SRS70 - Evaluating quality of colorectal cancer surgery across elective and emergency health systems: a secondary analysis of prospective cohort studies in 95 countries

Background Colorectal cancer is the world’s third most common malignancy and second leading cause of cancer death, yet 30% of patients still present as a surgical emergency. We aimed to determine whether surgical quality differs between potentially curative emergency and elective colorectal resections. Methods This pre-planned secondary analysis included patients undergoing curative-intent colorectal cancer surgery from three global prospective cohort studies (GlobalSurg-3, n = 5506; CovidSurg-Cancer, n = 6719; APOLLO, n = 876). Surgical quality was measured by margin-positive resection. Hierarchical multilevel logistic regression adjusted for patient-, disease- and health-system factors. Bootstrap simulations assessed modification by country income, cancer stage, and tumour site. Results Among 13 101 patients from 95 countries, 678 (5.4%) had margin-positive resections, with higher rates in emergency versus elective surgery (13.7 versus 4.5%, P < 0.0001). Emergency surgery independently increased odds of margin positivity (adjusted OR 2.45, 95% c.i. 1.86–3.22), consistent across all income groups. Bootstrap-derived absolute risk differences were greatest in stage III–IV rectal cancer: 12.6% (95% c.i. 10.2–15.7) in high-income countries, 19.0% (95% c.i. 13.6–23.9) in upper-middle, and 14.1% (95% c.i. 10.9–16.5) in lower-middle/low-income countries. Hospital- and country-level factors explained 76% of observed variation versus 23% at the patient level. Conclusions Emergency surgery conferred a two- to three-fold higher risk of margin positivity globally, independent of resources. These findings challenge the assumption that poor outcomes are solely due to advanced disease and highlight the urgent need for enhanced resectability assessment, specialist availability, and bridge-to-surgery pathways.