Impact of Surgical Specialization on Emergency Colorectal Surgery Outcomes

Biondo, Sebastiano; Kreisler, Esther; Millán, Mónica; Fraccalvieri, Doménico; Golda, Thomas; Frago, Ricardo; Miguel, Bernat

doi:10.1001/archsurg.2009.208

Cited by 111 publications

(75 citation statements)

References 27 publications

(34 reference statements)

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“…18 It is interesting that these data suggest that 30-day mortality appeared significantly lower if emergency colonic resection is performed by subspecialist colorectal surgeons rather than non-colorectal specialists. Significantly better postoperative morbidity, 19,20 mortality, 20,21 stoma rate, 19,21 primary anastomosis rate 21 and anastomotic leak rate 20 have been reported previously for those emergency colorectal cases operated on by colorectal subspecialists. The unadjusted data from this study are best regarded as preliminary.…”

Section: Discussionmentioning

confidence: 52%

Current UK practice in emergency laparotomy

Barrow¹,

Anderson²,

Varley³

et al. 2013

annals

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on behalf of the UK Emergency Laparotomy Network ABStRAct INTRODUCTION Emergency laparotomy is a common procedure, with 30,000-50,000 performed annually in the UK. This large scale study reports the current spectrum of emergency laparotomies, and the influence of the surgical procedure, underlying pathology and subspecialty of the operating surgeon on mortality. METHODS Anonymised data on consecutive patients undergoing an emergency laparotomy were submitted for a three-month period. The primary outcome measure was unadjusted 30-day mortality. Appendicectomy and cholecystectomy were among the procedures excluded. RESULTS Data from 1,708 patients from 35 National Health Service hospitals were analysed. The overall 30-day mortality rate was 14.8%. 'True' emergency laparotomies (ie those classified by the National Confidential Enquiry into Patient Outcome and Death as immediate or urgent) comprised 86.5% of cases. The mortality rate rose from 8.0% among expedited cases to 14.3% among urgent cases and to 25.7% among laparotomies termed immediate. Among the most common index procedures, small bowel resection exhibited the highest 30-day mortality rate of 21.1%. The presence of abdominal sepsis was associated with raised 30-day mortality (17.5% in the presence of sepsis vs 12.6%, p=0.027). Colorectal procedures comprised 44.3% and within this group, data suggest that mortality from laparotomy may be influenced by surgical subspecialisation. CONCLUSIONS This report of a large number of patients undergoing emergency laparotomy in the UK confirms a remarkably high mortality by modern standards across the range. Very few pathologies or procedures can be considered anything other than high risk. The need for routine consultant involvement and critical care is evident, and the case distribution helps define the surgical skill set needed for a modern emergency laparotomy service. Preliminary data relating outcomes from emergency colonic surgery to surgical subspecialty require urgent further study.

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Section: Discussionmentioning

confidence: 52%

Current UK practice in emergency laparotomy

Barrow¹,

Anderson²,

Varley³

et al. 2013

annals

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“…The fact that there is less expertise available on weekends might be a substantial contributor to our findings. This is supported by Biondo et al 41 and Zorcolo et al, 42 who showed that experienced and specialized colorectal surgeons perform more primary anastomoses compared with trainees or general surgeons. The results of this population-based study provide strong evidence that postoperative adverse outcomes of urgent operations for left-sided diverticulitis are more frequent in patients admitted on weekends than in patients admitted on weekdays.…”

Section: Commentmentioning

confidence: 70%

Worse Outcomes in Patients Undergoing Urgent Surgery for Left-Sided Diverticulitis Admitted on Weekends vs Weekdays

Worni¹,

Schudel²,

Østbye³

et al. 2012

Arch Surg

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Hypothesis: Among patients undergoing urgent surgery for left-sided diverticulitis, those admitted on weekends vs weekdays have higher rates of Hartmann procedure and adverse outcomes.Design: Analysis of data from the Nationwide Inpatient Sample between January 2002 and December 2008. Unadjusted and risk-adjusted generalized linear regression models were used.Setting: Academic research.Patients: Data on patients undergoing urgent surgery for acute diverticulitis.Main Outcome Measures: Rates of Hartmann procedure vs primary anastomosis, complications, length of hospital stay, and total hospital charges.Results: In total, 31 832 patients were included; 7066 (22.2%) were admitted on weekends, and 24 766 (77.8%) were admitted on weekdays. The mean (SD) age of patients was 60.8 (15.3) years, and 16 830 (52.9%) were female. A Hartmann procedure was performed in 4580 patients (64.8%) admitted on weekends compared with 13 351 patients (53.9%) admitted on weekdays (riskadjusted odds ratio [OR], 1.57; P Ͻ .001). In riskadjusted analyses, patients admitted on weekends had significantly higher risk for any postoperative complication (OR, 1.10; P=.005) and nonroutine hospital discharge (OR, 1.33; PϽ.001) compared with patients admitted on weekdays, as well as a median length of hospital stay that was 0.5 days longer and median total hospital charges that were $3734 higher (PϽ .001 for both).Conclusions: Patients undergoing urgent surgery for leftsided diverticulitis who are admitted on a weekend have a higher risk for undergoing a Hartmann procedure and worse short-term outcomes compared with patients who are admitted on a weekday. Further research is warranted to investigate possible underlying mechanisms and to develop strategies for reducing this substantial weekend effect.

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“…Interestingly, until recently, nonelective colorectal surgery in the Netherlands was performed by almost all general surgeons on call, while other high-risk procedures, such as acute aneurysm surgery, are performed by specialized surgeons only. Previous studies have demonstrated that the presence of a specialized surgeon during a nonelective operation improves outcome [18,19]. Unfortunately, our database did not contain information on the qualifications of the operating surgeon, but it is likely that referral of high-risk nonelective patients to centers with a specialized surgeon available during on-call hours, improves outcome.…”

Section: Discussionmentioning

confidence: 99%

Nonelective Colon Cancer Resections in Elderly Patients: Results from the Dutch Surgical Colorectal Audit

Kolfschoten¹,

Wouters

Gooiker³

et al. 2012

Dig Surg

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Aims: The aim of the study was to assess which factors contribute to postoperative mortality, especially in elderly patients who undergo emergency colon cancer resections, using a nationwide population-based database. Methods: 6,161 patients (1,172 nonelective) who underwent a colon cancer resection in 2010 in the Netherlands were included. Risk factors for postoperative mortality were investigated using a multivariate logistic regression model for different age groups, elective and nonelective patients separately. Results: For both elective and nonelective patients, mortality risk increased with increasing age. For nonelective elderly patients (80+ years), each additional risk factor increased the mortality risk. For a nonelective patient of 80+ years with an American Society of Anesthesiologists score of III+ and a left hemicolectomy or extended resection, postoperative mortality rate was 41% compared with 7% in patients without additional risk factors. Conclusions: For elderly patients with two or more additional risk factors, a nonelective resection should be considered a high-risk procedure with a mortality risk of up to 41%. The results of this study could be used to adequately inform patient and family and should have consequences for composing an operative team.

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Impact of Surgical Specialization on Emergency Colorectal Surgery Outcomes

Abstract: Specialization in colorectal surgery has a significant influence on morbidity, mortality, and anastomotic dehiscence after emergency operations.

Cited by 111 publications

References 27 publications

Current UK practice in emergency laparotomy

Current UK practice in emergency laparotomy

Worse Outcomes in Patients Undergoing Urgent Surgery for Left-Sided Diverticulitis Admitted on Weekends vs Weekdays

Nonelective Colon Cancer Resections in Elderly Patients: Results from the Dutch Surgical Colorectal Audit

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