The impact of surgical subspecialization on patient outcomes following emergency colorectal resections in the north of England: a retrospective cohort study

Abstract

Aim Emergency colorectal surgery is associated with significant morbidity and mortality. Most general surgeons have a subspecialty, which forms the focus of their elective work, allowing development of specialist skill sets. The aim of this study was to assess the impact of consultant subspecialization on patient outcomes following emergency colorectal resections. Methods Data were requested for all emergency admissions under a general surgeon between 1 January 2002 and 31 December 2016 within the north of England. These were acquired from individual Trusts following Caldicott approval. Data included demographics, diagnoses and any procedures undertaken. Patients were assigned to cohorts based on the subspecialist interest of the consultant they were under the care of. The primary outcome of interest was 30‐day postoperative mortality. Categorical data were compared with the chi‐squared test, and continuous data with the t test or ANOVA. A logistic regression model determined factors associated with 30‐day in‐hospital mortality. Results Overall, 7648 emergency colorectal resections were performed with a 30‐day postoperative mortality of 13.8%. This was significantly lower if the responsible consultant was a colorectal surgeon compared with other general surgery subspecialties (11.8% vs. 15.2%, P < 0.001). This was significant on univariate analysis (OR 0.75, P < 0.001); however, following multivariable adjustment, this was not statistically significant (P = 0.380). The colorectal specialists had a higher laparoscopy rate than their colleagues—9.8% versus 6.8% (P < 0.001). Stoma rates were also lower (46.9% vs. 51.0%, P = 0.001) and anastomosis rates higher (55.9% vs. 49.3%, P < 0.001) amongst colorectal surgeons. Conclusion These findings add to the growing body of evidence that patient outcomes may be improved by involving subspecialists in colorectal emergencies.

Colorectal Surgery Travelling Fellowships: Historical Perspective and Future Direction

“…The body of evidence supporting specialist fellowship training programs is considerable; demonstrating a signi cant impact on surgical pro ciencies and patient care outcomes [27][28][29][30][31][32][33]. Other research also points towards a consistent increase in the number of applicants pursuing surgical sub-specialities [34][35][36].…”

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

“…Recent large studies report an increase in mortality in patients operated on by surgeons whose area of expertise was not in the area of the pathology, and for colorectal patients not operated on by specialist colorectal surgeons there were lower rates of laparoscopy and an increase in return to the operating room [ 30 ], although these results must be interpreted with caution as factors such as the urgency of the procedure may not have been fully accounted for. Another study shows lower mortality and stoma formation if an emergency colorectal resection is done by a colorectal subspecialist [ 31 ]. Solutions may include partnering across specialties in the management of complex emergency surgical patients [ 32 , 33 ].…”

Editorial

“…Finally, surgical sub‐specialisation and the emergence of the ‘emergency surgeon’ raises questions about who should care for patients presenting acutely with colorectal cancer. A recent publication in this journal [6] reported that 30‐day mortality after emergency colorectal resection (not all for cancer) was significantly lower (11.8% vs. 15.2%) if the responsible consultant was a colorectal surgeon rather than another general surgeon.…”