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 percent) 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.
Bibliographical noteFunding Information:
This paper reports the results of two preregistered studies (ClinicalTrials.gov; NCT02179112 and NCT02662231). To minimize the possibility of unintentionally sharing information that can be used to reidentify private information, a subset of the summary data generated for this study are available in an online visualization application that can be accessed at http://ssi.globalsurg.org40. Organizations assisting in dissemination and/or translation: Asian Medical Students? Association; Association of Surgeons in Training; College of Surgeons of East, Central and Southern Africa; Cutting Edge Manipal; Egyptian Medical Student Research Association; International Collaboration for Essential Surgery; International Federation of Medical Student Associations; Italian Society of Colorectal Surgery; Lifebox Foundation; School of Surgery; Student Audit and Research in Surgery; The Electives Network; United Kingdom National Research Collaborative; World Society of Emergency Surgery; and World Surgical Association. This study was funded by Department For International Development?Medical Research Council?Wellcome Trust Joint Global Health Trial Development grant (MR/N022114/1) and a National Institute of Health Research (NIHR) Global Health Research Unit Grant (NIHR 16/136/79). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the UK Department of Health.
This study was funded by Department For International Development–Medical Research Council–Wellcome Trust Joint Global Health Trial Development grant (MR/N022114/1) and a National Institute of Health Research (NIHR) Global Health Research Unit Grant (NIHR 16/136/79). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the UK Department of Health.
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