## 4 Discussion
Patients with malignant colonic perforation face a high risk of peri-operative death, making septic source control the priority in the acute setting [31; 33]. Age, Charlson comorbidity index, and tumor stage IV were associated with increased mortality of colorectal cancers operated in emergency [32]. The COVID-19 pandemic has brought important challenges in surgical practice, which we have never been confronted with before. In a systematic review of [PERSON] et al., the COVID-19 pandemic was found to have a negative effect both on the diagnosis and treatment of colorectal cancer [34]. Decreased diagnosis of new cases of colorectal cancer was seen in most countries, varying from 43.1% to 73.1% among different studies, with important discontinuities reported in screening programs and patients' usual visits [34; 35; 36; 37]. Clinical studies found a significant increase in emergency presentations, for bowel obstruction or perforation [33; 34; 35]. [PERSON] et al. found an increase in emergency presentation for colorectal cancer in Spain from 3.6% in 2019 to 12.1% in 2020 [38]. [PERSON] et al. found an increase in neoplastic bowel obstruction from 4.3% in 2019 to 8.6% in 2020, and draw attention that only a short delay of 4 months in referral and diagnosis leads to an increase in patients presenting with large bowel obstruction [39]. Our department is a tertiary center in the biggest emergency hospital in the country. This fact explains the increased proportion of complicated colorectal cases treated in emergency (37% before the COVID-19 pandemic and 72% during the first year of the COVID-19 pandemic), in comparison with other published studies. In our research, we found significantly higher mortality in the pandemic group, which may be explained by the higher percentage of acute complicated cases. Emergency presentation of colorectal cancers has a severe impact upon patients' survival and should be prevented. On the other hand, healthcare providers should balance the increased risk of death from COVID-19 exposure with preventable deaths from undertreating cancer patients [25; 28; 40]. Previously published reports found that elective colorectal surgical procedures may be safely performed during the pandemic, in the condition of establishingCOVID-19 and non-COVID-19 circuits, strict visitor policy, and triage questionnaire for possible COVID-19 symptoms and RT-PCR testing before admission [24, 27, 41, 42]. Our results verify previous reports, as we also registered no in-hospital SARS-CoV-2 infection in the pandemic group. This result may be a solid argument for encouraging colorectal elective surgery during COVID-19 pandemic, and preventing the future burden of advanced cases and the loss of life years for these patients. The findings in the present research may support some recommendations to improve the outcomes of colorectal cancers patients admitted for surgery during the COVID-19 pandemic. In case of patients admitted in emergency for obstructive bowel cancer, minimal procedures, such as stenting or colostomy/ileostomy could be preferable to more extensive surgery, to decrease the risk of postoperative morbidity and mortality. Extensive lavage of peritoneal cavity, avoiding colonic anastomosis per primam, broad spectrum intravenous antibiotics and careful postoperative monitoring could be useful to prevent and treat septic shock. Treating emergency colorectal patients is associated with worse outcomes, when compared to elective colorectal cancer surgery. In our country, oncological cases were treated continuously during pandemic waves, except the first lockdown period. However, in clinical practice, admission of elective oncological cases was often put on hold because of the lack of available ICU beds. Ensuring intensive care resources necessary for elective oncological surgery is mandatory for maintaining the standard of care in colorectal cancer surgery.