Controversies in the emergency management of colorectal cancer and strategies for improved outcomes: a systematic review

Abstract

Background: Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide, with approximately 1.8 million new cases diagnosed annually and over 860 000 deaths per year. Despite established screening programmes, between 15% and 45% of patients present as emergencies due to obstruction or perforation, conditions associated with significantly increased morbidity and mortality compared with elective presentations. The objective was to evaluate the management of emergency CRC patients with obstruction or perforation and assess existing controversies.

Methods: A systematic search was conducted across PubMed, Cochrane Library, Embase, Scopus, and Google Scholar, focusing mainly on studies published between 2000 and 2024, including randomised controlled trials, meta-analyses, cohort studies, and clinical guidelines for managing adult emergency CRC cases.

Results: Emergency CRC is associated with significantly worse outcomes than elective surgery, with 30-day mortality ranging from 15–33% for obstruction and 26–77% for perforation. Management of obstruction and perforation differs substantially. Diverting stoma remains a standard and widely accepted intervention for left-sided and rectal obstruction, particularly in settings where self-expanding metal stents (SEMS) expertise or availability is limited. Although early trials raised concerns about SEMS-related perforation and tumour dissemination, large European randomised trials (ESCO and CReST) demonstrated comparable long-term oncologic outcomes between SEMS as a bridge to surgery and emergency resection when appropriately selected.

Conclusions: To improve outcomes in patients with obstructed and perforated colorectal cancer, a multidisciplinary, evidence-based approach is critical. Strategies include reducing the incidence of advanced CRC through screening and early diagnostic pathways, optimising emergency surgical management protocols, increasing access to colorectal units, centralising care to specialised colorectal units, refining the use of SEMS, adapting enhanced recovery after surgery (ERAS) protocols for emergency settings, and refining bridge-to-surgery strategies.