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

• Published in: BJS open Vol. 3; no. 3; pp. 403 - 414
• Main Authors: Ismaïl, Lawani, Zilinskas, Justas, Modolo, Maria Marta, Seisay, Sam, Oosterkamp, Antje, Lima, Caio Vinícius Barroso, Fraga, Gustavo Pereira, Botero, Jaime Andres Montoya, Elfil, Mohamed, Elkhadrawi, Mahmoud, Elmelegy, Rowida, Ammar, Mohamed, El Hameed, Ola Sherief Abd, Abouelnasr, Alaa, AlYoussef, Ibrahim, Saad, Mahmoud, Elazoul, Mohamed, Abozeid, Khaled, Mohammed, Mohammed Mustafa Hassan, Faure, Alice, Bray, Lemuel Davies, Kontos, Michail, Mak, Tony, Al‐Azraqi, Israa Abdullah Aziz, Kerley, Robert, Hanrahan, Michael, Osuoji, Roland, Yaseen, Tahir, Camacho, Rony, Aljohani, Emad, Hassan, Alaa, Wogensen, Fredrik, Björklund, Ida, Marshall, Dominic Charles, Attard, Myranda, Vlachogiorgos, Apostolos, Ayyar, Shruti, Houlden, Christopher, Lim, Pei J, Jackson, Paul, Harrison, Nicola, Koh, Samantha, Zakir, Mohamed, Parker, Jody, Kesinger, Matthew, Antezana, Diego, Giraldo, Ruben Santiago Restrepo, Sakr, Ahmad, Elfarargy, Arwa, Gamal, Dina, Elbisomy, Khaled Hesham, Hassan, Ahmed Tarek Abdelbaset, Mohammed, Mohammed Mustafa, Bahar, Suraya, Ata, Aya Yehia, Ali, Safia, Reda, Amira, Mesbah, Nourhan, Elnagar, Ahmedglal, Elhadad, Alaa, Matter, Sara Mamdouh, Mohamed, Amna, Hascoet, Juliette, Ackom, Eric, Cohen, David Monterroso, Rahmah, Dina Faizatur, Johanna, Nadya, Glynn, Martha, Occhionorelli, Savino, De Franciscis, Silvia, Dulskas, Audrius, Mazrimas, Povilas, Chung, Kuet Jun, Ayandipo, Omobolaji, Banipal, Gurpreet Singh, Qawasmi, Israa, Shaheen, Alaa, Abu‐toyour, Maram, El Jamassi, Alaa, Al‐farram, Hadeel, Firwana, Aya, Adawi, Mohammad, Saqlain, Muhammad, Velásquez, Armando José Román, Mutabazi, Alphonse Zeta, Aljiffry, Murad, Sena‐Ruiz, Fatima, Segura‐Sampedro, Juan Jose, Omer, Omer Abdelbagi, Murutoglu, Busra, Ireland, Philip, Teasdale, Ella, Ang, Yun Lin, Mclean, Kenneth, Johnston, Robin, Tyler, Robert, Guglielmo, Vania, Khan, Zain Ali, Chibuye, Chali, Rommaneh, Muna
• Format: Journal Article
• Language: English
• Published: Chichester, UK John Wiley & Sons, Ltd 01.06.2019; Oxford University Press
• Subjects: Adult; Aged; Aged, 80 and over; Anastomosis, Surgical - statistics & numerical data; Collaboration; Colorectal cancer; Colorectal Neoplasms - surgery; Colorectal surgery; Colostomy - statistics & numerical data; Developed Countries; Developing Countries; Elective Surgical Procedures; Emergencies; Ethics; Female; Global Health; Hospitals; Humans; Laparoscopy; Logistic Models; Male; Medical research; Medicin och hälsovetenskap; Middle Aged; Mortality; Multivariate Analysis; Original; Ostomy; Patients; Prospective Studies; Quality of life; Studies; Surgeons; Surgical outcomes; United Kingdom > UK; England
• ISSN: 2474-9842; 2474-9842
• DOI: 10.1002/bjs5.50138

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. This secondary analysis of an international prospective multicentre observational study demonstrates significant variation in the proportion of patients receiving an end stoma after left‐sided colorectal resection between high‐ and low–middle‐income countries; this cannot be accounted for by case mix alone. This could relate to unmeasured patient risk characteristics, but may also reflect delayed access to surgical care, lack of equipment for anastomosis formation, or differences in subspecialist colorectal training. Wide variation in stoma rates