PLoS One. 2013 May 16;8(5):e64245. doi: 10.1371/journal.pone.0064245.

Impact of procedure volumes and focused practice on short-term outcomes of elective and urgent colon cancer resection in Italy.

Lenzi J, Lombardi R, Gori D, Zanini N, Tedesco D, Masetti M, Jovine E, Fantini MP.


Lenzi J, Gori D, Tedesco D, Fantini MP: Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna, Bologna, Italy.

Lombardi R, Zanini N, Masetti M, Jovine E: General Surgery Unit, Department of Surgery, Maggiore Hospital, Bologna, Italy.



Background. The relationship between procedure volumes and short-term patients’ outcomes of colon cancer (CC) surgery is not well established in the literature. Moreover, evidence about short-term outcomes of urgent compared with elective CC procedures is scanty. The aims of this study are (i) to determine whether caseloads and other hospital characteristics are associated with short-term outcomes of CC surgery, and (ii) to compare the outcomes of urgent and elective CC surgery.

Methods. A total of 14 200 patients undergoing CC surgery between 2005 and 2010 in the General Surgery Units (GSUs) of the hospitals of Emilia-Romagna region, Northern Italy, were identified from the hospital discharge records database. The outcomes of interest were 30-day in-hospital mortality, re-intervention and 30-day re-admission. Using multilevel analysis, we analyzed the relationship of GSU procedure volumes and focused practice, defined as the percentage of CC operations over total operations, with the three outcomes.

Results. High procedure volumes were associated with a lower risk of 30-day in-hospital mortality, after adjusting for patients’ characteristics [aOR (95% CI) = 0.51 (0.33–0.81)]. Stratified analyses for elective and urgent surgery showed that high volumes were associated with a lower 30-day mortality for elective patients [aOR (95% CI) = 0.35 (0.17–0.71)], but not for urgent patients [aOR (95% CI) = 0.72 (0.42–1.24)]. Focused practice was an independent predictor of re-intervention [aOR (95% CI) = 0.67 (0.47–0.97)] and re-admission [aRR (95% CI) = 0.88 (0.78–0.98)].

Conclusions. The present study adds evidence in support of the notion that patients with CC undergoing surgery at high-volume and focused surgical units experience better short-term outcomes.

PMID: 23696873



In the present study, we found that patients undergoing CC surgery at GSUs with higher procedure volumes had a decreased risk of post-operative mortality (Figure 1). The relationship proved to be significant even when GSU volumes were subdivided into tertiles (Table 1). This adds to the growing body of evidence showing a relationship between care provider volume and post-operative CC mortality, and is in contrast with other studies that failed to demonstrate such a relationship.

Stratified analyses carried out in urgent and elective patients revealed that the adjusted risk of post-operative mortality was increased in low-volume GSUs for elective CC surgery, but not for urgent surgery (Table 1). This is in contrast with the results of a recent study in Denmark, in which a significant variation in mortality between low- and high-volume hospitals was found for urgent (but not elective) surgery [Osler M, et al. Hospital variation in 30-day mortality after colorectal cancer surgery in Denmark: the contribution of hospital volume and patient characteristics. Ann Surg 2011;253:733-38].

Because our results suggest a relationship between GSU procedure volumes and outcomes in elective patients, we argue that centralization might enhance the quality of surgery for these patients, including screen-detected ones, to avoid exposure of apparently healthy people to unnecessary harmful treatments. Yet, unintended negative consequences of centralizing colonic resection for cancer must be considered: referring a large number of cases to a limited number of centers might decrease accessibility for patients and their families, and threaten continuity of care after surgery.

Maria Pia Fantini-fig-1Figure 1. Risk-standardized post-operative mortality rates vs. mean GSU annual volumes.

Maria Pia Fantini-tab 1

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