Emergent Colon Resections: Does Surgeon Specialization Influence Outcomes?

Abstract

BACKGROUND: Relationships between high-volume surgeons and improved postoperative outcomes have been well documented. Colorectal procedures are often performed by general surgeons, particularly in emergent settings, and may form a large component of their practice. The influence of subspecialized training on outcomes after emergent colon surgery, however, is not well described. OBJECTIVE: The purpose of this study was to determine whether subspecialty training in colorectal surgery is associated with differences in postoperative outcomes after emergency colectomy. DESIGN: This was a retrospective cohort study. SETTINGS: Three tertiary care hospitals participating in the National Surgical Quality Improvement Project were included. PATIENTS: Patients undergoing emergent colon resections were identified at each institution and stratified by involvement of either a colorectal surgeon or a general or acute care surgeon. MAIN OUTCOME MEASURES: Propensity score matching was used to isolate the effect of surgeon specialty on the primary outcomes, including postoperative morbidity, mortality, length of stay, and the need for unplanned major reoperation, in comparable cohorts of patients. RESULTS: A total of 889 cases were identified, including 592 by colorectal and 297 by general/acute care surgeons. After propensity score matching, cases performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%; p = 0.001), postoperative morbidity (45.0% vs 56.7%; p = 0.009), and unplanned major reoperation (9.7% vs 16.4%; p = 0.04). In addition, length of stay was ≈4.4 days longer among patients undergoing surgery by general/acute care surgeons (p < 0.001). LIMITATIONS: This study was limited by its retrospective design, with potential selection bias attributed to referral patterns. CONCLUSIONS: After controlling for underlying disease states and illness severity, emergent colon resections performed by colorectal surgeons were associated with significantly lower rates of postoperative morbidity and mortality when compared with noncolorectal surgeons. These findings may have implications for referral patterns for institutions. See Video Abstract at http://links.lww.com/DCR/A767.

The role of laparoscopy in emergency colorectal surgery

“…Another propensity score-matched study showed that 88.9% of emergency laparoscopic colorectal colectomies were carried out by colorectal surgeons. 22 This observation aligns with several studies showing that colorectal surgery specialization is an independent factor for better outcomes in patients undergoing colorectal surgery. 23 This study showed that the laparoscopic approach in emergency settings is safe and feasible, with a trend towards better postoperative outcomes in line with growing evidence in the literature regarding the role of laparoscopy in emergency colorectal surgery.…”

Who should operate patients presenting with emergent colon cancer? A comparison of short- and long-term outcome depending on surgical sub-specialization

“…The use of diverting ileostomy was more often used by colorectal teams, i.e., in 16.9% (54/319) compared to 5.7% (12/210) in the EST group and 8.7% (11/127) in the GST group, (p < 0.05). In turn, patients in the CRT group had higher rate of stoma reversal and of all patients alive after 3 years, 24 The number of examined lymph nodes was significantly less in the GST group compared with the other groups. Moreover, the rate of microscopically radical resection of the primary tumor did not differ between groups (Table 6).…”

“…Operations performed by colorectal surgeons were associated with significantly lower rates of 30-day mortality (6.7% vs 16.4%, p = 0.001) and postoperative morbidity (45.0% vs 56.7%, p = 0.009). However, only 13.0% of the patients had a malignant disease [ 24 ]. A large population-based registry study from the UK showed that emergency laparotomy performed by consultants without a special interest in colorectal surgery had an increased adjusted 30-day mortality risk (OR 1.23, 95 CI 1.13–1.33) as well as increased risk of re-operation (OR 1.13, CI 1.05–1.20) compared to consultants with special colorectal interest [ 25 ].…”

Enhanced recovery after surgery in emergency resection for obstructive colorectal cancer: a systematic review and meta-analysis

“…Emergency resection of the tumor with or without anastomosis remains the mainstay treatment for obstructive CRC -especially right-sided colon cancer, left-sided colonic obstruction that is not eligible for colonic stenting, and CRC with suspected bowel perforation [3]. However, postoperative morbidities and mortalities following surgical treatment for obstructive CRC are high [4] -even performed by colorectal surgeons [5].…”