Advances in biomedical sciences over the past century have led to a steady increase in life expectancy, particularly in developed countries (1). In Italy and other Western countries, the proportion of elderly individuals has increased as birth rates decline, resulting in a steady rise in average age (2). This demographic shift has been accompanied by a growing demand for both social and healthcare services, necessitating their systematic enhancement and expansion (3). In this context, octogenarians now represent a substantial proportion of the general population and frequently require hospital admission and intensive care support (4, 5). Elderly patients are typically more frail and often suffer from multiple comorbidities, which may limit the feasibility of appropriate medical or surgical treatments (6). Accordingly, such studies have identified age as a negative prognostic factor, contributing to increased rates of postoperative morbidity and mortality (7). To mitigate the adverse impact of age, a comprehensive clinical and preoperative assessment is crucial. In the surgical field this challenge applies to both elective and emergency procedures, however, emergency settings often allow less time for thorough preoperative evaluation and optimization (8, 9). Furthermore, emergency surgery is consistently associated with higher morbidity and mortality rates compared to elective procedures, ranging from 33% to 64% and 20% to 34%, respectively (10). Thus, geriatric surgery, especially in emergency scenarios, represents a highly relevant and pressing issue in modern medicine. Many colonic emergencies, including colorectal cancer, diverticulitis, and colonic ischemia, are age-related conditions with a high prevalence among octogenarians (11, 12). In these situations, emergency surgeons are often required to decide between a palliative ostomy and a more complex procedure such as a visceral resection, whenever feasible. Emergency colorectal resections in elderly patients are well known to carry a significant risk of postoperative complications, with in-hospital mortality rates ranging from 15.6% to 37.8% (13, 14). Therefore, this scenario warrants further investigation to contribute to better predicting clinical outcomes in this patient population, and consequently, to improve their clinical outcomes. The primary aim of our study is to identify predictors of short-term mortality in octogenarians undergoing emergency colorectal resections. Additionally, we conducted a systematic review to evaluate the outcome of emergency colorectal resection in octogenarians highlighting key factors essential for appropriate patient selection.

Colorectal resections account for 7% of all emergency surgeries performed annually at Our Department, and in literature it is reported that 23.5% of colorectal cancer surgeries are performed in emergency settings (22). A high percentage of these interventions involved octogenarian patients (39%), a group with well-documented susceptibility to postoperative complications, which further contribute to the increased morbidity and mortality inherently associated with emergency surgical procedures (23). This disparity is primarily attributable to life-threatening nature of the underlying conditions, the frequent occurrence of physiologic derangements at presentation, and the need to operate under time pressure, frequently during night shifts or in suboptimal clinical settings (8). The main goal of surgeons in this scenario is to offer the most appropriate treatment with clinical benefit and the improvement of the residual quality of life. In selected patients, less invasive procedures such as stoma formation or endoscopic stents placement may be considered as safer alternatives to definitive resection, avoiding the risks associated with extensive surgical procedures (24). A comprehensive preoperative risk assessment is essential in case of high risk patients, thus, it is interesting to know how outcome prediction in this patient population could be improved and, more importantly, how their perioperative management could be optimized. The aim of this study was to identify short-term mortality predictors in elderly patients undergoing colorectal resections in emergency scenarios, enhancing surgical decision-making and optimizing patient management. Moreover, to our knowledge, this is the first systematic literature review specifically addressing outcomes and predictive factors in patients aged 80 years or over undergoing emergency colorectal resections.

Among octogenarians, our data showed an in-hospital mortality rate of 24%, which is significantly higher than in the younger group (8%). Our findings are consistent with those from previously published studies. A total of 12 studies were included in our systematic literature review, reporting in-hospital mortality rates among octogenarians ranging from 7% to 41% (13, 14). Higher mortality rate among octogenarians may be attributed in part to the frequent presence of atypical symptoms, such as generalized weakness, confusion, or mild abdominal discomfort, rather than the classic signs of acute surgical conditions, which can complicate clinical assessment and mask serious conditions, leading to delayed diagnosis (25).

Additionally, as confirmed in our analysis, octogenarians typically exhibited higher values of preoperative classical frailty markers such as ASA, ECOG, CCI, and P-POSSUM (26). However these variables do not reach statistical significance as prognostic factors in our study. This may be explained by an accurate preoperative selection with the promotion of non operative management and palliative care for the more severely ill patients.

By analyzing the cause of admission in our cohort we observed that octogenarians show higher incidence of obstruction (43%) and malignancy (56%). These findings align with existing literature, where colonic obstruction was the most frequently reported surgical indication in 5 of the 12 studies included in our systematic review (range: 33%–72%) and is commonly associated with cancer, which was identified in a substantial proportion of patients among those studies that explicitly reported malignancy rates (range: 9%–100%).

The high prevalence of emergency presentations of malignancy (56%) in our octogenarian group further highlights the importance of early detection and timely diagnosis of colorectal cancer. In this context, recent studies have investigated the integration of deep learning algorithms into clinical practice for the classification and diagnosis of CRC histopathology images, showing promising potential to enhance both the accuracy and efficiency of CRC detection (27, 28).

In contrast, the younger cohort shows a predominance of colonic perforations (52%) primarily related to acute diverticulitis (40%). This trend reflects the results reported by other authors (29, 30) in which perforated acute diverticulitis was significantly higher in young patients. Among octogenarians in our cohort, acute diverticulitis was identified in 28 patients (34%), a finding that is consistent with the results of our systematic review (31). In the elderly, as confirmed in our analysis, lower gastrointestinal bleeding was observed more frequently. Aging, as known, is associated with several changes in the gastrointestinal tract, including decreased mucosal perfusion, diminished regenerative capacity, and increased susceptibility to ischemia (32). Moreover, typically elderly present with higher rates of renal impairment and more frequent use of antithrombotic drugs (OR: 4.42, 95% CI: 1.03–13.16; p = 0.01). These factors make these patients particularly susceptible to bleeding complications, especially in the perioperative setting (33).

Wound infections—among the most common complications following colorectal surgery and a significant source of pain and morbidity for patients with a negative impact in terms of morbidity, LOS, economic impact, readmission and sepsis (34)—have been reported in the literature with an incidence of approximately 12% (35). In our cohort, surgical site infections (SSIs) were observed in 4 patients (5%) in the octogenarian group and in 8 patients (6%) overall, as detailed in Supplementary Material S3. This relatively low rate of SSIs is likely influenced by the limited sample size of our study and may also be partially explained by the frequent use of negative pressure wound therapy in this patient population. Additionally, although this parameter was not assessed in our study, recent research in this field has identified a correlation between reduced levels of butyrylcholinesterase (BChE)—a non-specific cholinesterase enzyme predominantly found in the liver and other tissues, and typically associated with systemic inflammation—on postoperative days 1 and 3, and an increased risk of surgical site infections (SSIs) (36).

Interestingly, in our study 19 octogenarians (23%) underwent laparoscopic surgery, a markedly higher rate compared to what is reported in the literature, where a higher percentage of emergency procedures in this population are typically performed via an open approach (37, 38). This finding underscores that, when appropriately applied in carefully selected patients, laparoscopic surgery does not compromise surgical outcomes in emergency settings. Nonetheless, in these patients an open approach is often preferred because of the increased anesthetic risk associated with their deteriorated clinical condition.

Reoperation is sometimes required to manage surgical complications or in the context of an open abdomen, where a second-look procedure is already planned.

In our series, major complications occurred in 18 patients (22%) among octogenarians, and only one of them required reoperation for evisceration, which is notably lower than the rates reported in previous studies (range: 6%–19%) (39, 40). These findings may be partially explained by the high number of stomas performed, a factor known to reduce the risk of postoperative complications, including anastomotic leakage. Additionally, management by a dedicated acute care surgery team, as in Our Institution, where surgeons are formally certified in acute care surgery, has been independently associated with a lower overall rate of postoperative complications compared to care provided by general surgeons alone (41). However, this population remains at increased risk of morbidity, therefore, treatment strategies should be individually tailored based on a comprehensive evaluation of the patient's clinical condition.

In our multivariate analysis, hyperlactatemia (>2 mmol/L) resulted as an independent predictor of short-term mortality in octogenarians. Mathijis et al. (31) first described this correlation: in their analysis hyperlactatemia (OR: 0.03; 95% CI: 1.00–1.72) and hypercreatininemia (OR: 1.00; 95% CI: 1.00–1.01) emerged as independent predictors of early postoperative mortality following emergency colorectal surgery in octogenarians. Notably, high lactate levels reflect tissue hypoperfusion and increased anaerobic metabolism, accounting for its association with severe clinical conditions such as hemorrhage, sepsis, ischemia or multi-organ failure (42, 43). Nevertheless, lactate levels are not routinely evaluated in every emergency department. Therefore, it is fundamental to emphasize their important role in the emergency setting, particularly in frail patients. Our analysis showed that hypercreatininemia was significantly associated with mortality in the univariate analysis, but did not remain significant when adjusted for other variables. This result could be explained by the small sample of impaired renal function in our cohorts among non-survivors and survivors (10% vs. 21%). Nonetheless, the association at univariate analysis confirms the pivotal role of this biomarker as a predictor (31, 44).

Preoperative comorbidity assessment, as measured by the ASA score, has also been previously described as a short-term prognostic factor in this population. In a study by Leong et al., 55% of patients aged ≥80 years undergoing emergency colorectal surgery had an ASA score ≥3, which significantly increased their risk of short-term mortality (45). Similarly, Modini et al. identified a high ASA grade as a significant risk factor in older patients (46), while another study further associated advanced tumor stage, palliative surgery, ASA score ≥4, and a CCI >17 with poorer outcomes (41). In our study, many patients, regardless of age group, were classified as ASA score ≥3 and this value was highly prevalent (90%) among non-survivors octogenarians, reaching significance only at univariate. In emergency scenarios most patients typically present with acute pathological conditions that, irrespective of baseline health status, justify classification as having a severe systemic disease with functional limitations. As such, the ASA score in this setting may be more indicative of the acute surgical indication rather than underlying chronic comorbidities, thereby limiting its discriminatory value across age groups.

The main limitation of this study is its retrospective, single-centre design, although data were retrieved from a prospectively maintained database. A larger patient cohort and longer follow-up period would also be beneficial to assess short- and long-term outcomes. This review is limited by the inclusion of only English-language studies. Moreover, all included studies were retrospective in nature, which may introduce inherent biases.

Nevertheless, this study provides important insights to improve the management of a population increasingly encountered in contemporary hospital settings. Reviewing comparable studies enables assessment of clinical outcomes and highlights the tools available to the emergency surgeon to optimize them.

Elderly often compels surgeons to make life-saving decisions in complex situations, where a clear clinical assessment is not always feasible. Nevertheless clinical evaluation remains fundamental in determining the appropriate therapeutic strategy, but a comprehensive patient assessment can be particularly helpful in borderline situations. As previously reported, ASA score, hypercreatininemia, and elevated lactate levels are among the most consistently described predictors of mortality in the literature. These factors must be carefully evaluated when treating elderly patients who present with limited disease and maintain an otherwise acceptable clinical status. In certain scenarios these predicting factors suggest a markedly increased short-term mortality risk, supporting less invasive procedures when feasible.

This study highlights the elevated risk of short-term mortality among octogenarian patients undergoing emergency colorectal resections. Adequate preoperative assessment is essential to ensure the safety of these procedures, and early identification of prognostic factors, such as serum lactate levels, can enhance patient selection and optimize perioperative management.

The presence of a specific acute care surgery department has led to an awareness of these situations, finally improving clinical outcomes.