Volume analysis of outcome following restorative proctocolectomy

Background: This observational study aimed to determine national provision and outcome following pouch surgery (restorative proctocolectomy, RPC) and to examine the effect of institutional and surgeon caseload on outcome. Methods: All patients undergoing primary RPC between April 1996 and March 2008 in England were identified from the administrative database Hospital Episode Statistics. Institutions and surgeons were categorized according to the total RPC caseload performed over the study interval. Results: Some 5771 primary elective pouch procedures were undertaken at 154 National Health Service hospital trusts. Median follow-up was 65 (interquartile range (i.q.r.) 28-106) months. The 30-day in-hospital mortality rate was 0.5 per cent and the 1-year overall mortality rate 1.5 per cent. Some 30.5 per cent of trusts performed fewer than two procedures per year, and 91.4 per cent of surgical teams (456 of 499) carried out 20 or fewer RPCs over 8 years. Median surgeon volume was 4 (i.q.r. 1-9) cases. Failure occurred in 6.4 per cent of cases. Low-volume surgeons operated on more patients at the extremes of age (P < 0.001) and a lower proportion with ulcerative colitis (P < 0.001). Older age, increasing co-morbidity, increasing social deprivation, and both lower provider and surgeon caseload were independent predictors of longer length of stay. Older patient age and low institutional volume status were independent predictors of failure. Conclusion: Many English institutions and surgeons carry out extremely low volumes of RPC surgery. Case selection differed significantly between high-and low-volume surgeons. Institutional volume and older age were positively associated with increased pouch failure.