Aging Clin Exp Res

DOI 10.1007/s40520-016-0643-1

ORIGINAL ARTICLE

Postoperative mortality and morbidity in older patients

undergoing emergency right hemicolectomy for colon cancer
Renata Tabola1 • George Mantese1 • Roberto Cirocchi2 • Alessandro Gemini2 •
Veronica Grassi2 • Carlo Boselli2 • Stefano Avenia3 • Alessandro Sanguinetti3 •
Nicola Avenia3 • Maciej Sroczynski4 • Jaroslaw Wierzbicki4

Received: 31 August 2016 / Accepted: 12 October 2016

Ó Springer International Publishing Switzerland 2016

Abstract abscess. The mean age of the pt with complications in

Introduction Even with the advances in surgical technique
and perioperative care, morbidity and mortality after col-
orectal cancer surgery remain considerable, and patients
(pt) who present as an emergency have an even higher
mortality and morbidity rate.
Methods A total of 35 pt with caecum or ascending colon
cancer between January 2007 and June 2015, three
departments in Italy and in Poland, were included in the
study. The intention of surgery in all cases was curative
resection with ileo-colic anastomosis. Comparative statis-
tical analysis was performed.
Results Acute bowel obstruction was the major compli-
cation of CRC that led to an emergency hemicolectomy.
Postoperative mortality and morbidity rates were in total
12.5 and 28.1%, respectively. All the deaths happened in
Poland. Of the pt, 42.8% had morbidity in Poland and
16.6% in Italy. Out of the pt, 25% presenting with perfo-
ration: 25% died, 25% had wound dehiscence, 12.5% had
pulmonary oedema, and 12.5% had an intra-abdominal
& Roberto Cirocchi
roberto.cirocchi@unipg.it
1
Department of Gastrointestinal and General Surgery, Medical
University of Wrocław, ul. Curie-Sklodowskiej 66,
50-369 Wrocław, Poland
2
Department of General and Oncological Surgery, University
of Perugia, Località Sant’Andrea delle Fratte 1,
06134 Perugia, Italy
3
Department of General Surgery, Terni Saint Mary Hospital,
University of Perugia, Via Tristano di Joannuccio 1,
05100 Terni, Italy
4 present higher mortality and morbidity rates than those
Department of Minimally Invasive Surgery and Proctology,
Medical University of Wroclaw, ul. Borowska 213,
50-556 Wrocław, Poland
Poland and in Italy was 79.3 and 72.0 years, respectively.
Conclusion We observed that particularly lethal combi-
nation is older age, perforation with peritonitis and
advanced stage of the cancer.
Keywords Older
Right hemicolectomy
Emergency

Surgery
Abbreviations
CRC Colon–rectal cancer
CT Computed tomography
ANOVA Analysis of variance
pt Patients
COPD Chronic obstructive pulmonary disease
Introduction
It is known that of the roughly 30–38% [1, 2] of patients
(pt) with colon cancer who present with an acute condition
and requiring an emergency surgery [3], most of these are
elderly pt [4]. It is believed that 80% have obstructions [5]
and 15% have perforations [6]. Massive bleeding from
colorectal cancer (CRC) is an uncommon presentation [7].
Perforation in particular has been reported to be a very
ominous prognostic factor for its septic complications [6].
Even in the last decades, with the advances in surgical
techniques and perioperative care, morbidity and mortality
after surgery for colorectal cancer remain considerable [8].
It ranges from 18 to 35% and 1 to 11%, respectively
[2, 8–12]. Hence, pt with colorectal cancer at emergency
undergoing elective surgery [2, 13].

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Above all, pt with colorectal cancer admitted as an
emergency are submitted to resection with curative intent
on a smaller scale, because of the more advanced stage of
the disease [14].
The most frequent postoperative surgical complication
after colorectal resections is surgical site infection
(2–25%). Anastomotic leakage with its frequency rate
ranging between 2.9 and 15.3% is responsible for at least
one-third of the mortality rate after colorectal surgery.
Other complications such as intra-abdominal abscess, ileus
and bleeding are less common [15].
Deteriorated general condition of a patient, especially
old age, under-nutrition and dehydration, has been associ-
ated with poorer outcomes [16–18].
The aim of this study was to evaluate clinical aspects
and compare the short-term complications of emergency
right hemi-colectomy in colon cancer in Italy and Poland,
taking as examples the university hospitals in Terni and in
Wroclaw.
Materials and methods
This retrospective observational study collected data on
35 consecutive pt with CRC who had an emergency right
hemicolectomy in the Department of Digestive Surgery,
‘‘S. Maria’’ Hospital, University of Perugia–Terni (Italy),
between January 2007 and June 2015 (18 pt); in the
Department of Gastrointestinal and General Surgery of
Wroclaw Medical University—Wroclaw (Poland),
between January 2008 and June 2015 (nine pt); and in the
Department of General and Oncological Surgery of
Wroclaw Medical University—Wroclaw (Poland),
between January 2008 and June 2015 (eight pt). The
inclusion criteria were: an intervention performed within
12 h of admission, after diagnosis of bowel obstruction,
perforation or bleeding based on pre-operative history,
clinical data, laboratory and radiographic findings (com-
puted tomography, plain radiogram of the abdominal
cavity).
The intention of surgery in all cases was curative
resection with ileo-colic anastomosis. Distal, peritoneal or
omental metastases and unrespectable local tumour were
criteria for surgical incurability. Operative mortality and
morbidity referred to disease, surgical complications and
death during the initial hospital stay. The median follow-up
was 30 days. TNM classification and stage of the disease
postoperatively, together with the number of lymph nodes
harvested, were evaluated. We classified postoperative
complications as surgical if they were connected directly to
the procedure, such as wound infection, wound dehiscence,
bleeding, anastomotic failure, ileus that occurred later than
3 days after the procedure, intra-abdominal abscess and
123
Aging Clin Exp Res
cardiopulmonary complications. Postsurgery mortality was
considered a complication and, however, was evaluated
separately.
The standard oncological right hemicolectomy with
resection of a portion of the terminal ileum, caecum, the
ascending colon, and variable parts of the transverse colon
with high vessel ligation and stapled or hand-sutured
double-layered side-to-side or end-to-side ileo-colonic
anastomosis, combined with the removal of lymph nodes,
was performed in all the pt. No mechanical bowel prepa-
ration was done. Antibiotic and anticoagulative prophy-
laxis did not differ among the institutions.
Statistical analysis
Statistical analysis was performed with use of ANOVA
test, Fischer’s test, Student’s t test, Chi-squared test and
logistic regression model to evaluate features that have an
influence on death.
Results
A total of 35 pt with caecum or ascending colon cancer (18
pt from Italy and 17 from Poland) who underwent emer-
gency right hemicolectomy between January 2007 and
June 2015 in three departments in Italy and in Poland were
included in the study.
Three pt, all from Poland, were excluded: two pt in a
poor general condition and sepsis caused by perforation of
the intestine (aged 89 and 91) underwent resection only
without the anastomosis and ileostomy was created. One
patient had cancer in two different segments of the colon:
in the caecum and in the splenic flexure. In that case, after
resection of the caecum, ascending, transverse and
descending colon, Hartmann’s operation was performed.
Baseline characteristics of the pt are presented in Table 1.
The Polish and Italian groups were equal as to age, sex and
stage of the cancer at the time of the operation. There
existed statistically significant difference in comorbidity in
Polish pt p \0.001.
Acute bowel obstruction was the major complication of
CRC that led to an emergency hemicolectomy in 77.7% of
cases (14 pt), perforation in 16.6% (three pt) and bleeding
in 5.5% (one patient) in Italy. In Poland, obstruction was
seen in 42.8% (six pt), perforation in 35.7% (five pt) and
bleeding in 21.4% (three pt). All pt with perforation had
diffuse peritonitis at the moment of presentation. Out of
five pt who presented with perforations and diffuse peri-
tonitis in Poland, two pt died (50% of all deaths),
one patient had pulmonary oedema, and one patient had
wound dehiscence. In Italy, three pt presented with
Aging Clin Exp Res
perforation and diffuse peritonitis, and complications were
seen in two of them (wound dehiscence and intra-abdom-
inal abscess).
Out of 32 pt included in the study, 11 pt presented
surgical complications: 3 from Italy and 8 from Poland,
including four deaths. All the surgical complications were
successfully treated. However, wound infection in two pt
who died was not the cause of death (Table 2).
Comorbidity was present in 22.2% (four pt) in Italy and
85.7% (12 pt) in Poland. Cardiovascular disease was the
most common comorbidity in Poland, occurring in 78.5%
(11 pt) followed by COPD seen in 35.7% (five pt). In Italy,
5.5% of pt (1 patient) had a significant single morbidity–
cerebrovascular disease. Two pt (11%) presented multiple
morbidity: type II diabetes, mitral stenosis and pulmonary
heart disease, while the other patient had atrial fibrillation,
ischaemic heart disease and arterial hypertension. Both pt
with multiple morbidity in Italy had postoperative surgical
complications. All four pt who died were diagnosed with
comorbidities. One patient had just one comorbidity (car-
diovascular disease), but was operated in sepsis for
necrosis of strangulated caecum, ascending colon and
ileum in the inguinal herniation. The tumour was found
within the caecum. Four pt had multiple comorbidities
(three or more concomitant diseases): cardiorespiratory,
cerebrovascular, chronic kidney failure and diabetes, three
of them died for cardiorespiratory complications, one had
pulmonary oedema and required intensive care treatment.
Lymphadenectomy was performed in all pt. The number
of lymph nodes harvested ranged between 0 (necrosis of
the mesentery made identification of lymph nodes impos-
sible) and 14 in Poland (average number of lymph nodes).
In Italy, the number of lymph nodes harvested ranged
between 20 and 27.
In Poland, stage 1 was diagnosed in 28.5% of the pt
(four pt), stage 2 in 42.8% of the pt (6 pt) and stage 3 in
28.5% of the pt (four pt). In Italy, stage 1 was diagnosed in
Table 1 Baseline characteristic of the patient
Poland Italy
pt n (%) 14 (43.75%) 18 (56.25%)
Age (mean) 76.85 75.2
Comorbidity
None 2 14
C. V disease 11 4 Bleeding
Pulmonary disease 5 0
Hypertension 4 1
Diabetes 1 1
Others 3 1
Two or more comorbidity 8 2
22.2% of the pt (four pt), stage 2 was not diagnosed, and
stage 3 was diagnosed in 77.7% of the pt (14 pt). Table 3
shows the relationship between stage of the colon cancer
and complications. Adenocarcinoma was the most common
histopathological type of cancer, seen in almost all pt, but
in one case, in Poland (undifferentiated carcinoma).
Discussion
To our knowledge, this is the first study on postoperative
complications after emergency right hemi-colectomy for
colon cancer in two different countries. This retrospective
database provided the opportunity to review the results of
the procedure over a short period of time and over two
different population samples.
After emergency right hemicolectomy for CRC, post-
operative mortality and morbidity rates were in total 12.5
and 28.1%, respectively. These results are in agreement
with reported postoperative mortality after right hemi-
colectomy 1.6–35% [19–25] and postoperative morbidity
ranging from 1.7 to 34% [19–21, 26–32]. The mortality
rate was higher in the past decade. In recent studies, it
ranges between 1.6 and 3.0% for the elective and emergent
procedures without the division between them [19–21].
Although the mortality rate in Poland appears high as
compared to Italy and the recent literature, the morbidity
rate was on a similar level in both Italy and Poland, in
comparison with other studies. The small number of cases
included in our study might be an explanation; however,
the higher mortality rate in Poland in comparison with Italy
could have been age related, even if the difference between
the ages was not statistically significant. The average age
of all pt who died in Poland was 84.2 years; meanwhile,
the average age of all the pt in Italy was 75.2 years.
According to Alves et al. [9] study, the risk of death
Table 2 Surgical complications
Poland Italy
Complications 8 (57.1%) 3 (16.6%)
pt n (%) 79.3 72.0
Age (mean) 4 0
Wound infection 1 1
Wound dehiscence 0 0
0 1
Anastomotic failure 0 1
Ileus 0 1
Intra-abdominal abscess 8 (57.1%) 3 (16.6%)
Cardiopulmonary 1 0
Death 4 0
123

doubles by decade in pt older than 50 years, even if the pt
older than 70 years were significantly associated with an
increased mortality rate.
Deteriorated general condition connected with age and
emergent intervention increases the risk of postoperative
morbidity and mortality [9, 33].
The average age of pt with morbidity in Italy was
72.0 years and 75.8 in Poland. The result differs from other
study [9]; age was not a risk factor for postoperative
morbidity in our study.
We found that gender was also not associated with a
higher mortality or morbidity rate. However, some authors
reported a correlation between gender and mortality
[34, 35].
In the English, Italian and Polish literature, there is a
lack of information related to the morbidity and mortality
in pt undergoing emergency right hemi-colectomy for
colon cancer.
Comorbidities, including cardiorespiratory [35, 36],
cerebrovascular diseases [9, 13], diabetes mellitus [36] and
prior radiotherapy [36], have been reported in several
studies as independent risk factors for postoperative mor-
tality. Age over 70 years, and emergent hemicolectomy for
cancer as well as the long duration of the operation and
faecal contamination of the peritoneal cavity, has been
associated with increased risk of postoperative morbidity
[9]. This remains with agreement with our statistical find-
ings: comorbidity was a statistically significant risk factor
p \0.033 in both groups.
In our study, cardiovascular disease was connected with
higher postoperative mortality. Cardiovascular disease was
present in 5.6% pt in Italy and 78.5% pt in Poland.
We found that the cause of emergency surgery in our
study could be an interesting risk factor in the outcomes.
Perforation with peritonitis had a notorious association in
the outcomes after right hemi-colectomy. The majority of
pt with perforation in Italy and in Poland had complica-
tions: 66.6 and 80%, respectively. A study by Debas and
Thompson [37] reported a significant difference in mor-
tality rate if there was general peritonitis and the anasto-
mosis was performed, compared with the uncomplicated
obstructed colon [38]. In our study, mortality rate after
perforation and diffuse peritonitis was significantly higher
than in others and reached 25% cases as compared to 10%
Table 3 Stage of the colon cancer and complications
Italy Poland
Morbidity Mortality Morbidity Mortality
Stage I 1 0 1 1
Stage II 0 0 2 1
Stage III 2 0 2 2
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Aging Clin Exp Res
[39]. Again, the difference might result from the small
sample population. No difference was seen in emergency
surgery caused by the obstruction or bleeding of the cancer
in our study.
We have also observed an association between a cancer
stage and complications (Table 3): the highest stage and the
highest incidence of serious complication. In our study,
statistically significant were: the number of metastatic
lymph nodes, T feature and stage of the cancer (p \ 0.004,
p \ 0.001, p \ 0.001, respectively). According to Simon
et al. [40] study, the group with higher cancer stage had
more complications. In the same study, the number of
lymph nodes removed was not associated with the out-
come, and the group with the higher average of lymph
nodes removed had less complications. But the group that
had a higher range of lymph nodes removed between 8 and
52 had more complications. In our study, the number of
lymph nodes harvested ranging between 0 and 14 did not
affect the complication rate.
Statistical analysis (logistic regression model) revealed
that the number of metastatic lymph nodes, complications
and number of concomitant diseases had statistically sig-
nificant influence on death occurrence in our cohort of pt.
In the last decade, the use of minimally invasive treat-
ments has become increasingly as an approach for cancer,
particularly for elder pt [41–45], but sufficient data to draw
definitive conclusions in surgical oncology are still not
available about the global safety and oncologic adequacy
of robotic or laparoscopic surgery for right colectomy
[46–48].
Conclusion
Our retrospective study showed that the mortality and
morbidity, 12.5 and 28.1%, respectively, were in a normal
range according to other studies. We observed that 25% of
pt presented perforation with diffuse peritonitis: 25% died,
25% had wound dehiscence, 12.5% had pulmonary
oedema, and 12.5% had an intra-abdominal abscess. We
believe that there is a positive relation between pt who
present perforation with diffuse peritonitis and worse out-
come after surgery, increasing the postoperative mortality
and morbidity.
We also notice that 28.5% of the pt in Poland presented
stage 3 and 50% died; however, in Italy 14 pt presented stage 3
and no death was registered. We also observed that particu-
larly lethal combination is older age, perforation with peri-
tonitis and advanced stage of the cancer.
Finally, this retrospective study suggested that the
number of metastatic lymph nodes, complications and
number of concomitant diseases had statistically significant
influence on death occurrence in our cohort of pt, and poor
Aging Clin Exp Res
general condition is an important risk factor for morbidity
and mortality.
Acknowledgements The authors thank the Medical University of
Wrocław and the University of Perugia for the technical assistance.
Compliance with ethical standards
Conflict of interest All authors listed have contributed sufficiently to
the project to be included as authors, and to the best of our knowl-
edge, no conflict of interest, financial or other exists.
Funding The authors declare that they have received no funding for
the study.
Human and animal rights All procedures performed in studies
involving human participants were in accordance with the ethical
standards of the institutional and/or national research committee and
with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards. This article does not contain any studies
with animals performed by any of the authors.
Informed consent Informed consent to the radiological procedure
and to the processing of own personal data was obtained from each
individual study participant. In accordance with Italian Drug Agency
(AIFA) guidelines, observational studies using retrospective data or
materials do not require formal approval by the local ethics
committee.
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