OPEN ACCESS

EDITORIAL

Quality of Oncologic Surgery in the Emergency Setting:

Colorectal cancer as a Model

Fábio de Oliveira Ferreira^1,2, Benedito M. Rossi²

¹Department of Surgery and Trauma, Faculty of Medicine, University of São Paulo, São Paulo, Brazil

Faculty of Medicine, University of São Paulo, São Paulo, Brazil

FOF: Surgical oncologist. Associate Professor (Livre Docente) at the Faculty of Medicine, University of São Paulo. Full Member of

the Brazilian Society of Surgical Oncology. Full Member of the Brazilian College of Surgeons.

BMR: Surgical oncologist. Associate Professor (Livre Docente) at the Faculty of Medicine, University of São Paulo. Full Member of

the Brazilian College of Surgeons

INTRODUCTION

To cite:

Quality Indicators in Emergency Oncologic

Surgery

de Oliveira Ferreira F, Rossi BM. Quality of

oncologic surgery in the emergency setting:

colorectal cancer as a model. Rev Argent

Coloproctol. 2026; 37(1):5-8.

doi:10.46768/8nmgxw44

The quality of oncologic surgery is typically

discussed under ideal circumstances, in which

patients undergo appropriate staging, complex cases

are reviewed at multidisciplinary tumor boards, and

treatment is delivered at specialized referral centers

with access to advanced imaging, endoscopy,

pathology, and local and systemic therapies within a

structured treatment pathway and follow-up

Healthcare quality may be defined as the ability to

deliver care that is safe, effective, timely, efficient,

equitable, and patient-centered.⁶In surgical

oncology, however, the assessment of quality is

complex. Quality indicators evolve over time, vary

across tumor types, and depend on multiple phases

of care. Donabedian’s classic framework—

structure, process, and outcomes—remains useful

for organizing this evaluation.⁷

In emergency colorectal surgery, structural

indicators include availability of CT imaging,

endoscopy, intensive care, blood banking,

anesthesia support, pathology services, antibiotics,

nutritional support, surgical teams, specialist

consultation, transfer capability, and institutional

protocols. Hospital volume, team experience, and

continuity of oncologic care must also be

considered.

Process indicators are among the most important,

and paradoxically among the most difficult to

measure. These include recognition of suspected

malignancy; accurate preoperative staging; explicit

definition of therapeutic intent (curative, palliative,

or damage-control); appropriate selection among

resection, diversion, primary anastomosis, or stoma

creation; adherence to oncologic resection

principles; achievement of adequate surgical

margins; performance of lymphadenectomy

appropriate to tumor location; and detailed

documentation of intraoperative findings. In colon

cancer, retrieval of at least 12 lymph nodes remains

an established quality indicator of adequate

pathologic staging and has been associated with

improved oncologic outcomes.⁸

Outcome indicators should not be limited to in-

hospital mortality. Evaluation should include 30-

and 90-day mortality, postoperative morbidity,

surgical site infection, anastomotic leak, intensive

care unit (ICU) utilization, reoperation, readmission,

length of stay, permanent stoma formation, margin

positivity, timely initiation of adjuvant therapy,

DFS, OS, and, whenever feasible, patient-reported

outcomes and quality-of-life measures.

Additional supplemental material is

published online only. To view, please visit

the journal online:

https://doi.org/10.46768/8nmgxw44

Received: May 1, 2026

Accepted: May 13, 2026

program. However,

substantial proportion of

patients with colorectal cancer (CRC) do not follow

this pathway. Many enter the healthcare system

through the emergency department with obstruction,

perforation, bleeding, sepsis, anemia, pain, or

clinical deterioration. In these situations, surgery

becomes not only a planned technical procedure, but

also

decision made under pressure, with

incomplete information, variable resources, and

substantial risk.

In the emergency setting, beyond disease-related

factors, two questions directly influence outcomes:

where will the patient be treated, and who will

operate? In many healthcare systems, patients

presenting with oncologic emergencies are managed

in general hospitals, frequently by on-call general

surgeons without formal training in surgical

oncology or colorectal surgery. This observation

should not be interpreted as criticism of emergency

surgeons, but rather as recognition of a healthcare

reality: emergencies expose structural, educational,

and organizational limitations in oncologic care

delivery.

Argentina de Coloproctología. Este artículo

se distribuye bajo licencia Creative

Commons Atribución–NoComercial–

SinDerivadas 4.0 Internacional (CC BY-NC-

ND 4.0).

https://creativecommons.org/licenses/by-nc-

nd/4.0/

Correspondence to

Benedito Mauro Rossi

bmrossi@me.com

CRC is

particularly suitable model for this

discussion. It is among the most common

malignancies worldwide, with its global burden

projected to increase substantially over the coming

decades.1 Moreover, a considerable proportion of

patients still present with acute complications, most

commonly obstruction, perforation, or bleeding.

Unlike many other malignancies, CRC provides

objective and measurable indicators of surgical

quality, including staging, operative approach,

extent of resection, margin status, lymph node yield,

stoma creation, morbidity and mortality,

readmission, reoperation, disease-free survival

(DFS), and overall survival (OS).

Operative documentation deserves particular

emphasis. In oncologic surgery, the operative report

is not merely an administrative requirement, but a

critical instrument for patient care, communication,

quality assessment, and research. In the emergency

setting, incomplete operative reports may preclude

to determine whether oncologic principles were

respected. Whenever feasible, the report should

document tumor location, extent of disease,

perforation or contamination, suspected invasion of

adjacent organs, metastatic disease, intraoperative

staging assessment, type of resection performed,

margin status, lymphadenectomy, justification for

primary anastomosis or stoma creation, and

operative intent. What is not documented cannot be

The central question, therefore, is not whether

emergency CRC surgery is associated with worse

outcomes; the evidence consistently confirms that it

is.

Compared to elective surgery, emergency

procedures result in increased morbidity and

mortality, longer hospital stays, higher readmission

and stoma rates, and poorer oncologic outcomes.^2–5

The more relevant question is which adverse

outcomes are unavoidable given the patient’s

clinical presentation, and which can be improved

through better organization and delivery of care.

REV ARGENT COLOPROCTOL | 2026 | VOL 37, No. 2

EDITORIAL

audited, and what cannot be audited is unlikely to improve.

This distinction is fundamental. Emergency presentation does not

inherently compromise oncologic quality, but it does increase the

risk of doing so. The worse prognosis may reflect a combination

of advanced disease, poor physiological reserve, delayed

diagnosis, structural constraints, lack of multidisciplinary

planning, and potential technical limitations. Therefore, the most

meaningful conclusion is not that emergency surgery is “worse,”

but that it requires dedicated mechanisms to safeguard quality of

care.

Who Should Operate: General Surgeon, Colorectal

Surgeon, or Surgical Oncologist?

CRC highlights a practical dilemma: who should operate on the

patient presenting to the emergency department with obstructing

or perforated colon cancer? The general surgeon experienced in

emergency surgery but without formal oncologic training, or the

colorectal surgeon or surgical oncologist, who may have less

exposure to routine emergency procedures? The answer should

not be based on a rigid, corporate model. Optimal care is achieved

not by placing specialists in opposition, but by integrating their

complementary expertise.

Strategies to Improve Quality

Quality improvement requires a minimum set of actions. First, the

definition of specific quality indicators. Second, the development

of prospective registries, preferably multicenter or national.

Third, the standardization of oncologic operative reporting in the

emergency setting. Fourth, the development of practical manuals

for the most common oncologic emergencies, starting with

obstruction and perforation in CRC. Fifth, the establishment of

criteria for transfer and postoperative multidisciplinary

discussion. Sixth, investment in formal training of frontline

professionals.

In practice, many patients presenting with CRC emergencies are

treated in general hospitals by general surgeons, often in lower-

volume institutions. In one series, elective procedures were

performed by colorectal surgeons in 37% of cases, surgical

oncologists in 10%, and general surgeons in 53%; in urgent

settings, these proportions were 19%, 10%, and 70%,

respectively.⁹ These findings underscore that the majority of CRC

emergencies will continue to be managed by general surgeons.

Accordingly, effective solutions cannot rely solely on the

availability of subspecialists for every emergency call schedule.

The issue is not whether every emergency surgeon should become

a colorectal surgeon or surgical oncologist. Rather, every patient

presenting with an oncologic emergency should receive an

operation guided by minimum oncologic quality standards.

Studies suggest that specialization, hospital volume, and

organization of care may influence outcomes, although the impact

of these variables appears more complex in emergency settings

than in elective surgery.^10,11In some circumstances, experienced

emergency surgeons may achieve acceptable oncologic results; in

others, the absence of oncologic training, standardized protocols,

and institutional support may increase the risk of inadequate

resection, positive margins, or insufficient lymphadenectomy.

The discussion, therefore, must move beyond the individual

surgeon and focus on the healthcare system. Who performs the

operation is important, but so are the hospital environment, time

of care, resource availability, operative documentation,

institutional protocols, transfer capability, postoperative

multidisciplinary discussion, and access to adjuvant therapy.

Multidisciplinarity, considered

cornerstone of quality in

oncology, must be adapted to the emergency setting. It is not

always possible to discuss the case before surgery, but minimal

workflows can be established: communication with medical

oncology, coloproctology, or surgical oncology when available;

definition

transfer

criteria;

early

postoperative

multidisciplinary discussion; appropriate pathological review;

and timely referral for systemic therapy when indicated.

Emergency presentation should not be regarded as an isolated

event in the continuum of care, but rather as a critical stage in the

oncologic care pathway.

In this context, as the result of a collaboration between the

Brazilian College of Surgeons (Portuguese acronym CBC) and

the Brazilian Society of Surgical Oncology (Portuguese acronym

SBCO), the Advanced Oncological Life Support (AOLS) has

been proposed. This ongoing Brazilian initiative represents a

natural evolution in the organization of care for oncologic patients

presenting in the emergency setting. We advocate for the

development of an advanced support program for oncologic

emergencies, modeled after established courses such as ATLS,

but tailored to the specific needs of cancer patients: early

recognition, resuscitation, decision-making, preservation of

oncologic principles, appropriate documentation, and planning of

follow-up after the acute event.¹⁴AOLS aims to disseminate a

minimum standard of oncologic quality among professionals

managing cancer patients in emergency departments, including

abdominal emergencies related to CRC.

Although this initiative originates in Brazil, the underlying

problem is shared by many Latin American health systems:

inequitable access, insufficient screening, delayed diagnosis,

structural heterogeneity, overcrowded general hospitals, and

limited access to referral to specialized centers. CRC, given its

frequency and the availability of measurable indicators, may

serve as a starting point for a broader program to assess the

quality of emergency oncologic surgery.

Outcomes in the Emergency Setting: Complications,

Recovery, and Survival

Patients with CRC operated on in the emergency setting

frequently have less access to preoperative staging studies, a

lower likelihood of complete staging, and a higher probability of

requiring procedures such as Hartmann’s operation, stoma

formation, and unplanned segmental resections.^3,4They have also

been reported to have an increased risk of positive margins, a

lower number of lymph nodes retrieved in some series, longer

length of stay, higher readmission rates, and worse survival

outcomes.^4,5

In the series by Wanis et al.,⁴patients undergoing emergency

resection for colon cancer had worse five-year disease-free and

overall survival compared with those treated electively. Xu et al.⁵

demonstrated that emergency colectomies were more frequently

performed in community hospitals and lower-volume centers and

were associated with a higher likelihood of positive margins,

inadequate lymph node assessment, increased unplanned

readmission, and worse overall survival. These findings support

the concern that emergency presentation may compromise both

perioperative and oncologic outcomes.

However, interpretation of these findings requires caution.

Patients presenting in the emergency setting are not equivalent to

those undergoing elective surgery. They are often older, more

frail, have greater comorbidity burden, more advanced disease,

higher inflammatory or infectious status, and less prior access to

screening programs. Emergency presentation may also reflect

socioeconomic vulnerability and delayed diagnosis.¹²In adjusted

analyses, some authors suggest that part of the poorer outcomes

is driven more by clinical and biological factors than by the

emergency setting itself.¹³

CONCLUSION

Patients with CRC do not choose to present as an emergency. The

health system, however, determines whether such presentations

are merely acts of rescue or opportunities to preserve oncologic

quality. Emergency care does not obviate the need for sound

surgical and oncologic principles; on the contrary, it makes their

consistent application even more critical.

CRC should serve as an initial model, given its frequency,

measurability, and the availability of objective quality indicators.

Improving outcomes requires the identification of modifiable

factors, enhancement of data collection systems, establishment of

clearly defined quality metrics, strengthening of professional

training, development and implementation of standardized

protocols, and full integration of emergency care into the

colorectal cancer care pathway. The contemporary challenge is

QUALITY OF ONCOLOGIC SURGERY IN THE EMERGENCY SETTING: COLORECTAL CANCER AS A MODEL

de Oliveira Ferreira F, Rossi BM.

REV ARGENT COLOPROCTOL | 2026 | VOL 37, No. 2

EDITORIAL

6. Hardt JL, Merkow RP, Reissfelder C, Rahbari NN. Quality assurance and

quality control in surgical oncology. J Surg Oncol. 2022;126(8):1560-

1572.

not only to operate faster, but to operate better, even when time is

limited.

7. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund

Q. 1966;44(Suppl):166-206.

Author Contributions

FOF: Drafting the original version, revision, and final editing.

BMR: Drafting the original version, revision, and final editing.

8. Shulman LN, Browner AE, Palis BE, et al. Compliance with cancer quality

measures over time and their association with survival outcomes: the

Commission on Cancer’s experience with at least 12 lymph nodes in colon

cancer resections. Ann Surg Oncol. 2019;26(6):1613-1621.

9. Patel SV, Patel SVB, Brackstone M. Emergency surgery for CRC does not

result in nodal understaging compared with elective surgery. Can J Surg.

2014;57(5):349-353.

10. Huijts DD, Dekker JWT, van Bodegom-Vos L, et al. Differences in

organization of care are associated with mortality, severe complication and

failure to rescue in emergency colon cancer surgery. Int J Qual Health Care.

2021;33(1):mzab038.

11. Schrag D, Cramer LD, Bach PB, Cohen AM, Warren JL, Begg CB.

Influence of hospital procedure volume on outcomes following surgery for

colon cancer. JAMA. 2000;284(23):3028-3035.

12. Gunnarsson H, Ekholm A, Olsson LI. Emergency presentation and

socioeconomic status in colon cancer. Eur J Surg Oncol. 2013;39(8):831-

836.

13. Weixler B, Warschkow R, Ramser M, et al. Urgent surgery after

emergency presentation for CRC has no impact on overall and DFS: a

propensity score analysis. BMC Cancer. 2016;16:208.

14. Ferreira FO, Lima TMA, Utiyama EM, Oliveira AF, Von Bahten LC,

Ribeiro HSC. Quality of emergency oncological surgery: time for advanced

oncological life support. Rev Assoc Med Bras. 2024;70(Suppl

1):e2024S109.

Conflict of interest statement: None

Funding: None

Data availability statement: The data are publicly available

ORCIDs:

Oliveira Ferreira F: 0000-0002-5340-2578

Mauro Rossi B: 0000-0003-2614-4910

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and long-term survival between emergency and elective surgery for CRC.

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QUALITY OF ONCOLOGIC SURGERY IN THE EMERGENCY SETTING: COLORECTAL CANCER AS A MODEL

de Oliveira Ferreira F, Rossi BM.