Global variation in anastomosis and end colostomy formation following left-sided colorectal resection.

Globalsurg Collaborative

doi:10.1002/bjs5.50138

Abstract

BackgroundEnd colostomy rates following colorectal resection vary across institutions in high‐income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left‐sided colorectal resection.MethodsThis study comprised an analysis of GlobalSurg‐1 and ‐2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left‐sided colorectal resection within discrete 2‐week windows. Countries were grouped into high‐, middle‐ and low‐income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model.ResultsIn total, 1635 patients from 242 hospitals in 57 countries undergoing left‐sided colorectal resection were included: 113 (6·9 per cent) from low‐HDI, 254 (15·5 per cent) from middle‐HDI and 1268 (77·6 per cent) from high‐HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low‐ compared with middle‐ and high‐HDI settings. The association with colostomy use in low‐HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001).ConclusionGlobal differences existed in the proportion of patients receiving end stomas after left‐sided colorectal resection based on income, which went beyond case mix alone.

Highlights

In 2015, the Lancet Commission on Global Surgery highlighted a substantial gap in access to safe and affordable surgical care across low- and middle-income countries (LMICs), raising the priority of surgery on the global health agenda[1]
Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone
This study demonstrated that end stoma rates in low-Human Development Index (HDI) countries were twice those in middle- and three times those in high-HDI countries

Summary

Introduction

In 2015, the Lancet Commission on Global Surgery highlighted a substantial gap in access to safe and affordable surgical care across low- and middle-income countries (LMICs), raising the priority of surgery on the global health agenda[1]. End colostomy rates following colorectal cancer resection vary substantially between centres in high-income countries, ranging from 15 to 70 per cent[4]. This may reflect variations in case mix, as the decision to create an end colostomy rather than a primary restorative anastomosis is influenced by the urgency of presentation, the presence of operative field contamination, disease severity and stage, as well as functional status of the pelvic floor. End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. Conclusion: Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

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