Left Colon Surgery in Adults: Indications, Surgical Procedures and Complications in Douala, Cameroon – A Multicenter Retrospective Study

This was a retrospective, analytical multicenter study conducted in four referral hospitals in Douala, Cameroon. All patients aged 15 years and above who underwent left colon surgery between January 1, 2013, and December 31, 2023, were included. Patients with incomplete medical records were excluded.

Collected variables included sociodemographic characteristics, clinical presentation, diagnostic investigations, surgical indications, operative procedures, and postoperative outcomes. Postoperative complications were defined as any adverse event occurring during hospitalization or within 30 days after surgery.

Statistical analysis was performed using SPSS version 25.0. Quantitative variables were expressed as means ± standard deviation, while qualitative variables were expressed as frequencies and percentages. Associations between potential risk factors and postoperative complications were assessed using univariate analysis, calculating Relative Risks (RR) and corresponding p-values. Multivariate analysis was not performed due to the limited number of postoperative complications. A p-value < 0.05 was considered statistically significant.

The retrospective nature of the study may expose it to selection and information bias. In addition, inter-center variability and the absence of long-term oncologic follow-up represent further limitations.

Study population and sociodemographic characteristics

During the study period, a total of 223 colon surgeries were performed in the four referral hospitals. Among these, 144 patients (64.6%) underwent left colon surgery and were included in the analysis.

The mean age of patients was 50 ± 15 years (range: 18–82 years), with a male predominance. Most patients were admitted through the emergency department. The sociodemographic characteristics of the study population are summarized in Table 1.

Clinical presentation and diagnostic assessment

Abdominal pain and bowel obstruction were the most frequent presenting symptoms. Most patients underwent computed tomography (CT scan) as part of the diagnostic workup, while colonoscopy was performed mainly in elective cases. Clinical presentation and diagnostic investigations are detailed in Table 2.

Surgical indications, localization, and procedures

Neoplastic pathology accounted for 75% of surgical indications, predominantly colorectal adenocarcinoma. The sigmoid colon was the most frequently involved segment.

Regarding operative strategy, segmental colectomy with primary anastomosis was the most commonly performed procedure, followed by Hartmann’s procedure, especially in emergency settings. Among the 45 Hartmann procedures performed, 34 (75.6%) were indicated for emergency neoplastic pathology, mainly obstructive or perforated colorectal cancer. Eight procedures (17.8%) were performed for emergency benign conditions, including complicated diverticular disease and volvulus. Only three Hartmann procedures (6.6%) were carried out in elective oncologic settings, mainly due to poor general condition or high anastomotic risk. Surgical indications, localization, and operative procedures are summarized in Table 3.

Postoperative complications and outcomes

Postoperative complications occurred in 12 patients (8.3%). Anastomotic fistula was the most frequent complication, accounting for 33.3% of all postoperative complications. The overall postoperative mortality rate was 2.8%. Postoperative outcomes are presented in Table 4.

Factors associated with postoperative complications

On univariate analysis, emergency surgery, advanced tumor stage, and sigmoid colon localization were significantly associated with postoperative complications. Other variables, such as age and sex, were not statistically associated with postoperative morbidity. The analysis of associated factors is summarized in Table 5.

This multicenter retrospective study provides a comprehensive overview of left colon surgery in a large urban referral setting in sub-Saharan Africa. The predominance of oncologic indications and the high rate of emergency surgical management reflect both global epidemiological trends and context-specific challenges inherent to low- and middle-income countries.

Colorectal cancer accounted for three-quarters of left colon surgeries in our series, consistent with findings from both African and Western studies [4-9]. Recent population-based data confirm a sustained increase in colorectal cancer incidence across sub-Saharan Africa, suggesting that the surgical burden observed in this study is likely to increase further in the coming decades [10,17].

The relatively young mean age of patients in our cohort contrasts with European and North American series, where colorectal cancer predominantly affects older individuals [4-6]. This younger age at presentation has been widely reported in African cohorts and may reflect demographic structure, genetic susceptibility, and the absence of screening programs [9,18].

Emergency surgery was performed in more than two-thirds of patients and emerged as the strongest predictor of postoperative morbidity. This finding is in line with extensive literature demonstrating significantly higher complication rates following emergency colorectal surgery compared with elective procedures [13-15].

The high proportion of emergency presentation among colorectal cancer patients in this study can be explained by several interrelated factors. These include the absence of organized colorectal cancer screening programs, delayed health-seeking behavior, limited access to colonoscopy, and financial constraints. Many patients initially resort to self-medication or traditional healers, leading to delayed diagnosis until complications such as bowel obstruction or perforation occur. Similar emergency presentation rates ranging from 60% to 75% have been reported in other sub-Saharan African series [19-21].

Limited access to advanced diagnostic procedures, particularly colonoscopy, further contributes to delayed diagnosis. In our setting, colonoscopy remains poorly accessible due to high out-of-pocket costs, limited availability of endoscopic facilities in public hospitals, and the predominance of emergency admissions. Consequently, computed tomography often represents the primary diagnostic modality in acute presentations [22,23].

The operative strategies adopted reflect a pragmatic balance between oncologic adequacy and patient safety. The near-exclusive use of laparotomy mirrors infrastructural limitations and the predominance of emergency cases. Although minimally invasive colorectal surgery is now standard in elective settings in high-income countries, its role in emergency contexts remains limited even in advanced centers [24,25].

The frequent use of Hartmann’s procedure in emergency oncologic settings reflects an appropriate risk-adapted strategy. Several studies have shown that Hartmann’s procedure remains a valid option in unstable or septic patients, albeit at the cost of low reversal rates and long-term stoma burden [26,27].

Socioeconomic transition, urbanization, dietary westernization, reduced physical activity, and rising income levels have been identified as major contributors to the increasing incidence of colorectal cancer in Africa. Recent studies report that colorectal cancer accounts for approximately 20% - 35% of digestive cancers in countries such as Nigeria and Ghana, compared with more than 50% in Western countries [10-12,28]. In Cameroon, hospital-based studies have reported proportions ranging from 18% to 30%, suggesting a progressive epidemiological transition [11,16].

Regarding oncologic management, the limited proportion of patients discussed in multidisciplinary team meetings reflects organizational constraints in cancer care. Multidisciplinary discussion has been shown to improve treatment planning and adherence to oncologic guidelines, and its broader implementation could enhance outcomes in low-resource settings [29,30].

Anastomotic fistula was the most frequent postoperative complication and represents a major determinant of morbidity. Emergency surgery, open approach, and advanced tumor stage have consistently been identified as key risk factors for anastomotic leakage after colorectal resection [14,31].

The limitations of this study include its retrospective design, potential selection bias, inter-center heterogeneity, and absence of multivariate analysis due to the limited number of complications. Nevertheless, the multicenter nature and relatively large sample size provide valuable insight into real-world surgical practice in an African urban setting.

Left colon surgery in Douala is predominantly performed for colorectal cancer under emergency conditions. Emergency presentation, advanced tumor stage, and sigmoid colon localization significantly increase postoperative morbidity. Strengthening early diagnosis and elective surgical management is essential to improve outcomes.