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Risk factors for unplanned 31-day readmission after surgery for colorectal cancer patients: a meta-analysis

BMC Gastroenterology volume 25, Article number: 285 (2025) Cite this article

Abstract

Background

The high incidence of unplanned readmissions within 31 days after colorectal cancer surgery remains a significant challenge. However, the identified risk factors for these readmissions are inconsistent across the literature. This study aims to perform a comprehensive meta-analysis to estimate the incidence of unplanned readmissions and systematically identify the factors associated with this risk, providing robust evidence for targeted interventions to reduce readmission rates.

Methods

This study was conducted in accordance with the PRISMA guidelines. All study steps, including study selection, data extraction, and quality assessment, were independently performed by two authors, with any disagreements resolved through consultation with a third author. A comprehensive search for published studies was conducted across the following databases up to January 2025: VIP Journal Database, Wanfang Data, CNKI, SinoMed, PubMed, Embase, Web of Science, and the Cochrane Library. Statistical analyses were performed using RevMan 5.4 and Stata 17.0, with a p-value of less than 0.05 considered statistically significant.

Results

This meta-analysis identified several significant risk factors associated with unplanned readmission during this period (P < 0.05), including age (OR = 1.13), postoperative complications (OR = 1.87), tumor stage (TNM ≥ III) (OR = 2.01), tumor site in the rectum (OR = 1.64), stoma creation (OR = 1.70), Complicated diabetes (OR = 1.56), Charlson Comorbidity Index (CCI) (OR = 1.27), blood transfusion (BT) (OR = 1.24), Length of hospital stay (LOS) (OR = 1.65), and surgical approach (OR = 1.22). Notably, female (OR = 0.85) was identified as a protective factor against unplanned readmission.

Conclusion

The unplanned readmission rate within 31 days after colorectal cancer surgery was 11.73%. Current evidence suggests that age, postoperative complications, TNM ≥ III, tumor site in the rectum, stoma creation, complicated diabetes, Charlson Comorbidity Index (CCI), blood transfusion (BT), length of hospital stay (LOS), and surgical approach are significant risk factors for unplanned readmission. Conversely, female has been identified as a protective factor. To mitigate these risks and reduce readmission rates, healthcare professionals should implement targeted educational and clinical interventions.

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Introduction

Colorectal cancer (CRC) refers to a primary malignant tumor originating from the epithelium of the large intestine, encompassing both colon and rectal cancers [1]. It is one of the most common malignant tumors of the digestive system, with its development influenced by various factors such as genetic, physiological conditions, behavioral habits, lifestyle, and underlying diseases [2]. According to the latest GLOBOCAN data released by the International Agency for Research on Cancer (IARC), more than 1.9 million new cases of CRC were diagnosed worldwide in 2022, with over 900,000 deaths. This makes CRC the second most common cancer globally in terms of incidence and the third leading cause of cancer-related deaths [3, 4]. Historically, the incidence of CRC in China was relatively low compared to developed countries in Europe and North America [5]. However, in recent decades, with rapid economic development and significant changes in dietary patterns and lifestyle habits, the incidence and mortality rates of CRC have risen sharply. In 2022 alone, China reported 517,100 new cases and 240,000 deaths due to CRC, making it the second most common malignancy and placing a heavy burden on both families and society [6]. The prevention and treatment of CRC currently face significant challenges.

The management of CRC includes surgical resection, chemotherapy, radiotherapy, and neoadjuvant therapy. Among these, surgery remains the primary and preferred treatment for patients with CRC [7]. However, postoperative instability and susceptibility to various risk factors make these patients prone to developing a range of complications, such as postoperative intestinal obstruction, anastomotic leakage, bleeding, surgical site infections, and septic shock [8]. These complications can significantly increase the risk of unplanned readmission (UR) after discharge.

Unplanned readmission (UR) refers to the re-hospitalization of patients shortly after discharge for the same condition, typically due to factors such as inadequate discharge planning, disease-related complications, and insufficient medical or nursing care [9]. Studies have shown that the 31-day UR rate is particularly high in patients undergoing CRC surgery, with reported rates reaching as high as 20.5% [10]. Frequent UR not only jeopardizes patient health and quality of life but also places substantial burdens on families, healthcare systems, and society [11]. Furthermore, a study by Singh et al. found that patients experiencing UR within 31 days after CRC surgery have a significantly lower 3-year survival rate, underscoring the long-term impact of early readmission on patient outcomes [12].

Existing strategies to reduce postoperative readmissions primarily focus on improving postoperative care, early identification of complications, and optimizing discharge planning [13]. For example, some studies have implemented personalized care pathways to closely monitor high-risk patients after discharge, while others have explored the role of multidisciplinary care teams in reducing postoperative complications [14]. Despite these efforts, UR within 31 days post-surgery remains a significant issue. The gaps in current practices, particularly the inconsistency in identifying key risk factors, highlight the need for further research.

There are varying reports in the literature on factors associated with UR within 31 days postoperatively in CRC patients. Some studies have indicated that postoperative complications are the primary cause of UR [15, 16], while others have found that LOS is positively correlated with the incidence of UR [17, 18]. Additionally, several studies have suggested that preoperative comorbidities, tumor location, tumor stage, and surgical approach are important risk factors for UR within this period [19, 20]. However, there remains a lack of robust evidence regarding the effect of these potential risk factors. Therefore, further verification of these risk factors is essential. This study conducts a meta-analysis to evaluate the incidence and risk factors of UR within 31 days after CRC surgery, providing robust evidence for early identification of high-risk patients and the development of effective prevention strategies.

Methods

A meta-analysis was conducted following a predefined protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [21] (Supplementary Material 1). The search protocol was prospectively registered with PROSPERO (CRD42024499642). Institutional Review Board approval was waived as the study used only anonymized data from previously published literature.

Literature retrieval

Four major Chinese databases were searched: VIP Journal Database, Wanfang Data, CNKI, SinoMed. The search period covered from the inception of the databases to January 2025. The keywords used were"colorectal cancer, colon cancer, colorectal adenocarcinoma, colorectal tumor; readmission, rehospitalization, unplanned readmission, unplanned rehospitalization; influencing factors, risk factors, danger factors, high-risk factors, associated factors". Four major English databases were searched: Web of Science, PubMed, Cochrane Library, and Embase. The keywords included"Colorectal Neoplasms*, Colorectal Tumor*, Colorectal Cancer*, Colorectal Carcinoma*, Patient Readmission, Rehospitalizations, Unplanned Readmission, Thirty-Day Readmission, 30-Day Readmission, Hospital Readmissions; Risk Factors, Risk, Relative Risk, predictor*, predictive*, recurrence, protective factor". No language restrictions were applied. A combination of subject terms, keywords, and free words was used to search the databases and merge the search results. The search strategy is outlined in Supplementary Material 2.

Inclusion criteria and exclusion criteria

Inclusion criteria: (1) The study design was a case–control or cohort study; (2) The study population consisted of patients aged ≥ 18 years, diagnosed with CRC through endoscopy or pathology, and who underwent surgical treatment; (3) The study focused on the incidence of UR and associated risk factors within 31 days after CRC surgery; (4) Studies were required to provide multivariate analysis results, including odds ratios (OR) and 95% confidence intervals (CI) for readmission risk factors. (5) Only studies published from 2000 to the present were included, ensuring relevance to contemporary clinical practices.

Exclusion criteria: (1) Studies involving non-CRC patients or those that failed to clearly distinguish CRC from other types of cancer, as well as studies focusing on readmissions occurring more than 31 days postoperatively; (2) Case reports, reviews, commentaries, preprints, conference abstracts, unpublished studies, animal studies, and in vitro studies, as well as studies that did not provide complete data; (3) Duplicate studies; (4) Studies that did not explicitly report UR or only reported planned readmissions, as well as studies that did not analyze influencing factors or merely described readmission rates; (5) Studies with incomplete data or data that could not be extracted, as well as studies with low methodological quality (Newcastle–Ottawa Scale score < 4); (6) Studies published in languages other than English or Chinese.

Literature screening and data extraction

All included studies were imported into NoteExpress software. Two researchers (QN, LT) independently performed the literature search, screening, and data extraction. The consistency of the quality assessment was measured using the Kappa statistic (0.79), indicating substantial agreement. Any discrepancies between the two reviewers were first discussed. If a consensus could not be reached, a third independent reviewer (ZL) made the final decision. The extracted data included the first author, publication year, study region, study design, sample size, number of UR, number of non-UR, UR incidence, and associated risk factors.

Study risk of bias assessment

The Newcastle–Ottawa Scale (NOS) was used to assess the quality of the included studies [22]. This scale evaluates case–control and cohort studies based on three dimensions: the selection of the study population, the comparability between groups, and the assessment of exposure or outcomes. Study quality is classified into three levels: low quality (0–3 stars), moderate quality (4–6 stars), and high quality (7–9 stars) [23]. Each study was independently assessed by two reviewers (QN, LT), and any disagreements were resolved through discussion. If necessary, a third reviewer (ZL) was consulted for arbitration. The quality assessment results of the included studies are presented in the results section.

Statistical analysis

Statistical analysis will be conducted using RevMan 5.4 software, with the UR rate within 31 days post-CRC surgery as the effect size. The incidence rate will be calculated with a 95% CI. Risk factors will be expressed as OR with their corresponding 95% CI, provided that data from at least three studies are available for pooling. For factors reported in only one or two studies, a descriptive analysis will be conducted, summarizing their findings qualitatively without statistical pooling. Heterogeneity will be assessed using the I2 statistic: when I2 < 50% and P > 0.05, indicating low heterogeneity, a fixed-effect model will be applied; when I2 > 50% and P ≤ 0.05, indicating high heterogeneity, a random-effects model will be used [24]. For factors with high heterogeneity, subgroup analyses will be conducted to explore its sources. Sensitivity analyses will also be performed using a systematic leave-one-out method to evaluate the stability of the results.

Egger's test (α = 0.05) will be conducted using Stata 17.0 software to assess publication bias in studies with at least 10 articles. A P-value greater than 0.05 suggests a low likelihood of publication bias. If bias is detected, the trim-and-fill method will be applied to evaluate the stability of the results after bias correction.

Results

Literature search results

A total of 801 studies were initially identified, including 702 English articles and 99 Chinese articles. After removing duplicates, 256 studies remained. Screening the titles and abstracts yielded 74 articles, from which those not meeting the inclusion criteria or with unusable data were excluded. Ultimately, 15 studies (12 in English, 3 in Chinese) were included. The literature screening process and results are shown in Fig. 1.

Fig. 1
figure 1

Flow chart of the literature screening process

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Characteristics and risk of bias assessment of included studies

A total of 15 studies were included, comprising 13 cohort studies and 2 case–control studies, with a combined sample size of 693,917 patients. Among them, 63,906 CRC patients experienced UR within 31 days post-surgery, involving 26 potential risk factors. The overall quality of the included studies ranged from moderate to high. According to the NOS assessment, 11 studies (73%) were rated as high quality (7–9 stars), while 4 studies (27%) were rated as moderate quality (4–6 stars). The basic characteristics and quality assessment of the included studies are summarized in Table 1, with detailed quality evaluation results provided in Supplementary Material 3.

Table 1 Basic characteristics and methodological quality assessment of included studies [10], [16], [18], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36]
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Meta-analysis results

The incidence of UR within 31 days after CRC surgery

A total of 15 studies examined the incidence of UR within 31 days following CRC surgery. Meta-analysis revealed substantial heterogeneity across the included studies (I2 = 100%, P < 0.001). Using a random-effects model for the pooled analysis, the overall UR rate was estimated at 11.73% (95% CI, 9.46%–14.00%). The reported UR rates varied widely, with the highest incidence reaching 20.50% (95% CI, 20.11%–20.89%) and the lowest at 5.13% (95% CI, 3.96%–6.29%) (Fig. 2).

Fig. 2
figure 2

Forest plot of the UR incidence within 31 days after CRC surgery

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Risk factors for UR within 31 days after CRC surgery

This meta-analysis identified several factors associated with 31-day UR after CRC surgery. Significant risk factors included age (OR = 1.13, 95% CI [1.03, 1.25]), postoperative complications (OR = 1.87, 95% CI [1.32, 2.65]), TNM ≥ III (OR = 2.01, 95% CI [1.73, 2.33]), tumor site: rectum (OR = 1.64, 95% CI [1.19, 2.26]), stoma creation (OR = 1.70, 95% CI [1.06, 2.71]), CCI (OR = 1.27, 95% CI [1.21, 1.34]), BT (OR = 1.24, 95% CI [1.09, 1.41]), LOS (OR = 1.65, 95% CI [1.58, 1.72]), and surgical approach (OR = 1.22, 95% CI [1.01, 1.47]). Female was identified as a protective factor (OR = 0.85, 95% CI [0.83, 0.87]), while disseminated tumor showed no significant association with UR risk (OR = 1.05, 95% CI [0.77, 1.45]) (Table 2). The forest plot is shown in Supplementary Material 4.

Table 2 Heterogeneity test and meta-analysis results of risk factors for UR within 31 days after CRC surgery
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Heterogeneity analysis revealed substantial variability (I2 > 70%) in age, postoperative complications, tumor site: rectum, stoma creation, complicated diabetes, CCI, BT, and surgical approach, necessitating the use of a random-effects model. For TNM ≥ III (I2 = 10%, P = 0.33), length of stay (I2 = 7%, P = 0.34), and female (I2 = 26%, P = 0.26), a fixed-effects model was applied, indicating more stable results (Table 2).

Sensitivity analysis

Sensitivity analysis for UR incidence

A leave-one-out sensitivity analysis was conducted for studies with I2 > 50% and at least two included studies. The 31-day UR rate for CRC patients ranged from 11.51% to 12.23%, aligning closely with the overall UR rate of 11.73%. This indicates that the meta-analysis results are stable.

Sensitivity analysis UR risk factors

A sensitivity analysis was conducted for highly heterogeneous risk factors associated with UR within 31 days after CRC surgery. The results showed a significant reduction in heterogeneity (I2 < 50%) for age, postoperative complications, tumor site: rectum, stoma creation, complicated diabetes, CCI, BP, and surgical approach. Consequently, a fixed-effects model was applied (Table 3). The forest plot is shown in Supplementary Material 5.

Table 3 Sensitivity analysis of the influencing factors of UR within 31 days after CRC surgery
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Subgroup analysis

Subgroup analysis for UR incidence

We conducted subgroup analyses based on Age, gender, study period, study type, geographic region, and sample size. The results showed that Age, study type and region significantly influenced the 31-day UR rate after CRC surgery (P < 0.05). The UR rate was 5.20% (95% CI: 4.20%–6.21%) in case–control studies and 12.77% (95% CI: 10.32%–15.22%) in cohort studies. By region, the UR rates were 7.70% (95% CI: 4.86%–10.54%) in Asia, 13.05% (95% CI: 1.43%–24.66%) in Europe, 11.62% (95% CI: 11.09%–12.16%) in North America, and 14.98% (95% CI: 12.34%–17.62%) in Oceania.

For gender and sample size, differences in UR rates were observed but were not statistically significant (P > 0.05). The incidence of UR was 5.67% (95% CI: 3.75%− 7.60%) in patients aged < 60 years, while it was 11.48% (95% CI: 8.92%− 14.03%) in patients aged > 60 years. The UR rates for male and female patients were 13.33% (95% CI: 10.61%–15.84%) and 13.93% (95% CI: 11.01%–16.84%), respectively. Based on sample size, the UR rates were 12.54% (95% CI: 8.77%–16.31%) for ≤ 1000, 8.52% (95% CI: 1.92%–15.12%) for 1000–10000, and 12.01% (95% CI: 8.52%–15.50%) for > 10,000 (Table 4). The forest plot is shown in Supplementary Material 6.

Table 4 Subgroup analysis results of UR incidence within 31 days after CRC surgery
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Subgroup analysis for UR risk factors

Subgroup analysis was conducted for risk factors with I2 > 50% to explore the sources of heterogeneity. The results indicated that sample size, Source of the sample, and surgical approach were the primary sources of heterogeneity for various risk factors. Detailed results are presented in Table 5. The forest plot is shown in Supplementary Material 7.

Table 5 Subgroup analysis results of UR risk factors within 31 days after CRC surgery
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Descriptive analysis

Single study showed that hypoproteinemia, pulmonary disease, liver disease, a 10% weight loss in the past six months, readiness for discharge, smoking, American Society of Anesthesiologists (ASA) score, surgical site infection, BMI (kg/m2) of 25–30, intestinal obstruction or perforation, unplanned intubation, and admission to a general ward (non-ICU) were all significantly associated with UR within 31 days after CRC surgery (all P < 0.05).

Publication bias

Publication bias was assessed using Egger’s test for meta-analyses that included at least 10 studies. The results indicated no significant publication bias across different analyses, including the overall meta-analysis, age > 60 subgroup, male and female subgroups, and cohort studies (P > 0.05). As shown in Fig. 3, the funnel plots for these analyses appeared symmetrical. Detailed results of Egger’s test are provided in Supplementary Material 8. For other risk factors with fewer than 10 included studies, the power to detect publication bias was limited; thus, funnel plots and Egger’s test were not conducted.

Fig. 3
figure 3

Funnel plots assessing publication bias: (A) overall incidence of UR, (B) age > 60 subgroup, (C) male and female subgroups, and (D) cohort study subgroup. RD: Risk Difference; SE(RD): standard Error of the Risk Difference

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Discussion

Current status of 31-day UR after CRC surgery

UR within 31 days after CRC surgery remains a significant global challenge. This meta-analysis identified an overall UR rate of 11.73% within 31 days postoperatively, which is comparable to the 14% reported by Tsai et al. [37] and the 8.1% reported by Jiang et al. [38].

A subgroup analysis based on age showed that patients aged > 60 had a higher incidence of UR compared to those aged < 60. This difference may be attributed to the reduced postoperative recovery capacity in elderly patients, a higher prevalence of chronic diseases, an increased risk of complications, and a decline in functional status, leading to greater postoperative care needs [39]. Additionally, older patients may have lower tolerance to perioperative treatment and a prolonged recovery process [40], further increasing the risk of readmission.

A subgroup analysis based on study design revealed that cohort studies generally reported higher UR rates than case–control studies. This discrepancy may stem from the more extensive and comprehensive data sources in cohort studies, which provide a more accurate estimate of the overall population’s UR levels. In contrast, case–control studies may be subject to selection bias and incomplete information, potentially leading to an underestimation of UR rates [41]. Therefore, future assessments of UR should carefully consider the impact of study design to enhance the comparability and generalizability of findings.

From a geographical perspective, UR rates in Oceania, Europe, and North America were generally higher than those in Asia. One possible explanation is that Western countries have a higher prevalence of obesity and diabetes, both of which are well-documented risk factors for postoperative complications and increased UR risk [42]. In contrast, certain Asian countries exhibit dietary patterns and lifestyles that are more conducive to metabolic health, which may mitigate postoperative complications and reduce readmission rates. Additionally, postoperative follow-up tends to be more stringent in Western countries, where patients are regularly evaluated and readily admitted for further treatment. Conversely, in some Asian countries, limited healthcare resources or differing healthcare-seeking behaviors may lead patients to self-manage mild complications or delay seeking medical attention, potentially contributing to lower or underestimated UR rates. Therefore, clinical strategies should be tailored to the specific characteristics of each region. In areas with higher UR rates, strengthening chronic disease management, implementing dietary improvements, and enhancing perioperative health interventions may help reduce the risk of postoperative complications and further lower the likelihood of UR. Conversely, in regions where UR rates may be underestimated, improving follow-up systems and ensuring better access to postoperative health monitoring can help patients enhance their ability to prevent risks and enable timely interventions to avoid adverse outcomes due to delayed treatment. Furthermore, this study found that sex, study year, and sample size did not have a significant impact on the 31-day UR rate following CRC surgery.

Factors influencing 31-day UR after CRC surgery

Age

Age has been identified as a significant factor influencing UR within 31 days after CRC surgery. Although substantial heterogeneity was observed in the pooled analysis, sensitivity analysis confirmed that the results remained stable, reinforcing the reliability of this association. Pucciarelli et al. [16] suggested that age was not significantly associated with the rate of UR within 30 days after surgery, a finding that may be closely related to the quality of postoperative management and nursing care. However, studies by Li et al. [25], Schneider et al. [36], and Lucas et al. [35] reached contrasting conclusions, identifying age as a critical factor influencing UR. Notably, the age distribution of participants in Li et al.'s [25] study was broad, while Schneider et al. [36] and Lucas et al. [35] primarily focused on participants around 75 years old. This difference in sample characteristics may be the main reason for the heterogeneity in the study outcomes. Given these findings, future research should further investigate the differences in UR risk among patients of different age groups to provide more precise guidance for clinical practice.

The risk of UR after surgery is significantly increased in elderly patients undergoing colorectal procedures, primarily due to factors such as geriatric frailty, polypharmacy, impaired postoperative recovery, and inadequate post-discharge care [43]. American Society of Colon and Rectal Surgeons (ASCRS) recommends a stratified intervention strategy, including preoperative comprehensive geriatric assessment to screen for frailty, intraoperative adjustments based on individual risk, and enhanced postoperative specialist follow-up and family support [44]. American College of Cardiology emphasize the importance of cardiovascular risk assessment in elderly patients undergoing non-cardiac surgery to reduce the incidence of postoperative cardiovascular events and UR [45]. Additionally, enhanced recovery after surgery (ERAS) protocols tailored for elderly colorectal cancer patients, such as modified fasting regimens and stepwise pain management, combined with prehabilitation interventions, have been shown to significantly improve postoperative recovery and reduce UR rates [46]. Therefore, multidisciplinary interventions and personalized management strategies are essential for minimizing the risk of postoperative UR in elderly colorectal cancer patients.

Female

This study found that female patients had a lower risk of UR compared to male patients. Existing evidence suggests that this sex-based disparity is likely influenced by a combination of socio-behavioral factors and biological mechanisms. On the one hand, Zhang et al. suggested that women, as primary caregivers in daily life, tend to develop superior self-management knowledge and skills [47]. Female patients generally exhibit higher adherence to medical advice—including medication compliance, wound care, and dietary recommendations—leading to a reduced incidence of postoperative complications [48] and, consequently, a lower UR risk. On the other hand, biological mechanisms may also play a role. Research indicates that estrogen exerts immunomodulatory effects, potentially mitigating surgical stress and inflammatory responses by suppressing pro-inflammatory cytokines (e.g., TNF-α and IL- 6), thus promoting postoperative recovery [49, 50]. In contrast, androgens may negatively affect tissue repair by suppressing macrophage activity [51]. However, the precise biological mechanisms underlying these sex differences remain unclear and warrant further investigation to elucidate their impact on postoperative outcomes and UR.

Based on the findings of this study and existing evidence highlighting gender differences, it is recommended to implement postoperative management strategies that balance universal applicability with gender sensitivity. In clinical practice, standardized discharge guidance should be provided to all patients, while tailored interventions should address gender-specific risk factors. For male patients, emphasis should be placed on enhancing self-management skills through visual educational tools and peer support mechanisms to improve caregiving proficiency and adherence. For female patients, attention should be given to caregiving burden and mental health to prevent care omissions resulting from overconfidence or fatigue. Additionally, clinical monitoring should incorporate gender-related biomarkers (e.g., inflammatory factors) to guide individualized interventions. Future research should employ gender-stratified study designs to further validate the effectiveness of these measures and establish a more precise gender-specific management system.

Diabetes and CCI

This study found that diabetes patients had a significantly higher risk of UR. Rattan et al. [52] reported that postoperative complications such as wound infections, delayed healing, and metabolic disorders are more common in diabetes patients, which may be important contributors to the increased risk of UR. Although the meta-analysis revealed substantial heterogeneity, the sensitivity analysis confirmed the robustness of the results. The source of this heterogeneity may be related to factors such as glycemic control levels or treatment strategies. However, due to the lack of detailed reporting on these factors in the original studies, further analysis could not be conducted.

In this study, a higher CCI score was associated with an increased risk of UR, likely due to reduced postoperative recovery capacity, a higher likelihood of complications, and prolonged hospital stays. However, the meta-analysis of CCI exhibited high heterogeneity. Sensitivity analysis indicated that the results were relatively stable, and further investigation suggests that variations in the baseline disease spectrum across studies may contribute to this heterogeneity, as certain comorbidities may have a greater impact on UR risk than others. Additionally, preoperative optimization strategies—such as prehabilitation programs, perioperative blood glucose management, and nutritional interventions—may also influence the association between CCI and UR. However, reporting of these factors was inconsistent across studies, and some studies did not account for them, making it difficult to accurately assess their impact. Future research should aim to explore the independent contributions of different types of comorbidities to UR risk while also considering the potential influence of preoperative optimization strategies.

For colorectal surgery patients with multiple chronic conditions and diabetes, clinical guidelines recommend a multidisciplinary comprehensive intervention approach to reduce the risk of UR. The ASCRS advises conducting a thorough preoperative risk stratification assessment and collaborating with endocrinology specialists to optimize glycemic control, ensuring HbA1c levels are within the ideal range. Intraoperatively, minimally invasive techniques should be prioritized, with enhanced blood glucose monitoring. Postoperatively, structured discharge management and specialized follow-up care are emphasized [44]. For patients with multiple comorbidities or significant functional impairment, a multimodal prehabilitation program may be considered before elective surgery. A meta-analysis of 35 studies involving 3,402 patients undergoing major abdominal surgery demonstrated that prehabilitation significantly reduces overall postoperative complications, including pulmonary and cardiac complications [53]. Therefore, strengthening a multidisciplinary approach is essential for optimizing perioperative management in patients with diabetes and a high comorbidity burden.

Tumor stage

This study found that TNM ≥ III is an independent risk factor for UR within 31 days after CRC surgery. This finding is consistent with the results of QUINTANA et al. [54]. Patients with advanced TNM stages tend to have deeper tumor infiltration and more severe involvement of adjacent organs, often requiring more complex surgical procedures, such as extended resection or multiorgan resection. These procedures result in greater surgical trauma, slower postoperative recovery, and a higher incidence of complications. Additionally, patients with a higher tumor burden may experience disease progression or recurrence within a short period, necessitating readmission for further treatment, which contributes to an increased UR rate.

To mitigate this risk, the National Comprehensive Cancer Network (NCCN) and the ASCRS recommend a multidisciplinary intervention strategy. Preoperatively, emphasis is placed on optimizing nutritional status, enhancing functional reserves, and determining the optimal timing for individualized neoadjuvant therapy. Intraoperatively, a preference for minimally invasive surgical techniques is advocated. Postoperatively, systematic follow-up and early identification and management of complications are prioritized [55, 56]. Notably, incorporating the ERAS protocol into the comprehensive management of these patients has been shown to further reduce the risk of postoperative unplanned readmission [46]. These evidence-based interventions provide valuable guidance for clinical practice.

Tumor site

This study found that rectal cancer patients have a higher risk of UR compared to colon cancer patients, consistent with the findings of Doumouras et al. [57]. Their study highlighted that the deeper anatomical location of the rectum, its rich pelvic neurovascular structures, and the increased surgical complexity contribute to a higher incidence of anastomotic leakage (AL), pelvic infections, bowel obstructions, and stoma-related complications in rectal cancer patients. These complications, in turn, increase the likelihood of UR. Notably, patients with low rectal cancer who undergo low anterior resection (LAR) or abdominoperineal resection (APR) are at an elevated risk of AL and bowel dysfunction [58]. AL, in particular, can lead to severe infections requiring reoperation [59], while bowel dysfunction affects nutritional intake and quality of life, further increasing the risk of UR.

Although this meta-analysis exhibited a high degree of heterogeneity, sensitivity analysis confirmed the stability of the results, further supporting the conclusion that rectal cancer patients are more likely to experience UR. The heterogeneity may primarily stem from differences in data sources. The studies by Pucciarelli et al. [16] and Johan et al. [10] were based on national databases, whereas those by He et al. [30] and D’Souza et al. [26] were single-center studies, with the latter reporting a significantly higher UR risk. A possible explanation is that national databases encompass large sample sizes, broad coverage, and extended study periods, incorporating data from multiple medical institutions with varying patient management practices, which may lead to an underestimation of UR rates. In contrast, single-center studies focus on a single hospital, where follow-up tends to be more rigorous, and postoperative management and readmission events are recorded in greater detail, potentially resulting in higher observed UR rates.

The ASCRS recommends a multilayered intervention strategy to reduce the risk of UR in rectal cancer patients [44]. First, a multidisciplinary team should develop an individualized treatment plan preoperatively, routinely considering a protective stoma for patients undergoing low anastomosis (< 5 cm). Second, standardized total mesorectal excision techniques should be employed intraoperatively, with reinforcement measures for the anastomosis considered when necessary. Finally, a structured postoperative management plan, including pelvic floor rehabilitation and early complication monitoring, should be implemented. These measures can help minimize complications, promote recovery, and ultimately reduce the risk of UR.

Stoma creation

This study confirms that stoma creation is an important factor influencing UR in CRC patients. Although the heterogeneity of the meta-analysis is relatively high, sensitivity analysis indicates that the results remain stable. Previous studies have shown that patients undergoing stoma creation may experience complications such as retraction, stenosis, leakage, and skin irritation [60]. These issues not only affect patients'adaptability and quality of life but may also lead to infections, electrolyte imbalances, or malnutrition, thereby increasing the risk of UR. Additionally, some patients may lack sufficient stoma care experience or professional guidance after discharge, resulting in functional abnormalities or improper management, ultimately necessitating UR [61].

The high heterogeneity in the meta-analysis may be attributed to differences in data sources. D’Souza et al.’s [25, 26, 33] study was based on single-center data, while Mazrou et al.’s [16, 34] study utilized data from a national database. Such differences in data sources may contribute to increased heterogeneity between studies and affect result comparability. Furthermore, Mazrou’s [34] study primarily examined the impact of stoma creation on UR within 0–5 days, suggesting that stoma creation might reduce the risk of early UR. In contrast, Pucciarelli’s [16] study analyzed stoma creation’s effect on UR within 31 days, identifying it as a significant risk factor for UR within 31 days post-CRC surgery. Differences in study design and follow-up duration may further amplify heterogeneity, leading to inconsistencies in the conclusions regarding stoma creation’s impact on UR. Future research should further investigate the impact of stoma creation on UR at different time points to clarify its role in early and late readmissions. Additionally, adopting multicenter study designs and establishing standardized data collection and analysis frameworks could enhance the comparability and generalizability of results, providing more robust evidence for clinical practice.

In clinical practice, UR related to stomas are primarily caused by complications and difficulties in self-management. The ASCRS recommends a three-tiered intervention strategy to mitigate this risk: (1) preoperative multidisciplinary assessment, including precise stoma site marking and risk evaluation with the involvement of a stoma therapist; (2) intraoperative preference for minimally invasive techniques, such as laparoscopy, to reduce surgical trauma; and (3) postoperative implementation of standardized management protocols, including structured education (covering complication recognition and stoma care techniques), early follow-up within seven days, and remote monitoring [44]. Studies have shown that implementing a clinical pathway incorporating stoma output monitoring and dedicated follow-up nurses can reduce dehydration-related UR among stoma patients from 15.5% to 0% [62]. Furthermore, the adoption of the ERAS protocol has been found to lower the 30-day dehydration-related UR from 9% to 3.9% [63].

Surgical approach

This study indicates that the surgical approach is a significant risk factor for postoperative UR. Specifically, Pucciarelli et al. [16] found that laparoscopic surgery serves as an independent protective factor, significantly reducing the incidence of UR. Similarly, Clausen et al. [10, 16, 29, 32] reported that patients undergoing open surgery faced a higher risk of UR compared to those receiving laparoscopic surgery. The heterogeneity observed in this meta-analysis may be attributed to variations in how different studies define surgical approaches. Extensive clinical research evidence suggests that minimally invasive surgery (MIS) has significant clinical value in the field of colorectal surgery. According to the guidelines jointly developed by the ASCRS, high-quality randomized controlled trials and large-scale clinical data analyses have demonstrated that laparoscopic surgery offers several perioperative advantages, including reduced intraoperative blood loss, improved postoperative pain management, accelerated recovery of bowel function, and shortened hospital stays [44].

Notably, the application of MIS has been shown to significantly reduce the overall incidence of complications, particularly in lowering the risk of surgical site infections (SSI) and other wound-related complications, which may help decrease the likelihood of UR [64]. Existing evidence indicates that integrating MIS—especially laparoscopic surgery—with the ERAS protocol can produce a synergistic effect, a concept supported by studies such as the LAFA trial [65]. Therefore, when carefully selecting appropriate candidates and ensuring that the surgical team possesses the necessary technical expertise, the combined approach of MIS and ERAS can be considered one of the preferred strategies for optimizing perioperative management in colorectal surgery patients, potentially further reducing the risk of UR.

Blood transfusion

This study found that perioperative BT was closely associated with an increased risk of UR within 31 days after CRC surgery. However, inconsistencies in BT timing across different studies may contribute to the heterogeneity observed in our analysis. Some studies focus on perioperative BT [10], while others include BT administered upon admission or before discharge [18, 36]. Due to the lack of detailed data on BT timing and frequency in the included studies, we were unable to further analyze their specific effects.

An international study reported that CRC patients who received BT had a higher likelihood of UR within 31 days postoperatively than those who did not [66]. Multiple mechanisms may explain the association between BT and UR risk. This may be attributed to BT-induced immunosuppression, as the infusion of plasma or whole blood can reduce the number and activity of macrophages and natural killer cells, thereby weakening the body’s ability to fight infections. This increased susceptibility to postoperative infections is considered a major contributor to UR [67]. Additionally, BT may impair bone marrow function, inhibit new blood cell production, and delay tissue repair, further prolonging postoperative recovery. Some studies have also suggested that BT might promote the survival of residual tumor cells, potentially increasing the risk of cancer recurrence [68]. Despite growing evidence linking BT to a higher risk of UR, research on this topic remains limited in China. Future studies should further investigate the impact of different BT timings, blood components, and BT frequencies on UR risk and explore strategies to mitigate these risks.

Restrictive transfusion strategies and patient blood management (PBM) can effectively reduce the risk of UR. To minimize transfusion-related adverse outcomes, the American Association of Blood Banks (AABB) recommends a restrictive transfusion threshold (Hb ≤ 7 g/dL) for hemodynamically stable patients [69]. This approach emphasizes preoperative optimization (such as using iron supplements or erythropoiesis-stimulating agents to correct anemia), intraoperative blood loss reduction (e.g., through minimally invasive techniques and tranexamic acid), and postoperative monitoring. The ACS and ERAS guidelines further support a multimodal PBM approach, including preoperative anemia screening, intraoperative autologous BT, and early postoperative mobilization [46, 70]. These combined interventions can reduce the need for transfusions, improve postoperative recovery, and ultimately decrease the risk of UR.

length of stay

This study demonstrates a significant association between LOS and the risk of UR in postoperative CRC patients. Patients with prolonged LOS tend to have more severe conditions, undergo more complex surgeries, experience slower recovery, and face a higher likelihood of complications, all of which contribute to an increased risk of UR. This trend aligns with previous research [71], which reported UR rates of 7% for patients with LOS ≤ 3 days, 9.8% for those with LOS of 4–5 days, 13.2% for those with LOS of 6–7 days, and as high as 14.9% for patients with LOS ≥ 8 days.

In clinical practice, the ERAS protocol has been widely adopted and shown to effectively shorten LOS, reduce postoperative complications, and improve recovery outcomes [72]. A Cochrane review found that, compared with traditional perioperative management, the ERAS protocol is associated with a lower overall complication rate and a shorter LOS [73]. The ASCRS guidelines also recommend early postoperative mobilization with a gradual increase in activity to promote recovery and reduce LOS [44]. However, while ERAS enables some patients to be safely discharged within 3–5 days postoperatively, older patients, those with multiple comorbidities, or those experiencing delayed recovery may still require prolonged hospitalization, further increasing their UR risk. Therefore, future research should focus on optimizing perioperative management within the ERAS framework, particularly by developing individualized intervention strategies for high-risk populations. By ensuring patient safety while minimizing LOS, these strategies could help reduce UR rates [74].

Postoperative complications

Our study indicates that patients experiencing postoperative complications have a significantly higher risk of UR compared to those without complications. Sensitivity analysis confirmed the robustness of this association, while further subgroup analysis identified sample size variation as a primary source of heterogeneity. However, even after accounting for heterogeneity, postoperative complications remained a significant predictor of UR, consistent with existing literature. Lawson et al. [75] reported that bowel obstruction and surgical site infections are among the most common postoperative complications, with an increasing number of complications correlating with a higher UR risk. Similarly, Orcutt et al. [76] highlighted that postoperative immunosuppression increases susceptibility to infections, which may delay recovery, prolong hospital stays, and ultimately elevate the likelihood of UR. However, the included studies did not provide a detailed classification of postoperative complications, despite the fact that different types of complications may have varying impacts on patient outcomes. This lack of specificity may represent another important source of heterogeneity. Therefore, future research should further stratify postoperative complications to delineate their specific contributions to UR risk. Additionally, large-scale, multicenter studies are needed to explore how the severity, management strategies, and recovery trajectories of complications influence UR rates, thereby improving the accuracy and clinical applicability of findings.

In clinical practice, optimizing perioperative management, particularly in preventing and addressing high-risk complications such as infections and intestinal obstruction, is a key strategy for reducing the incidence of UR after surgery. The ASCRS emphasizes the importance of preventing surgical site infections (SSI) in clinical practice and recommends implementing evidence-based SSI prevention bundles. Studies have demonstrated that these comprehensive interventions effectively reduce the incidence of SSI in patients undergoing colorectal surgery [77]. A 2018 RCT demonstrated that an enhanced SSI prevention bundle—comprising antibiotic peritoneal lavage, triclosan-coated sutures to inhibit bacterial growth, and mupirocin ointment for additional infection control—reduced SSI rates from 16 to 4% [78]. Furthermore, a study from Finland highlighted the role of preoperative bowel preparation combined with oral antimicrobial agents in reducing not only overall postoperative complications but also SSI and anastomotic leakage in colorectal cancer patients, ultimately lowering the risk of postoperative readmission [79]. Beyond infection control, early recovery of bowel function is crucial in preventing postoperative intestinal obstruction. A meta-analysis showed that early oral intake within 24 h postoperatively, compared to delayed feeding, significantly promotes the recovery of gastrointestinal function [80]. A review further highlighted several effective interventions for enhancing gastrointestinal recovery and preventing postoperative intestinal obstruction. These include coffee consumption and chewing gum to stimulate gut motility, probiotic supplementation to support gut microbiota, minimally invasive surgery to reduce surgical trauma, and Daikenchuto—a traditional Japanese herbal medicine composed of dried ginger, ginseng, and zanthoxylum fruit—known for its prokinetic and anti-inflammatory effects [81]. These measures not only improve patient outcomes but also shorten hospital stays, ultimately reducing the risk of unplanned readmission.

Limitations

This study has several limitations. First, we searched only four Chinese and four English databases, which may have led to the omission of relevant studies, thereby limiting the comprehensiveness of the literature coverage. Second, our meta-analysis was based on 13 cohort studies and 2 case–control studies, and the differences in study design may have introduced confounding factors, potentially affecting the accuracy of the results. Third, the number of included studies for certain influencing factors was relatively small (< 10), resulting in limited statistical power and potential instability in the Meta regression results. Therefore, this study did not adopt this method. Fourth, the influencing factors analyzed in different studies varied, making it impossible to merge certain variables, which may have limited the comprehensiveness of our assessment. Future research should expand the scope of literature retrieval, include more high-quality studies, and refine the classification of influencing factors to enhance the robustness and reliability of the analysis.

Conclusion

In conclusion, UR within 31 days after CRC surgery not only significantly increases the healthcare burden but may also prolong the recovery period and negatively impact the patient's quality of life. The occurrence of postoperative UR is the result of multiple contributing factors; therefore, healthcare providers need to systematically assess patient risks and develop targeted intervention strategies. In clinical practice, special attention should be given to high-risk groups, including patients with postoperative complications, those with TNM stage ≥ III, patients with rectal, those undergoing stoma procedures, diabetic patients, individuals with an elevated CCI, patients requiring BT during hospitalization, those with LOS, those undergoing open surgery, and elderly patients. By establishing risk alert systems, optimizing perioperative management protocols, and implementing individualized interventions, the incidence of postoperative UR can be effectively reduced, thereby improving short-term outcomes and enhancing overall healthcare quality.

Data availability

All data supporting the findings of this study are available within the paper and its Supplementary Information.

Abbreviations

CRC:

Colorectal cancer

UR:

Unplanned readmission

CCI:

Charlson Comorbidity Index

BT:

Blood transfusion

LOS:

Length of hospital stays

NOS:

Newcastle-Ottawa Scale

RD:

Risk Difference

SE (RD):

Standard Error of the Risk Difference

LAR:

Low anterior resection

APR:

Abdominoperineal resection

AL:

Anastomotic leakage

ASCRS:

American Society of Colon and Rectal Surgeons

ERAS:

Enhanced recovery after surgery

MIS:

Minimally invasive surgery

SAGES:

Society of American Gastrointestinal and Endoscopic Surgeons

PBM:

Patient blood management

ACS:

American College of Surgeons

SSI:

Surgical site infections

RCT:

Randomized controlled trial

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Authors and Affiliations

  1. School of Nursing, Shanxi University of Chinese Medicine, Jinzhong, 030619, China

    Nan Qu, Tiantian Li, Lifeng Zhang & Xingyu Liu

  2. Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China

    Lifeng Zhang

  3. Department of Nursing, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China

    Liping Cui

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  1. Nan Qu
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  2. Tiantian Li
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  3. Lifeng Zhang
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  4. Xingyu Liu
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Contributions

Qu Nan: Conceptualization, Methodology, Software, Data Curation, Writing – Original Draft, Writing – Review & Editing, Visualization, Project Management; Li Tiantian, Zhang Lifeng, Liu Xingyu: Conceptualization, Methodology, Investigation, Resources, Data Management, Writing – Review & Editing, Visualization, Project Management; Cui Liping: Conceptualization, Methodology, Investigation, Resources, Data Management, Writing – Review & Editing, Project Management. All authors reviewed the manuscript.

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Correspondence to Liping Cui.

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Qu, N., Li, T., Zhang, L. et al. Risk factors for unplanned 31-day readmission after surgery for colorectal cancer patients: a meta-analysis. BMC Gastroenterol 25, 285 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12876-025-03872-5

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12876-025-03872-5

Keywords

BMC Gastroenterology

ISSN: 1471-230X

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