource limitations.

The greatest disparity was observed in Stage III–IV rectal cancer, where emergency surgery resulted in substantially higher rates of margin-positive resections.

Importantly, hospital- and country-level factors accounted for most of the variation in surgical quality, highlighting the critical influence of healthcare systems, specialist expertise, and organizational practices.

Clinical Impact:

This landmark global analysis demonstrates that emergency colorectal cancer surgery is an independent marker of poorer surgical quality, not simply a consequence of more advanced disease. The findings emphasize that improving emergency surgical pathways—through earlier specialist involvement, multidisciplinary decision-making, better assessment of resectability, and the use of bridge-to-surgery strategies when appropriate—could significantly improve oncological outcomes worldwide. These are practical, relatively low-cost interventions that can be implemented across healthcare systems regardless of national income level.

Bottom Line:

Patients undergoing emergency colorectal cancer surgery are more than twice as likely to have incomplete (margin-positive) tumor resections compared with those undergoing elective surgery. Strengthening emergency colorectal cancer pathways, ensuring specialist surgical expertise, and expanding bridge-to-surgery strategies represent immediate opportunities to improve cancer outcomes globally.