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

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 48h (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.