title: The effect of surgical subspecialization on outcomes in peptic ulcer disease complicated by perforation and bleeding.
abstract: BACKGROUND
  Emergency surgical services in Edinburgh were restructured in July 2002 to deliver subspecialist management of colorectal and upper-gastrointestinal emergencies on separate sites. The effect of emergency subspecialization on outcome from perforated and bleeding peptic ulceration was assessed.
  
  
  METHODS
  All patients admitted with complicated peptic ulceration (January 2000-February 2005) were identified from a prospectively compiled database.
  
  
  RESULTS
  Perforation: 148 patients were admitted with perforation before the service reorganization (period A - 31 months) of whom 126 (85.1%) underwent surgery; 135 patients were admitted in period B (31 months) of whom 114 (84.4%) were managed operatively. The in-hospital mortality was lower in period B (14/135, 10.4%) than period A (30/148, 20.3%; P = 0.023; relative risk (RR), 0.51; 95% confidence interval (CI), 0.28-0.91). There was a significantly higher rate of gastric resection in the second half of the study (period A 1/126 vs. period B 8/114; P = 0.015; RR, 8.84; 95% CI, 1.48-54.34). Length of hospital stay was similar for both groups. Bleeding: 51 patients underwent operative management of bleeding peptic ulceration in period A and 51 in period B. There were no differences in length of stay or mortality between these two groups.
  
  
  CONCLUSIONS
  Restructuring of surgical services with emergency subspecialization was associated with lower mortality for perforated peptic ulceration. Subspecialist experience, intraoperative decision-making, and improved postoperative care have all contributed to this improvement.
authors.affiliation: Department of Surgery, Royal Infirmary of Edinburgh, Lecturers' Office (F3339) - Ward 106, United Kingdom. andrew.robson@ed.ac.uk
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Robson
authors.forename: Jennifer M J
authors.initials: JM
authors.lastname: Richards
authors.forename: Nicholas
authors.initials: N
authors.lastname: Ohly
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Nixon
authors.forename: Simon
authors.initials: S
authors.lastname: Paterson-Brown
mesh_terms: D000368:Aged; D013505:Digestive System Surgical Procedures / Q000401:mortality; D004381:Duodenal Ulcer / Q000150:complications; D004632:Emergency Medical Services / Q000458:organization & administration*; D005260:Female; D017052:Hospital Mortality; D006754:Hospital Restructuring; D006801:Humans; D008297:Male; D008875:Middle Aged; D010438:Peptic Ulcer Hemorrhage / Q000401:mortality / Q000601:surgery*; D010439:Peptic Ulcer Perforation / Q000401:mortality / Q000601:surgery*; D012606:Scotland; D013043:Specialties, Surgical / Q000458:organization & administration*; D013276:Stomach Ulcer / Q000150:complications; D016896:Treatment Outcome