Propensity score matching analysis of acute care (ACS) versus colorectal surgeons (CRS) in the management of left colonic perforation: Patient and system-level insights from a multicenter study

Background Left-sided colonic perforation is a severe surgical emergency requiring prompt, technically expert intervention. In Italy, the coexistence of heterogeneous Acute Care Surgery (ACS) models and traditional Colorectal Surgery (CRS) programs provides a unique context to assess differences in outcomes and management for this condition. Methods We conducted a retrospective, multicenter cohort study across six tertiary Italian hospitals (2019-2023) including patients undergoing emergency resection for left-sided colonic perforation. Patients treated by ACS or CRS teams were compared after 1:1 propensity score matching for demographic, clinical, and operative factors. The primary outcome was in-hospital mortality. Secondary outcomes included surgical strategy, minimally invasive use, postoperative complications, reoperation, readmission, 12-month survival, and stoma reversal. Results Of 516 eligible patients, 437 were analyzed (287 ACS, 150 CRS). After matching, 117 patients per group were balanced for 10/11 covariates. In-hospital mortality did not differ (ACS 9.4% vs. CRS 15.4%; p = 0.234), nor did 12-month survival (ACS 80.0% vs. CRS 77.5%; p = 0.813). ACS teams used more conservative strategies (Hartmann's 47.9% vs. CRS 35.0%), with lower rates of successful laparoscopy (8.6% vs. 18.8%; p = 0.036). Notably, ACS management was associated with significantly fewer unplanned reoperations (8.6% vs. 28.2%; p < 0.001) and hospital readmissions (5.7% vs. 17.4%; p = 0.017). Severe complication rates and anastomotic leak incidence were not significantly different, despite favorable trends for ACS. Conclusions In a nationwide matched cohort, ACS surgeons achieved outcomes equivalent to CRS specialists for left-sided colonic perforation, with lower reoperation and readmission rates despite lower rates of primary anastomosis and less frequent successful minimally invasive procedures. ACS may have prioritized physiology oriented approaches rather than anatomical ones, resulting in possible better patients' selection. These findings support ACS as a safe and effective model of emergency surgical care in Italy, underscoring the need for structured training programs and investment in minimally invasive skills to enhance system performance and policy planning.