The value of specialization - Is there an outcome difference in the management of fistulas complicating diverticulitis

PURPOSE: The value of specialization has frequently been challenged by many health care institutions and providers. This review was conducted to deter mine whether there were any outcome differences in the management of fistul as complicating diverticulitis. METHODS. We conducted an historical cohort study using hospital charts of all cases of fistulas complicating diverticu litis that were operated on in four university-affiliated hospitals between 1975 and 1995. There were 122 patients, with 37 under the care of fully tr ained colorectal surgeons and 85 under die care of general surgeons. RESULT S: There were no significant differences in patient demographics, preoperat ive comorbidities, or the number of preoperative diagnostic investigations between the two groups. The colorectal surgeons performed more intraoperati ve ureteral stenting (Colorectal Surgery 55.5 percent vs. General Surgery 2 4.4 percent, P = 0.001). The general surgeons performed more initial divert ing Hartmann's and colostomy procedures (Colorectal Surgery 5.4 percent vs. General Surgery 27 percent, P = 0.013) The patients in the General Surgery group had longer preoperative lengths of stay (median Colorectal Surgery 3 (range, 1-28) days vs. General Surgery 8 (range, 0-29) days; P < 0.001), l onger postoperative lengths of stay (median Colorectal Surgery 11 (range, 5 -40) days vs. General Surgery 14 (range, 2-80) days; P = 0.001), and longer total lengths of stay (median Colorectal Surgery 14 (range, 6-62) days vs. General Surgery 24 (range, 6-100) days; P < 0.001). The patients in the Ge neral Surgery group experienced a higher rate of wound infections (Colorect al Surgery 5.4 percent vs. General Surgery 12.9 percent), and a larger prop ortion of them experienced complications (Colorectal Surgery 27 percent vs. General Surgery 41.2 percent). CONCLUSIONS: We conclude that specializatio n in colon and rectal surgery contributed to an improved outcome, with a lo wer rate of diverting procedures, a shorter hospital stay, and a lower rate of complications.