Published online Jul 15, 2026. doi: 10.4251/wjgo.120893
Revised: March 17, 2026
Accepted: April 16, 2026
Published online: July 15, 2026
Processing time: 125 Days and 0.4 Hours
Emergency surgery in colorectal cancer (CRC) is traditionally considered a tech
To evaluate whether emergency presentation is associated with a more advanced pathological stage in patients undergoing surgical resection for CRC.
This retrospective study included patients undergoing surgical resection for colorectal adenocarcinoma between January 2021 and December 2025. Patients were grouped as emergency or elective. Pathological stage was defined according to the tumor-node-metastasis classification and analyzed as an ordinal variable (stage I-IV). Ordinal logistic regression using a proportional odds model was performed to determine whether emergency presentation predicted a higher pathological stage, adjusting for age, sex, American Society of Anesthesiologists physical status, and tumor location (rectal/rectosigmoid vs others).
Among the 152 patients, 56 (36.8%) underwent emergency surgery and 96 (63.2%) elective surgery. Emergency presentation was significantly associated with higher pathological stage (P < 0.001). Stage IV disease was more frequent in the emer
Emergency presentation in CRC is strongly associated with more advanced pathological disease at diagnosis. This stage-shifting effect may partly explain the poorer short-term outcomes observed in emergency colorectal surgery and highlights the importance of early detection and timely intervention.
Core Tip: Emergency presentation in colorectal cancer is commonly associated with poorer surgical outcomes; however, its relationship with pathological disease stage has not been fully clarified. In this retrospective study, pathological stage was analyzed as an ordinal outcome to preserve the biological continuum of tumor progression. Emergency presentation was strongly associated with a higher pathological stage and remained an independent predictor of advanced disease after adjustment for clinical covariates. These findings suggest that emergency presentation reflects a substantial oncological disease burden rather than merely surgical urgency, providing important context for the poorer short-term outcomes observed in emergency colorectal surgery.
- Citation: Gökdere OG, Kanat BH. Emergency presentation predicts advanced pathological stage in colorectal cancer: An ordinal regression analysis. World J Gastrointest Oncol 2026; 18(7): 120893
- URL: https://www.wjgnet.com/1948-5204/full/v18/i7/120893.htm
- DOI: https://dx.doi.org/10.4251/wjgo.120893
Colorectal cancer (CRC) remains a leading cause of cancer-related morbidity and mortality worldwide, and a substantial proportion of cases continue to present with acute complications despite widespread adoption of screening programs and advances in diagnostics and multimodal treatment strategies[1]. While most patients are diagnosed and treated in an elective setting, a significant subset presents emergently with complications such as bowel obstruction, perforation, or severe bleeding, necessitating urgent surgical intervention[2]. Emergency colorectal surgery is consistently associated with poorer short-term outcomes, including increased postoperative morbidity, higher rates of intensive care unit (ICU) admission, prolonged hospitalization, and elevated perioperative mortality compared with elective procedures. These findings reflect the combined effects of added physiological stress and suboptimal preoperative preparation commonly encountered in this setting[3]. These unfavorable outcomes have traditionally been attributed to factors such as limited physiological reserve, inadequate preoperative optimization, and the inherently urgent nature of the surgical setting, underscoring the complexity of managing patients presenting acutely[4].
However, beyond its surgical implications, emergency presentation may reflect a fundamentally different oncological context. Recent multicenter and population-based studies have demonstrated that patients presenting emergently with CRC are significantly more likely to have advanced pathological disease at diagnosis compared with those undergoing elective surgery, suggesting a higher intrinsic oncological burden in this subgroup[5]. Consistent findings from compa
Despite these observations, the relationship between emergency presentation and pathological stage remains incom
Pathological stage in CRC represents an inherently ordered biological construct, reflecting the stepwise progression of local invasion, lymphatic dissemination, and distant metastasis. Emerging evidence from CRC prognostic research suggests that moving beyond traditional tumor-node-metastasis (TNM) categories to incorporate additional pathological dimensions - such as lymph node ratio or other continuous markers of tumor spread - can improve prognostic accuracy and better reflect the hierarchical nature of disease progression[9]. Consequently, whether emergency presentation is associated with a systematic upward shift across successive pathological stages warrants focused investigation using stage-preserving analytical methodologies that respect the hierarchical nature of TNM classification[10].
In this study, we aimed to investigate the association between emergency presentation and pathological disease stage in patients undergoing surgery for CRC. By analyzing pathological stage as an ordinal outcome and adjusting for key clinical confounders, we sought to determine whether emergency presentation independently predicts more advanced disease at diagnosis. Secondary objectives included the evaluation of short-term postoperative outcomes to contextualize the clinical implications of advanced-stage disease at emergency presentation.
This retrospective observational study included consecutive patients who underwent surgical resection for histologically confirmed colorectal adenocarcinoma at a tertiary referral center between January 2021 and December 2025. Patients were identified from a prospectively maintained institutional database and categorized according to the mode of presentation as emergency or elective.
Emergency surgery was defined as an unplanned operative intervention performed during the index hospitalization for acute CRC-related complications, including bowel obstruction, perforation, and uncontrolled gastrointestinal bleeding. These indications represent the clinical spectrum of emergency presentation in the study cohort. Elective surgery was defined as a planned operative procedure performed following outpatient evaluation and appropriate preoperative optimization.
Patients with non-adenocarcinoma histology, incomplete pathological staging data, or those who underwent palliative procedures without tumor resection were excluded from the analysis.
Demographic characteristics, clinical variables, and perioperative data were extracted from electronic medical records. Collected variables included age, sex, American Society of Anesthesiologists (ASA) physical status classification, tumor location, operative characteristics, and postoperative outcomes.
Pathological data were obtained from standardized histopathology reports and included tumor, nodal, and metastatic status, total lymph node yield, and final pathological stage.
Surgical procedures were performed according to tumor location and clinical presentation. Resection types included colon and rectal oncologic resections appropriate to the tumor site. Emergency procedures were predominantly per
Pathological staging was performed according to the American Joint Committee on Cancer TNM classification system. The final pathological stage was categorized as stage I, II, III, or IV based on postoperative histopathological evaluation. Given the inherently ordered structure of pathological staging, this variable was treated as an ordinal outcome in the primary analysis to preserve the biological continuum of disease progression.
Adequate lymph node retrieval was defined as the examination of at least 12 lymph nodes, in accordance with estab
Postoperative complications occurring within 30 days of surgery were recorded and classified according to the Clavien-Dindo classification system. Major postoperative complications were defined as Clavien-Dindo grade III or higher.
Additional short-term outcomes included anastomotic leakage, ICU admission, length of hospital stay, reoperation, stoma formation, and 30-day mortality.
Continuous variables were summarized as mean ± SD or median with interquartile range, according to data distribution. Categorical variables were presented as n (%). Comparisons between emergency and elective groups were performed using the Student’s t test or the Mann-Whitney U test for continuous variables, and the χ2 test or Fisher’s exact test for categorical variables, as appropriate.
The primary outcome was pathological stage, analyzed as an ordinal variable (stage I-IV). To assess whether emer
Sensitivity analyses were conducted using binary logistic regression comparing advanced-stage disease (stage III-IV) with early-stage disease (stage I-II) to evaluate the robustness of the findings.
All statistical tests were two-sided, and a P value < 0.05 was considered statistically significant. Because of the retrospective design of the study, a formal a priori sample size calculation was not performed. Instead, all consecutive eligible patients treated during the study period were included to minimize selection bias. To reduce the risk of model overfitting given the available sample size, the number of covariates included in the ordinal regression model was intentionally limited to clinically relevant baseline variables (age, sex, ASA physical status, and tumor location). Statistical analyses were performed using SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, United States).
The study was approved by the Malatya Turgut Özal University Non-Interventional Clinical Research Ethics Committee, approval No. E-30785963-020-295071 and conducted in accordance with the principles of the Declaration of Helsinki.
Given the retrospective nature of the study and the use of anonymized data, the requirement for informed consent to participate was waived by the Malatya Turgut Özal University Non-Interventional Clinical Research Ethics Committee.
A total of 152 patients who underwent surgical resection for colorectal adenocarcinoma between January 2021 and December 2025 were included in the analysis. Of these, 56 patients (36.8%) underwent emergency surgery, whereas 96 patients (63.2%) underwent elective surgery. Among patients undergoing emergency surgery, the most common indication was acute bowel obstruction (n = 39, 69.6%), followed by perforation (n = 9, 16.1%) and severe gastrointestinal bleeding (n = 8, 14.3%).
Baseline demographic characteristics were largely comparable between the two groups, with no significant differences observed in age (67.0 ± 11.5 years vs 67.2 ± 11.6 years; P = 0.900) or sex distribution (55.4% vs 54.2% male; P = 1.000). However, patients in the emergency surgery group had significantly higher ASA physical status scores compared with those in the elective surgery group (3.1 ± 0.7 vs 2.8 ± 0.7; P = 0.012), indicating poorer preoperative physiological status. Tumor localization and adequacy of lymph node retrieval were comparable between the groups (P = 0.932 and P = 0.136, respectively), suggesting similar surgical and pathological quality (Table 1).
| Variable | Emergency (n = 56) | Elective (n = 96) | P value |
| Age, years, mean ± SD | 67.0 ± 11.5 | 67.2 ± 11.6 | 0.900 |
| Male sex | 31 (55.4) | 52 (54.2) | 1.000 |
| ASA score, mean ± SD | 3.07 ± 0.74 | 2.76 ± 0.71 | 0.012 |
| Tumor localization | 0.932 | ||
| Right colon | 18 (32.1) | 33 (34.4) | |
| Left colon | 13 (23.2) | 18 (18.8) | |
| Sigmoid colon | 3 (5.4) | 9 (9.4) | |
| Rectosigmoid | 11 (19.6) | 20 (20.8) | |
| Rectum | 4 (7.1) | 6 (6.3) | |
| Diffuse colon | 7 (12.5) | 10 (10.4) | |
| Pathological stage | < 0.001 | ||
| Stage I | 1 (1.8) | 20 (20.8) | |
| Stage II | 10 (17.9) | 31 (32.3) | |
| Stage III | 19 (33.9) | 35 (36.5) | |
| Stage IV | 26 (46.4) | 10 (10.4) | |
| Advanced stage (stage III-IV) | 45 (80.4) | 45 (46.9) | < 0.001 |
| ≥ 12 lymph nodes retrieved | 46 (82.1) | 88 (91.7) | 0.136 |
Emergency presentation was associated with a markedly different pathological stage profile. The distribution of pathological stages differed significantly between the emergency and elective surgery groups (P < 0.001), with a clear shift toward more advanced disease among patients presenting emergently.
Stage IV tumors were substantially more frequent in the emergency surgery group (46.4%) compared with the elective surgery group (10.4%), whereas early-stage disease was considerably more common in the elective surgery group.
Overall, 80.4% of patients in the emergency surgery group presented with advanced-stage disease (stage III-IV), com
These findings indicate a pronounced shift toward more advanced disease among patients requiring emergency surgical intervention.
To evaluate whether emergency presentation independently predicted a more advanced pathological stage, pathological stage was analyzed as an ordinal outcome (stage I-IV) using a proportional odds regression model.
In the adjusted analysis, emergency presentation remained a strong independent predictor of higher pathological stage (adjusted proportional odds ratio = 5.27, 95% confidence interval: 2.60-10.70; P < 0.001), after controlling for age, sex, ASA physical status classification, and tumor location (Table 2).
| Variable | aPOR | 95%CI | P value |
| Emergency presentation | 5.27 | 2.60-10.70 | < 0.001 |
| Age (per year) | 1.01 | 0.98-1.04 | 0.412 |
| Male sex | 1.12 | 0.60-2.11 | 0.720 |
| ASA score | 1.41 | 1.05-1.90 | 0.022 |
| Rectal/rectosigmoid localization | 0.93 | 0.48-1.82 | 0.834 |
Sensitivity analyses using a binary staging model comparing advanced-stage disease (stage III-IV) with early-stage disease (stage I-II) yielded consistent results, further confirming the robustness of the primary findings.
Short-term postoperative outcomes differed significantly between the two groups. Emergency surgery was associated with higher rates of overall postoperative complications (50.0% vs 27.1%; P = 0.008) and major complications (28.6% vs 11.5%; P = 0.015). Anastomotic leakage was more frequent in the emergency surgery group than in the elective surgery group (14.3% vs 2.1%; P = 0.006). ICU admission was significantly more frequent among emergency surgery patients (28.6% vs 6.3%; P < 0.001), and hospital stay was substantially longer (median 10 days vs 6.5 days; P < 0.001). Reoperation was required only in the emergency surgery group (5.4% vs 0%; P = 0.048). Stoma formation and 30-day mortality did not differ significantly between the groups (Table 3).
| Outcome | Emergency (n = 56) | Elective (n = 96) | P value |
| Any postoperative complication | 28 (50.0) | 26 (27.1) | 0.008 |
| Major complication (Clavien-Dindo ≥ III) | 16 (28.6) | 11 (11.5) | 0.015 |
| Anastomotic leakage | 8 (14.3) | 2 (2.1) | 0.006 |
| ICU admission | 16 (28.6) | 6 (6.3) | < 0.001 |
| Length of hospital stay, days, median (IQR) | 10 (7-13.3) | 6.5 (5-10) | < 0.001 |
| Reoperation | 3 (5.4) | 0 (0) | 0.048 |
| Stoma formation | 26 (46.4) | 34 (35.4) | 0.243 |
| 30-day mortality | 4 (7.1) | 4 (4.2) | 0.467 |
Collectively, these results demonstrate that emergency presentation in CRC is associated with a systematic shift toward a more advanced pathological stage at diagnosis, accompanied by significantly poorer short-term surgical outcomes. Importantly, the association between emergency presentation and advanced pathological stage persisted after adjustment for relevant clinical confounders, underscoring the independent oncological significance of this presentation pattern.
In this study, we demonstrated that emergency presentation in CRC is strongly associated with a systematic shift toward a more advanced pathological stage at diagnosis. In our cohort of 152 surgically treated patients, individuals presenting emergently were substantially more likely to harbor stage III-IV disease compared with those undergoing elective sur
This stage-shifting effect may partly explain the consistently poorer short-term outcomes observed in emergency colorectal surgery, including increased postoperative morbidity and reduced opportunities for curative oncological treatment[13]. However, the observational design of this study precludes causal inference. Emergency presentation may primarily reflect delayed diagnosis or barriers to timely healthcare access rather than a direct biological determinant of tumor progression. Therefore, emergency presentation should be interpreted as a clinical marker of advanced disease at diagnosis rather than a causal driver of tumor stage.
Previous studies have consistently reported inferior short-term outcomes following emergency colorectal surgery, including increased postoperative morbidity, prolonged hospitalization, and higher early mortality compared with elective procedures[14]. These unfavorable outcomes have traditionally been attributed to patient-related factors such as advanced age, greater comorbidity burden, and the limited opportunity for adequate preoperative optimization inherent to emergency surgical settings[15]. While our findings corroborate the higher postoperative complication rates associated with emergency presentation, they further suggest that advanced pathological stage may represent an important and potentially underrecognized contributing factor to these inferior outcomes, in addition to patient-related and perioperative risk factors[16].
Importantly, many prior studies evaluating disease stage in emergency CRC have relied on dichotomized staging approaches, most commonly categorizing disease as early or advanced, which may inadequately reflect the true distribution of tumor burden observed in clinical practice[17]. Although clinically intuitive, such binary classifications risk obscuring meaningful variation across the full spectrum of tumor progression and may mask incremental shifts in disease severity associated with delayed diagnosis or emergency presentation[18].
By analyzing pathological stage as an ordinal outcome, our study offers a more nuanced representation of oncological burden, demonstrating that emergency presentation is associated with a graded increase across successive pathological stages rather than a simple binary distinction. This stage-shifting pattern is consistent with the biological continuum of CRC progression and enhances the interpretability and clinical relevance of our findings[19].
Beyond demonstrating an association between emergency presentation and advanced disease, our findings highlight the importance of using analytical approaches that preserve the hierarchical structure of pathological staging. By modeling stage as an ordinal outcome rather than collapsing it into binary categories, our study captures incremental shifts across the entire spectrum of tumor progression and provides a more biologically meaningful representation of oncological burden. This approach may, therefore, improve the interpretability of clinical research that examines disease severity at presentation[18].
The association between emergency presentation and advanced disease stage in our cohort was further reflected in the marked predominance of advanced-stage disease, particularly the substantially higher proportion of stage IV tumors among emergency presentations[20]. Importantly, the adequacy of lymph node retrieval was similar between emergency and elective resections, suggesting that differences in surgical technique or pathological assessment are unlikely to account for the observed disparities in stage distribution. Accordingly, the high proportion of stage IV disease among patients presenting emergently likely reflects delayed diagnosis and advanced disease burden at first clinical contact, consistent with recent prospective data demonstrating a higher prevalence of advanced-stage disease among patients with emergency presentation of CRC[21].
Clinically, this advanced-stage profile provides important context for the significantly higher rates of major postoperative complications, ICU admission, and prolonged hospital stay observed in patients undergoing emergency colorectal surgery. While the emergency setting itself undoubtedly imposes substantial physiological stress, the coexistence of advanced pathological disease may further increase vulnerability to postoperative adverse events. Recognizing the interaction between oncological disease burden and surgical urgency may, therefore, help refine perioperative risk stratification and guide tailored postoperative management strategies in this high-risk population, in line with contemporary recommendations for risk assessment in non-elective major surgery[22].
It should also be noted that the higher postoperative complication rates observed in the emergency surgery group may partly reflect the greater prevalence of advanced-stage disease in this population. Because postoperative outcomes were not adjusted for pathological stage in the present analysis, the relative contribution of surgical urgency vs oncological disease burden cannot be fully distinguished. Consistent with this observation, anastomotic leakage was also more frequent in the emergency surgery group than in the elective surgery group, reflecting the unfavorable physiological and intraoperative conditions often encountered in emergency colorectal surgery. Not all anastomotic leaks required surgical reintervention, and several cases were managed conservatively according to their clinical severity.
This study has several limitations that should be acknowledged. First, its retrospective, single-center design introduces the potential for selection bias and may limit the generalizability of the findings. Although adjustments were made for key clinical confounders, residual confounding from unmeasured variables cannot be excluded. In particular, potentially relevant factors such as symptom duration before diagnosis, participation in CRC screening programs, socioeconomic status, and detailed tumor biological characteristics were not available in the dataset. These variables may influence both emergency presentation and pathological stage and could, therefore, contribute to residual confounding.
Second, the analysis focused primarily on short-term surgical outcomes, and long-term oncological endpoints, including disease-free survival and overall survival, were not evaluated. Future studies with longer follow-up are required to better define the prognostic implications of emergency presentation in CRC.
Third, while pathological staging was rigorously and consistently assessed using standardized criteria, the observational nature of the study precludes causal inference regarding the relationship between emergency presentation and advanced pathological stage.
Additionally, the ASA physical status classification may partially reflect underlying disease severity at presentation and could, therefore, lie on the causal pathway between emergency presentation and pathological stage. Nevertheless, emergency presentation remained strongly associated with a higher stage after adjustment for clinical covariates, supporting its independent clinical relevance.
Despite these limitations, the use of a stage-preserving analytical approach and standardized pathological assessment strengthens the robustness of the analysis and supports the validity of the study conclusions.
Emergency presentation in CRC is strongly associated with a systematic shift toward a more advanced pathological stage at diagnosis. Using a stage-preserving analytical approach, we demonstrated that emergency presentation independently predicts increased oncological disease burden beyond baseline patient characteristics. This stage-shifting effect provides important clinical context for the inferior short-term surgical outcomes consistently observed in emergency settings. Recognizing emergency presentation as a marker of advanced pathological disease underscores the importance of earlier detection and timely intervention in CRC.
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