The effect of surgical training and hospital characteristics on patient outcomes after pediatric surgery: a systematic review

Abstract Background/Purpose A systematic review aimed to compare patient outcomes after (1) appendicectomy and (2) pyloromyotomy performed by different surgical specialties, surgeons with different annual volumes, and in different hospital types, to inform the debate surrounding children's surgery provision. Methods Embase, Medline, Cochrane Library, and Health Management Information Consortium were searched from January 1990 to February 2010 to identify relevant articles. Further literature was sought by contacting experts, citation searching, and hand-searching appropriate journals. Results Seventeen relevant articles were identified. These showed that (1) rates of wrongly diagnosed appendicitis were higher among general surgeons, but there were little differences in other outcomes and (2) outcomes after pyloromyotomy were superior in patients treated by specialist surgeons. Surgical specialty was a better predictor of morbidity than hospital type, and surgeons with higher operative volumes had better results. Conclusions Existing evidence is largely observational and potentially subject to selection bias, but general pediatric surgery outcomes were clearly dependent on operative volumes. Published evidence suggests that (1) pediatric appendicectomy should not be centralized because children can be managed effectively by general surgeons; (2) pyloromyotomy need not be centralized but should be carried out in children's units by appropriately trained surgeons who expect to see more than 4 cases per year.