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Association Between Hospital and Surgeon Volume and Rectal Cancer Surgery Outcomes in Patients With Rectal Cancer Treated Since 2000

Systematic Literature Review and Meta-analysis

Chioreso, Catherine, M.P.H.1; Del Vecchio, Natalie, M.S.1; Schweizer, Marin L., Ph.D.2; Schlichting, Jennifer, Ph.D.1; Gribovskaja-Rupp, Irena, M.D.3; Charlton, Mary E., Ph.D.1

doi: 10.1097/DCR.0000000000001198
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BACKGROUND: Previous reviews and meta-analyses, which predominantly focused on patients treated before 2000, have reported conflicting evidence about the association between hospital/surgeon volume and rectal cancer outcomes. Given advances in rectal cancer resection, such as total mesorectal excision, it is essential to determine whether volume plays a role in rectal cancer outcomes among patients treated since 2000.

OBJECTIVE: The purpose of this study was to determine whether there is an association between hospital/surgeon volume and rectal cancer surgery outcomes among patients treated since 2000.

DATA SOURCES: We searched PubMed and EMBASE for articles published between January 2000 and December 29, 2017.

STUDY SELECTION: Articles that analyzed the association between hospital/surgeon volume and rectal cancer outcomes were selected.

INTERVENTION: Rectal cancer resection was the study intervention.

MAIN OUTCOME MEASURES: The outcome measures of this study were surgical morbidity, postoperative mortality, surgical margin positivity, permanent colostomy rates, recurrence, and overall survival.

RESULTS: Although 2845 articles were retrieved and assessed by the search strategy, 21 met the inclusion and exclusion criteria. There was a significant protective association between higher hospital volume and surgical morbidity (OR = 0.80 (95% CI, 0.70–0.93); I2 = 35%), permanent colostomy (OR = 0.51 (95% CI, 0.29–0.92); I2 = 34%), and postoperative mortality (OR = 0.62 (95% CI, 0.43–0.88); I2 = 34%), and overall survival (OR = 0.99 (95% CI, 0.98–1.00); I2 = 3%). Stratified analysis showed that the magnitude of association between hospital volume and rectal cancer surgery outcomes was stronger in the United States compared with other countries. Surgeon volume was not significantly associated with overall survival. The articles included in this analysis were high quality according to the Newcastle–Ottawa scale. Funnel plots suggested that the potential for publication bias was low.

LIMITATIONS: Some articles included rectosigmoid cancers.

CONCLUSIONS: Among patients diagnosed since 2000, higher hospital volume has had a significant protective effect on rectal cancer surgery outcomes.

1 Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa

2 Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa

3 Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (

Funding/Support: None reported.

Financial Disclosure: None reported.

Correspondence: Catherine Chioreso, M.P.H., College of Public Health Department of Epidemiology, University of Iowa, 145 N Riverside Dr, Iowa City, IA 52242. E-mail:

© 2018 The American Society of Colon and Rectal Surgeons