ORIGINAL CONTRIBUTION
Emergency First Presentation of Colorectal
Cancer Predicts Significantly Poorer Outcomes:
A Review of 356 Consecutive Irish Patients
Gary Bass, M.B., B.Ch., B.A.O., M.Sc.1 & Cathy Fleming, M.Sc.2
John Conneely, B.Sc., M.B.A., M.R.C.S.I.1 & Zenia Martin, M.D., M.R.C.S.I.1
Kenneth Mealy, M.D., F.R.C.S.I.1
1 Department of Surgery, Wexford General Hospital, Wexford, Ireland
2 Clinical Trials Resource Unit, St. Luke’s Hospital, Dublin, Ireland
PURPOSE: Colorectal cancer commonly presents first as
an emergency and is likely to be complicated by bowel
obstruction/perforation requiring more difficult
procedures, with poorer outcomes. Analysis of all of
the procedures performed on patients diagnosed in
Wexford General Hospital, Ireland, during the period
2000 to 2006 was carried out to validate this hypothesis in
our western European population.
METHODS: Retrospective analysis of a prospectively
maintained database of patient demographics,
diagnosis, procedures, and mode of presentation (elective,
emergency) was undertaken.
RESULTS: A total of 356 patients with colorectal cancer
underwent 498 procedures during the years 2000 to 2006.
Eighty-four emergency endoscopies and 100 emergency
bowel resections were performed. Obstructive lesions
were more likely to require emergency resection
(P G 0.001). Median survival time for patients treated
electively was 82 months vs. 59 months for patients
treated on an emergency basis.
CONCLUSIONS: Of all colonic resections, 34 percent were
carried out as emergencies and were significantly more
likely to be complicated by obstruction or perforation
(P G 0.001). Emergency resections were associated with a
significantly poorer perioperative mortality and five-year
survival rate (P G 0.001). Forty-one percent of colorectal
Presented at the XXXIInd Sir Peter Freyer Lecture and Surgical
Symposium, September 9 to 10, 2007, Galway, Ireland.
Address of correspondence: Gary Bass, M.B., B.Ch., B.A.O., M.Sc.,
Department of Surgery, Wexford General Hospital, Wexford, Ireland.
Email: garbass@rcsi.ie
Dis Colon Rectum 2009; 52: 678Y684
DOI: 10.1007/DCR.0b013e3181a1d8c9
BThe ASCRS 2009
678
Copyright @ The ASCRS 2009. Unauthorized reproduction of this article is prohibited.
cancers diagnosed at endoscopy were first seen
emergently. These data raise concerns regarding public
awareness of colorectal cancer and resource allocation
and reemphasize the need for a national colorectal
screening program.
KEY WORDS: Colorectal neoplasms; Survival analysis;
Ireland; Surgical procedures; Elective; Emergency.
ancers of the colon and rectum remain the second
C most common malignancy among both males and
females, with an age-adjusted incidence in the Irish
population of 49.8/100,000, which is greater than in the
European Union or the United States.1 Ireland’s overall an-
nual mortality rate for colorectal cancer is 16.6/100,000,
1.5 times the U.S. rate.1
The initial diagnosis of colorectal cancer is commonly
made following admission in the emergency department
(ED) for the management of symptomatic disease. Few
data are available for our western European population (a
health care model different from that in which previous
studies were undertaken) regarding the incidence and out-
comes of patients who initially present with colorectal can-
cer as an emergency.
In the United States, retrospectively gathered admis-
sion data from the Connecticut Tumor Registry revealed
that 20 percent of the 11,023 patients diagnosed with co-
lorectal cancer between 1992 and 1996 were first admitted
to the hospital in the ED.2 Within this cohort, inpatient
admission in an ED was significantly associated with older
age and was a significant risk factor for more advanced
stage at diagnosis. A similar study from the United
Kingdom reported that 27 percent of their patients first
presented at the ED.3
In a smaller retrospective analysis of 102 patients di-
agnosed with colorectal cancer over a 2-year period in an
DISEASES OF THE COLON & RECTUM VOLUME 52: 4 (2009)
Diseases of the Colon & Rectum Volume 52: 4 (2009)
Irish catchment area, 41 percent of patients initially pres-
ented to an ED, with the remainder attending the out-
patient department following referral by their general
practitioner.4 This percentage is substantially higher than
that reported in other populations,2,3 and thus we wanted
to determine whether our data, a larger cohort from a
similar population, were comparable.
Using an extensive, single-institution cancer database,
we performed a comprehensive retrospective review of a
prospectively maintained dataset to examine the influence
of mode of initial presentation primarily on outcome fol-
lowing tumor resection (perioperatively and at 5 years),
and then on tumor location, colonic obstruction or per-
foration, histopathologic characteristics of the tumor, and
operative management.
PATIENTS AND METHODS
Patients, Mode of Presentation, and Interventions
From January 2000 to December 2006, 356 consecutive
patients underwent 498 procedures leading to a diagno-
sis of colorectal cancer at Wexford General Hospital, a
283-bed acute care hospital serving a predominantly rural
catchment area of 131,615 people (Fig. 1). All of the pa-
tients were identified from a prospectively accrued colo-
rectal cancer database containing demographic, clinical,
operative, and pathologic data. All 6 consultant surgeons
operating at the hospital during the study period were in-
cluded; 2 surgeons accounted for 79 percent of the pro-
cedures performed. All of the procedures were codified at
the time of entry into the database as either elective or
emergency. These procedures were identified as either di-
agnostic (colonoscopy, sigmoidoscopy, or examination un-
der anesthesia) or surgical resection (right and extended
FIGURE 1. Time from first (diagnostic) elective endoscopy to
elective surgical resection. Vertical bar represents the median time
(15 days) from endoscopy to resection.
Copyright @ The ASCRS 2009. Unauthorized reproduction of this article is prohibited.
679
right hemicolectomy, left hemicolectomy, subtotal colec-
tomy, anterior/abdominoperineal resection). Sixteen mis-
cellaneous follow-up procedures, such as the reversal of
Hartmann’s procedure or closure of other diverting en-
terostomy, were excluded from the analysis. Survival was
calculated from the date of colonic resection until the
date of death from any cause or the last recorded clini-
cal interaction.
Histopathology
Final histopathology reports confirmed the presence of a
primary colorectal adenocarcinoma in each of the surgical
specimens included in this study. The anatomic location of
the tumor and the presence or absence of bowel obstruc-
tion or perforation was extracted from the database. Pri-
mary tumor size was recorded as the largest diameter axis
through the sectioned specimen. Histologic grade was cate-
gorized into two groups for analysis: poor/undifferentiated
or moderate/well differentiated. A margin-negative
(R0) resection was determined as the absence of micro-
scopic disease at the specimen resection margins. Total
lymph node yield (the number of histologically positive
metastatic lymph nodes) and the presence of extramural
vascular invasion within each surgical specimen were
recorded. Cancer staging was based on pathologic findings
in the sixth edition of the American Joint Committee on
Cancer guidelines for colon and rectal cancer.5
Statistical Analyses
Statistical analyses were performed with SPSS version
15.0 for Windows (SPSS, Chicago, IL). Continuous vari-
ables were expressed as median T standard deviation or
mean T standard error of the mean and were compared
using a 2-sample t-test. Categorical variables were com-
pared using a # 2 test, with Fisher’s exact test used where
appropriate. Survival probabilities for clinical, pathologic,
and treatment variables were estimated using the Kaplan-
Meier method6 and compared using a log-rank test. The
effect of type of first presentation on the size and stage
of the tumor, the presence of positive lymph nodes, and
extramural vascular invasion on survival were examined
using logistic regression, and optimal cutoffs were deter-
mined using the maximal # 2 method. Significant univar-
iate factors were included in a Cox proportional hazards
regression model to establish independent predictors of
survival. Further substratification analysis was performed
using the Mantel-Haenszel test.7 P values of less than 0.05
were considered statistically significant.
RESULTS
Demographics
The Wexford General Hospital colorectal database docu-
ments 498 procedures on 356 patients with a diagnosis of
colorectal carcinoma (Table 1). The median age of these
680 BASS ET AL: EMERGENCY VS. ELECTIVE BOWEL RESECTIONS FOR COLORECTAL CANCER

TABLE 1. Patient and procedure characteristics

Characteristics Elective Emergency Total
Total patients 356
Median age, yr (range) 69 72 71 (34Y95)
Sex 2:1 (M 9 F)
Male (% patients, by presentation) 133 (63.6) 81 (57) 217 (67)*
Female (% patients, by presentation) 76 (36.4) 61 (43) 139 (33)*
Endoscopies 120 (58%) 84 (42%) 204
All operations 187 (67%) 91 (33%) 278
Right hemicolectomy 55 (58.5%) 39 (41.5%) 94
Left hemicolectomy 48 (58.5%) 34 (41.5%) 82
Subtotal colectomy 2 (22.2%) 7 (77.8%) 9
Anterior/Abdominoperineal resection 84 (90.3%) 9 (9.7%) 93
*Procedures on three male and two female patients were not codified as either Elective or Emergency on data entry and thus treated as Missing data during analysis.

patients was 71 (range, 34Y95) years; the median age of
elective attendees was 69 (range, 34Y95) years, and the me-
dian age of emergency presentations was 72 (range, 37Y94)
years, however, this difference was not significant (P =
0.643). Of the total number of patients, 217 (67 percent)
were male and 107 (33 percent) were female; this 2:1 ratio
was unaffected by mode of presentation (P = 0.182).
Procedures Performed
During the study period, 204 diagnostic endoscopies were
performed when there was a clinical suspicion of colorectal
cancer. Of these, 120 (58 percent) were performed on
elective lists and 84 (42 percent) were performed on an
emergency basis. Operative management studied 110 of the
120 elective endoscopies (92 percent), with a median time
from diagnosis to surgical intervention of 15 T 3.8 days.
Surgeons performed 278 bowel resections for colo-
rectal cancer during the study period (Table 1). Of these,
187 (67 percent) were performed on elective lists and 91
(33 percent) were catalogued as emergency cases. The
median number of bowel resections performed per
annum was 68 T 12 (42 T 7.4 elective, 28 T 4.9
emergency). Resection of left colon and rectal tumors
(via left hemicolectomy, anterior resection, or abdomi-
noperineal resection) accounted for 187 (67 percent)
surgical interventions. Transverse and right-sided tumors
accounted for the remainder of cases (right and extended
right hemicolectomy = 55 elective, 39 emergency; subtotal
colectomy = 2 elective, 7 emergency cases). Anterior and
abdominoperineal resections were significantly more likely
to be carried out in the elective setting (P G 0.001), whereas
emergency bowel resections almost entirely comprised
39 right (43 percent) and 32 left hemicolectomies (35
percent; P = NS).
The indication for bowel resection was analyzed by mode
of presentation. Bowel resection uncomplicated by obs-
truction or perforation was significantly more likely to take
place on an elective operative list (170 vs. 32; P G 0.001).
Colorectal cancers complicated by bowel obstruction (55
emergency vs. 12 elective resections; P G 0.001) or perfora-
tion (8 emergency vs. 3 elective resections; P G 0.001) were
significantly more likely to require emergency resection.

TABLE 2. Tumor characteristics

Tumor stage
T1 7/196 (3.5%) 1/92 (1%) 8/288 (3%)
T2 45/196 (23%) 6/92 (6%) 51/288 (18%)
T3 118/196 (60%) 50/92 (54%) 168/288 (58%)
T4 26/196 (13%) 35/92 (38%) 61/288 (21%)
Histologic grade
Well/moderately well differentiated 185/196 (94%) 88/92 (96%)
Poorly/undifferentiated 11/196 (6%) 4/92 (4%)
Nodal status
Negative (N0) 120/195 (61%) 38/92 (41%)
Positive (N1) 53/195 (27%) 38/92 (41%)
Positive (N2) 22/195 (11%) 16/92 (17%)
Extramural lymphovascular invasion
Present 12/196 (6%) 4/92 (4%)
Absent 184/196 (93%) 88/92 (95%)
Resection margin status
Negative/total specimens (%) 202/204 (99) 84/93 (90)
Positive/total specimens (%) 2/204 (1) 9/93 (10)

Copyright @ The ASCRS 2009. Unauthorized reproduction of this article is prohibited.

Diseases of the Colon & Rectum Volume 52: 4 (2009)
Tumor Characteristics
Histologic examination was carried out on all of the re-
sected specimens. Ninety-four percent (185/196) of elective
specimens were graded ‘‘well or moderately differenti-
ated’’, and 6 percent (11) of specimens were graded
‘‘poorly or undifferentiated’’ (Table 2). Of all emergency
resection specimens, 95 percent (88/92) were graded ‘‘well
or moderately differentiated’’ and 5 percent (4/92) were
graded ‘‘poorly or undifferentiated’’. There was no sig-
nificant difference in cellular differentiation between elec-
tive and emergency resection specimens (P = 0.653).
The incidence of T1 or T2 stage tumors in electively
resected specimens was 27 percent (52/196), compared
with 8 percent (7/92) in emergency resections. T3 and
T4 tumors accounted for 73 percent (144/196) in elective
resection cases and 92 percent (85/92) in emergency re-
section cases; the proportion of later stage tumors was sig-
nificantly greater in emergency resection compared with
those performed electively (P = 0.001).
Macroscopic and microscopic R0 resection was
achieved in 96 percent of all cases (286/297). Only 1 percent
(2/202) of specimens from elective resections showed evi-
dence of tumor at the surgical margin compared with
10 percent (9/93) of emergency resections (P = 0.001).
In patients who underwent elective resection, 39 per-
cent (75/195) of lymph nodes were involved by tumor (N1
or N2), compared with 59 percent (54/92) of nodes har-
vested from emergency patients (P = 0.002). Extramural
lymphovascular invasion (ELVI) was noted in 6 percent
(12/196) of elective specimens and 20 percent (19/92) of
emergency specimens, and this difference was found to be
significant (P G 0.001) when the Mantel-Haenszel test to
control for tumor stage was applied.7
FIGURE 2. Annual number of patients requiring elective or
emergency large bowel resection for colorectal carcinoma per year
during the study period January 2000 to December 2006.
Copyright @ The ASCRS 2009. Unauthorized reproduction of this article is prohibited.
681
Survival Analysis
Survival analysis by the Kaplan-Meier method (Fig. 2)
demonstrated a significant survival advantage for patients
treated electively compared with those treated emergently
(P G 0.001). The median survival time for patients treated
electively was 82 months in comparison to 59 months for
those treated on an emergency basis. Twelve patients died
in the immediate postoperative period; 92 percent (11/12)
following emergency resection, and 8 percent (1/12) after
an elective operation.
A multivariate Cox regression was performed with the
covariates of type of procedure, presence of complication
(obstruction or perforation), margin status, T stage, N status,
histologic grade, and presence of ELVI (Table 3). Three of
these variables were found to be independent predictors of
outcome. Subtotal colectomy was associated with a poorer
outcome (hazard ratio [HR] = 6.239; 95 percent confidence
interval [CI] = 1.645Y23.664; P = 0.007). Both uncompli-
cated carcinoma (HR = 0.234; 95 percent CI =
0.082Y0.671; P = 0.007) and the absence of ELVI (HR =
0.370; 95 percent CI = 0.168Y0.815; P = 0.014) were
independently associated with better outcomes.
DISCUSSION
In our experience, patients diagnosed with colorectal cancer
who first present to the ED represent a large proportion of all
patients undergoing colon resection for primary malignancy.
Indeed, 33 percent of patients in our study first presented at
the ED rather than by referral to an outpatient clinic.
This figure compares to 20 percent in a U.S. popula-
tion,2 27 percent in the United Kingdom,3 and 41 percent
in a smaller study in a rural, western Ireland population.4
The American data are surprisingly low when it is con-
sidered that admission data, not operations, were recorded.
Inpatient admissions data are inadequate surrogates for
rates of surgical intervention and may include patients with
disseminated disease for whom operative management was
not indicated.2Y4 Our data, however, represent all cases of
disease amenable to curative resection in our center during
the study period.
Manning et al.4 argued that the large proportion of
emergency first presentation in colorectal cancer in their
rural Irish population can be explained by an ignorance of
the symptoms associated with the disease. They report that
just 27 percent of 350 patients surveyed at an outpatient
clinic could name a symptom associated with ‘‘bowel can-
cer,’’ compared with 53 percent for ‘‘lung cancer’’ and
72 percent for ‘‘breast cancer.’’ It is likely, given the small
population of the country (4.3 million) and nationwide
public information campaigns, that similar rates of symp-
tom awareness would be found in our population.
The sex ratio (2:1 male to female) and age distribution
(median age, 71 years) of the 356 patients in our series are
similar to those seen in other studies in Ireland,4 the United
682
TABLE 3. Multivariate analysis of predictors* of survival after colorectal resection
Risk Factor
Uncomplicated colorectal carcinoma
Subtotal colectomy
No extramural lymphovascular invasion
*Cox proportional hazards regression model (included in multivariate analysis: type of procedure, pathology, T stage, N stage, histologic grade, margin status, and presence
of ELVI).
Kingdom,8Y12 the United States,13Y15 and elsewhere.16,17
Diggs et al.18 showed that two-thirds of patients discharged
following colorectal cancer resections were for those older
than 65 years, with the oldest age group (Q85 years)
undergoing more emergency colorectal cancer resections.
Rabeneck et al.19 reported a small majority of male patients
(53.5 percent), but again most patients were 50 years or
older. In our population, there was no significant difference
in median age at presentation (P = 0.643) or sex ratio (P =
0.182) when comparing elective and emergency groups;
however, perioperative mortality in our patients was
associated with increased age. The median age of patients
who died in the postoperative period was 79.5 years
(range, 65Y94 years; n = 12), compared with the median
age of 71 years across all groups; this difference was
statistically significant (P = 0.04).
On examination, our database did not contain a record
of subsequent bowel resection for colorectal carcinoma in
any patient who underwent primary resection of his or her
disease; however, this information is a poor surrogate for
incidence of recurrent disease in our population. Given the
nature of data collection in this study (retrospective
extraction and analysis of a prospectively entered database
of surgical interventions, based on the Lothian Surgical Audit
System), information on recurrence would only have been
codified in our database if a patient in the cohort had
undergone repeat colonic or rectal resection in our center.
The patterns of recurrence in patients resected with curative
intent in the elective and emergency settings is an interesting
clinical question which, although not answerable in the
present study, merits serious consideration and further work.
Of the diagnostic endoscopies carried out during the
study period, 42 percent were performed on an emer-
gency basis. Because of the finite nature of resources, both
in terms of equipment and personnel, there is a consid-
erable waiting list for access to elective colonoscopy at our
institution, and the volume of emergency cases seen in
our population further affects the length of this list. This
is the published experience of many correspondents, es-
pecially those who practice in the United Kingdom, and
emphasizes the need to establish a national endoscopic
screening program.4,9,12,18,20,21
The median time from diagnosis of colorectal car-
cinoma following an elective diagnostic endoscopy to sur-
gical intervention was 16 days (Fig. 1). The median time,
Copyright @ The ASCRS 2009. Unauthorized reproduction of this article is prohibited.
BASS ET AL: EMERGENCY VS. ELECTIVE BOWEL RESECTIONS FOR COLORECTAL CANCER
Hazard ratio 95% confidence interval P
0.234 0.082Y0.671 0.007
6.239 1.645Y23.664 0.007
0.370 0.168Y0.815 0.014
rather than the mean, is the appropriate statistical mea-
sure because the data were not normally distributed;
instead they broadly describe early intervention in the
majority of cases, with a small cohort of late operation in
patients undergoing cytoreductive neoadjuvant chemo-
therapy or radiotherapy at other specialist centers before
definitive operative management.
Anterior and abdominoperineal resections were sig-
nificantly more likely to be carried out in an elective set-
ting, whereas operations for right-sided and left-sided
tumors were performed both in the elective and emer-
gency settings (Table 1). Emergency bowel resection for
colorectal cancer was significantly more likely in our
study to be complicated by bowel obstruction (P G 0.001).
This finding may be influenced by the symptomatic na-
ture of a presentation of this type, increasing the likeli-
hood that a patient would seek urgent medical attention.9
Disease resected under emergency circumstances is also
more likely to be of greater bulk, higher histologic grade,
and exhibit ELVI. Alvarez et al.22 have ascribed symptom-
atic emergency presentation to obstruction and perfora-
tion. This association is not absolute because a number of
investigators have demonstrated no correlation in their
populations between the duration of symptoms before the
first presentation and pathologic staging.16,20,21 It is
intuitive that mechanically obstructing colorectal cancer
tends to present at a more advanced histologic stage when
the tumor (often an annular lesion) is of sufficient bulk
to prevent the passage of feces. Patients with obstructing
tumors have been found to have a lower probability of
survival than patients with nonobstructing lesions be-
cause there is higher risk of lymph node positivity, ELVI
(likely to be related to the high T stage, as demonstrated in
our data and elsewhere), and metastatic tumor recurrence
but not a higher local recurrence rate in such patients.
Perforation may occur within the friable tumor because of
necrosis or adjacent inflammatory changes or proximal to
an obstructing tumor because of increasing hydrostatic
pressure and distension obeying the law of Laplace. The
poorer outcome following perforation is thought to be the
result of the cumulative effect of fecal peritonitis and ma-
lignancy, along with the combination of preexisting co-
morbidity and a grossly disturbed pathophysiology.
Tumor size, tumor differentiation, surgical margin status,
extramural vascular invasion, and lymph node status are
Diseases of the Colon & Rectum Volume 52: 4 (2009)
among the clinicopathologic features that have been identi-
fied that predict survival following resection for colorectal
adenocarcinoma.23,24 Pathologic analysis by Burton et al.24
of 445 colonic tumor and rectal tumor specimens retrieved
during elective and emergency operations demonstrated that
T4, N2, and poorly differentiated tumors (themselves
indicators of poor outcome) were more likely to present first
in an emergency. Retrieval of an appropriate number of
lymph nodes is important in staging colorectal cancer.25 A
number of groups have demonstrated that the ratio of the
number of metastatic lymph nodes to the number of
examined lymph nodes (lymph node ratio, LNR) is an in-
dependent prognostic factor for overall survival, with a de-
creasing LNR correlating with a longer overall survival.25,26
Because the histopathology reports on the patients in our
series did not report the number of nodes examined, it was
not possible to perform the LNR calculation.
As may be expected, a significantly greater number of
higher grade tumors occurred in patients who presented
in an emergency (P = 0.001). These high-grade tumors
were more likely to be node positive (P G 0.001) and
demonstrate ELVI (P = 0.009), but they did not have a
greater frequency of positive resection margins (P = 0.08).
In several large studies from the United States and
the United Kingdom, poorer outcomes were identified in
patients with colorectal cancer who initially presented as
emergency cases. However, the mode of initial presenta-
tion and its effect on all-cause mortality have not been
characterized for the Irish population. In a large retro-
spective analysis of 3200 patients who underwent large
bowel resection in Scotland between 1991 and 1994, the
HR for crude overall 5-year survival was 1.68 for patients
who underwent emergency operations compared with
those who were operated on electively, whereas the HR
for cancer-specific 5-year survival was 1.90 for emergency
vs. elective presentation.27 It has been argued that
the negative impact of emergency procedures is confined
to the immediate postoperative period and probably cor-
relate with the acute medical pathology in these pa-
tients.14,17 Mortality in the perioperative period (n = 12)
was associated with emergency surgery for obstruction or
perforation. All 12 resections were performed for colo-
rectal carcinoma that was complicated: 50 percent (6/12)
of patients presented with large bowel obstruction, 25
percent (3/12) had perforated large bowel, and 25 percent
(3/12) had another unspecified complication, such as
bleeding or infection. However, our data demonstrate a
poorer patient survival at 5 years following emergency
resection in excess of the effect of greater perioperative
mortality associated with emergency surgery (Fig. 2). Sur-
vival analysis demonstrated poorer outcomes for emer-
gency operations compared with elective operations both
overall and after substratification of the data for T stage,
nodal status, and ELVI; the difference was significant in
each case (P G 0.001), with the exception of T1 disease, in
Copyright @ The ASCRS 2009. Unauthorized reproduction of this article is prohibited.
683
which no comparison could be made because no T1 tu-
mors were resected in the emergency group.
On multivariate analysis (Table 3), 3 variables were
found to be independent indicators of survival probabil-
ity: subtotal colectomy (poorer outcome), uncomplicated
carcinoma, and the absence of ELVI (both associated
with improved outcome). A similar study by Rabeneck
et al.19 found older age, site proximal to the rectum, co-
morbidities, and lack of primary care to be independently
associated, on multivariate analysis, with emergency
admission.
Diggs et al.18 found a significant association between
insurance status and emergency presentation. Although
the United States health care system is different from the
Irish system, this finding supports the idea that the ac-
cessibility of primary health care leads to a reduction in
emergency presentations. They also showed that patients
requiring emergency surgery had a mean predicted length
of stay that was 4 days longer than that of nonemergency
patients with an excess cost of US$19,073. It is calculated
that this placed an excess burden on the health care sys-
tem of 54,979 hospital days and more than $250 million
in hospital charges in 2002.18
We have demonstrated more advanced disease in pa-
tients who underwent emergency resection of their pri-
mary colorectal tumors in comparison with patients who
had elective surgery. These patients experienced sig-
nificantly poorer outcomes both perioperatively and at
five years compared with nonemergent counterparts.
Because many patients present without symptoms but
rather because of serendipitous ad hoc screening by their
primary care physician,3,9 it seems reasonable and cost-
effective18 to consider a national screening program for
colorectal carcinoma in our at-risk population.
ACKNOWLEDGMENTS
The authors thank Ms. Margaret Murphy, stoma care nurse
specialist, for assistance in collating the pathologic data herein,
and Mr. Ezzat Tadros, M.D., F.R.C.S.I., and the late Mr. John
Bosco O’Mahony, M.D., M.R.C.P., F.R.C.S.I., consultant sur-
geons, for access to the Wexford Colorectal Database.
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