Is there a weekend effect in emergency surgery for colorectal carcinoma? Analysis from the German StuDoQ registry

Friedrich Anger; Sven Lichthardt; Imme Haubitz; Johanna Wagner; Stefan Löb; Heinz Johannes Buhr; Christoph-Thomas Germer; Armin Wiegering

doi:10.1371/journal.pone.0277050

Peer Review History

Original SubmissionApril 23, 2022
10 Sep 2022 Decision Letter - Leonardo Solaini, Editor PONE-D-22-11972Is there a weekend effect in emergency surgery for colorectal carcinoma? Analysis from the German StuDoQ registryPLOS ONE Dear Dr. Anger, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Oct 25 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author ******** Review Comments to the Author Reviewer #1: The topic chosen by the authors is no doubt interesting. The so-called weekend effect is a well-studied but yet-to-be-demonstrated and defined hypothetical impact suggesting that patients hospitalized and treated on weekends may have different outcomes than those admitted and treated during normal workday hours. The authors immediately focus in the Introduction one of the major problems in the interpretation of this effect “The published data originates from different health care systems varying in the provision of acute and hospital care, weakening their comparability “. Choosing to select a defined disease confined to a homogeneous health system can be a very effective choice. The aims of the study are clearly stated. They also provide an opportunity to learn about a specific tool of the German Health care system, MTL 30, well explained in the bibliographic references provided. Both the structure of the statistical analysis and the definition of primary and secondary outcomes are well defined. The conclusion of the study is consistent with the available data and should be an incentive for surgeons to require in their institutions a work structure that considers the skills of the medical teams that are assembled. An adequate arrangement of resources protects the patient (and also the surgeons) any day of the week. Some notes In Results: the conversion rate in open surgery should be specified in the text In tab 1 and 2 it is clear that in all cases an anastomosis was performed. In table 2 the rate of diverting stoma is specified; it would be interesting to know the indications for protective stomas. In the tab 2 the part related to ostomy should be better clarified: prior? After resection surgery: Is this a redo surgery due to complication? . Unfortunately, due to the characteristics of the database, it is not possible to know how many patients were operated for occlusion, how many for perforation and / or bleeding nor the data of mortality at 90 days and this leads to lose part of the value of the paper. Reviewer #2: This is a generally well written paper on an important and topical subject. The authors have obtained data on a large number of patients with CRC treated as an emergency. The outcome measures chosen are relevant and well recognized in similar studies. Their data was obtained form the German StuDoQ registry, which would be familiar to German readers. However, for the benefit of non-German readers it would be helpful if the authors could add a sentence or two in the first paragraph of the Methods section to indicate if this registry captures all cases of CRC in Germany, or if it is selective. There is one area of the results/discussion where I would like further clarification- Overall there was a higher rate of severe post operative complications and return to theatre for weekday versus weekend patients, but there was no difference in mortality or other outcomes. The reason for this may be due to case mix. The authors allude to the fact that defunctioning stoma is widely used in Germany for emergency cases. It would be helpful if the authors could explicitly state (or show on a table) whether there is any significant difference in the type of surgery performed on different days. For example were there more resectional operations done on Mon-Fri and more defunctioning operations done on a weekend? There are also several areas where the grammar/ syntax should be changed- Methods Section - "Study Population" - line 3-4 should be "classified as an emergency" Methods Section - "Study Population" - Line 9 - should be "clinical features such as the American....." Methods Section - "Study Population" - Line 13 - should be "logistic measures such as the day..." Methods Section - "Statistical analysis and outcome measures" - Line 1- should be " a two-step approach" Results Section - "Emergency Surgery" - Line 2 - should be "where surgery had been performed on a week day rather" Results Section - "Emergency Surgery" - penultimate line - should be "The timing of emergency surgery...." Discussion Section - Paragraph 2 - Line 10 - should be "as bridge to surgery is the preferred rout in German hospitals," Discussion Section - Paragraph 2 - Line 11- should be "multimodality treatment prior to resection." Discussion Section - Paragraph 3 - Line 4-6 - The sentence should be rephrased so that it reads as - "In 2011, the National Confidential Enquiry into Patient Outcome and Death report (17), showed that there had been inadequate post-operative care or monitoring in over 50% of patients who died after emergency visceral surgery in the United Kingdom." ******** While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0277050.r001
Revision 1
27 Sep 2022 Author Response We would like to thank the reviewers for their valuable time and useful contributions. We highly appreciate the inputs you have given which definitely helped to improve our manuscript. In the following, please find point-to-point answers to your comments. All corrections or implementations are highlighted in the revised manuscript. Reviewer #1: 1) In Results: The conversion rate in Open surgery should be specified in the text. Thank you for this important point. We added the significant difference in the surgical approach to the results section in the text. 2) In tab 1 and 2 it is clear that in all cases an anastomosis was performed. In table 2 (now table 1) the rate of diverting stoma is specified; it would be interesting to know the indications for protective stomas. Thank you for this query. Unfortunately, the StuDoQ registry does not provide data on the indications for protective stomas. But the most reasonable indications for diverting stoma prior surgery is a tumor stenosis, simultaneously to resection surgery is protection of the actual anastomosis. In case of a diverting stoma placement after resection surgery, patients underwent re-operation due to anastomotic leakage. 3) In the tab 2 the part related to ostomy should be better clarified: prior? After resection surgery: Is this a redo surgery due to complication? Thank you for this valid point. We restructured this part in table 2 (now table 1) to clarify this information for the reader. It now says whether patients received a diverting stoma and at what time with regard to the resection surgery. Although the registry does not provide information on the indication for diverting stoma placement, all patients who received a diverting stoma after resection surgery had re-operation performed. Reviewer #2: 1) There is one area of the results/discussion where I would like further clarification- Overall there was a higher rate of severe post operative complications and return to theatre for weekday versus weekend patients, but there was no difference in mortality or other outcomes. The reason for this may be due to case mix. The authors allude to the fact that defunctioning stoma is widely used in Germany for emergency cases. We appreciate this relevant comment. Indeed, severe post-operative complications and return to theatre for weekday patients occurred (significantly) more often, but the same was found for re-admission, length of stay, MTL30 and 30d mortality. The latter remain without statistical significance, most likely due to the rather small sample size of weekend surgeries included. The higher rate of postoperative complications triggering reoperations can be explained by more extended colectomies and rectal resections performed on a weekday. This might be due to the fact that in case of obstructing colorectal cancer the sole creation of an ostomy without resection surgery is performed more often on a weekend. However, patients without resection of their colorectal cancer were not included in this study. Case mix seems to be a rather unlikely reason for a higher rate of postoperative complications and reoperations for weekday patients, since UICC tumor stages in patients who underwent emergency colorectal cancer resections on the weekend were significantly higher than in patients who received emergency surgery on a weekday. In addition, no difference was found for Age, BMI, ASA, functional status and comorbidities between the two groups (new table 1). 2) It would be helpful if the authors could explicitly state (or show on a table) whether there is any significant difference in the type of surgery performed on different days. For example were there more resectional operations done on Mon-Fri and more defunctioning operations done on a weekend? Thank you for this important query. There is a significant difference in resection strategy between weekday and weekend surgery, mostly due to more rectum resections on weekdays (10.4%) compared to weekends (2.8%) (new table 1). This led to the conclusion, that emergencies due to e.g. obstructing rectal cancer were managed by decompressing ostomy as bridge to surgery, as pointed out in the discussion section (second paragraph). Cases with no resection but just decompressing or defunctioning surgery in terms of stoma creation were not included in this study. Regarding the creation of a diverting stoma, no difference could be found between weekday and weekend emergency resection surgeries due to colorectal cancer. 3) There are also several areas where the grammar/ syntax should be changed- Please excuse us for this shortcoming and thank you for the detailed revision. We changed all errors according to your suggestions. Attachments Attachment Submitted filename: Response to reviewers comments.docx https://doi.org/10.1371/journal.pone.0277050.r002
19 Oct 2022 Decision Letter - Leonardo Solaini, Editor Is there a weekend effect in emergency surgery for colorectal carcinoma? Analysis from the German StuDoQ registry PONE-D-22-11972R1 Dear Dr. Anger, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Leonardo Solaini, MD Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0277050.r003
Formally Accepted
25 Oct 2022 Acceptance Letter - Leonardo Solaini, Editor PONE-D-22-11972R1 Is there a Weekend Effect in Emergency Surgery for Colorectal Carcinoma? Analysis from the German StuDoQ Registry Dear Dr. Anger: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Leonardo Solaini Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0277050.r004

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