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Observational Study
. 2019 Feb 28;3(3):403-414.
doi: 10.1002/bjs5.50138. eCollection 2019 Jun.

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

GlobalSurg Collaborative
Collaborators
Observational Study

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

GlobalSurg Collaborative. BJS Open. .

Abstract

Background: End 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.

Methods: This 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.

Results: In 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).

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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Figures

Figure 1
Figure 1
Map of included countries
Figure 2
Figure 2
Presentation of patients undergoing left‐sided colorectal resection by Human Development Index tertile. HDI, Human Development Index
Figure 3
Figure 3
Indications for left‐sided colorectal resection by Human Development Index tertile and urgency of surgery. a Elective and b emergency. HDI, Human Development Index
Figure 4
Figure 4
End colostomy formation rates by Human Development Index tertile, indication for surgery and presence of perforated disease. HDI, Human Development Index
Figure 5
Figure 5
Percentage of patients who died within 30 days after left‐sided colorectal resection by Human Development Index tertile and urgency of surgery. a Elective and b emergency. HDI, Human Development Index
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