Comment on: Effect of centre volume on pathological outcomes and postoperative complications after surgery for colorectal cancer: results of a multicentre national study

Dear Editor

We read with interest the recent article by Rottoli et al.¹, who present data suggesting improved outcomes for colorectal cancer in high-volume centres. We agree the data provide a compelling case for centralization of rectal resection and the complexity of pelvic surgery warrants this. However, Rottoli et al.¹ do not address the question of whether it is safe for lower-volume centres to routinely undertake colon cancer surgery.

Where data are presented for colon and rectal cancer combined, despite low-volume centres performing more emergency surgery for more advanced disease, rates of R0 resection and node clearance are comparable to, or better than, those of high-volume centres¹. This begs the question, if colonic resections are analysed alone, would any differences persist across volume settings and change the authors’ conclusions?

As a surgical team on a remote island, we face the following question on a daily basis: where is the best place for my patient to have an operation? Arguing for centralization of all colorectal cancer surgery necessitates the end of elective procedures in centres expected to perform emergency operations. This runs the risk of surgical teams becoming less familiar with such procedures and rescuing subsequent complications, increasing the likelihood of poor outcomes on top of the risk already conferred by emergency surgery.

With 43% of the global population living rurally, case volume–outcome research is essential to surgical decision-making in rural settings. For patients, tertiary centres are often far from home and support networks. Not every patient can have their operation in a tertiary centre, therefore maintaining the skills of rural teams is crucial for sustainable delivery of surgery for all.

Author contributions

Alice Joyce (Conceptualization, Writing—original draft, Writing—review & editing), Thomas M. Drake (Conceptualization, Supervision, Writing—original draft, Writing—review & editing), Caitlin Hampson (Writing—original draft, Writing—review & editing), Alice Monaghan (Writing—original draft, Writing—review & editing), Stuart Fergusson (Writing—original draft, Writing—review & editing), and Gordon McFarlane (Supervision, Writing—original draft, Writing—review & editing)