Original article Volume analysis of outcome following restorative proctocolectomy E. M. Burns 1 , A. Bottle 2 , P. Aylin 2 , S. K. Clark 3 , P. P. Tekkis 1 , A. Darzi 1 , R. J. Nicholls 1 and O. Faiz 1 1 Department of Surgery, Imperial College London, St Mary’s Hospital, and 2 Dr Foster Unit, Department of Primary Care and Social Medicine, Imperial College London, London, and 3 Department of Surgery, St Mark’s Hospital, Harrow, UK Correspondence to: Mr O. Faiz, Department of Surgery, Imperial College London, 10th Floor QEQM Building, St Mary’s Hospital, Praed Street, London W21NY, UK (e-mail: omarfaiz@aol.com) 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. Presented to the Annual Scientific Meeting of the European Society of Coloproctology, Prague, Czech Republic, September 2009, to the International Surgical Congress of the Association of Surgeons of Great Britain and Ireland, Liverpool, UK, April 2010, and to the Annual Meeting of the Association of Coloproctology of Great Britain and Ireland, Bournemouth, UK, June 2010 Paper accepted 9 September 2010 Published online 11 November 2010 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.7312 Introduction Restorative proctocolectomy with ileal reservoir (RPC), described in 1978 1 , has become the operation of choice for patients with ulcerative colitis requiring surgery and for some with familial adenomatosis polyposis. Several studies have reported short- and long-term outcomes following RPC 2,3 . Despite its widespread acceptance and use, considerable postoperative morbidity has been reported in large series, with more than 60 per cent of patients experiencing complications 4 . Surgical results have improved with increased operative experience 5–7 . The UK National Inflammatory Bowel Disease (IBD) Audit 2006 reported that the institutional median volume was four RPCs per year 8 . The low volumes carried out by most individual surgeons have resulted in little published information from low-volume centres. One approach to achieving the sample sizes required for the meaningful analysis of outcome is to use either national clinical registry and/or national administrative data sets.  2010 British Journal of Surgery Society Ltd British Journal of Surgery 2011; 98: 408–417 Published by John Wiley & Sons Ltd Downloaded from https://academic.oup.com/bjs/article/98/3/408/6148531 by guest on 07 June 2022