The main objective of this study was to study the short-term surgical outcome for curative colorectal resections from our center. The literature pertaining to the short-term outcomes from such a setup from our region, i.e., the eastern part of the Indian subcontinent, is scanty. We observed the median number of colectomies, rectal surgeries, and overall colorectal resections per year (2021–2024) as 11, 10.5, and 23, respectively, ie 70.5% (146/207) of the total cohort. Firstly, to answer the question of whether we qualify as low-volume or a high-volume center, we do not have any published literature from our country for such classification. Furthermore, surgical volume-based categorization for colorectal units from elsewhere, based on the number of surgeries, is also wide-ranging, with some defining it based on the individual surgeon’s volume or hospital volume and some literature defining volume for colon and rectal surgeries separately [8, 9, 10, 11]. On using Damle et al. definition for colonic resections, we stand as a medium-volume center (9–18 per year) though we are at the cusp of transitioning to a high-volume center (18 or more per year) [9]. The German Cancer society (DKG) defined high volume as more than 40 colonic resections, which is far more than the number of cases we are currently performing; hence, we remain a low-volume center by this definition [12]. In the context of rectal primaries, 20 or more resections are defined as the number to categorize a high volume, and our median yearly output was 11 cases per year [10]. Overall, the definition for high volume for colorectal resections was wide ranging, with the American colorectal society suggesting 21 cases per year and the Dutch definition being 50 cases per year [12, 13]. Although with respect to the number of cases we operate, we are a low-volume center, we are transitioning to a high volume with increasing complexity of cases and challenges associated with them. Apart from this, the number of complex colorectal resections is also on the rise at our center, which poses unique challenges to carefully select patients and the surgical skills to perform the same [14].

Secondly, with regard to where we stand in terms of short-term surgical outcomes when compared to the published outcomes, we compared our outcomes both with low- and high-volume centers (Table 4). On average, our duration of surgeries was longer compared to Tan et al. and Yılmaz et al. (Table 4) [15, 16]. But it is important to note that we are a training center with surgical trainees also performing surgeries under the guidance of senior surgeons to ensure quality training without compromising patient safety. In the pathological quality of surgical resections indices, our margin-positive resection status and suboptimal nodal yield rates were lower than the results published by Warps et al., Siraguasa et al., and Rottoli et al., but not comparable to the results of Damle et al. [8, 9, 17, 18]. Readmission after discharge, which could be considered a surrogate for poor postoperative recovery and increased health care expenditure, was 3.4% in our cohort. While this number is lower than the results in the Dutch Colorectal audit (7.5% for colon and 13.8% for rectum), it is nevertheless a number we need to improve [17]. Our perioperative mortality was 2.9% [6 cases] of which three were due to medical complications. Our major short-term morbidity, defined as Clavien-Dindo Grade 3 or above, was higher in the rectal patients than in colonic patients (Table 2). But it is important to understand that the treatment approach is different for both subsets, and our outcomes were similar to the ones published by the Dutch colorectal audit [17]. Based on these results (Table 4), we could achieve safe oncological resection and ensure reasonably good short-term surgical outcomes comparable to that of other low-volume and high-volume centers [8, 9, 15, 16, 17, 18, 19].

Ours is a tertiary cancer center under the Tata Memorial Centre (Mumbai) under the Department of Atomic Energy, Government of India, and this larger association has helped in pushing for standardization of certain protocols, particularly in terms of preoperative treatment planning. However, the limited access to resources, particularly due to the remote location and limited man-power, there are certain challenges like the limited availability of mechanical sutures, energy devices, and laparoscopy-trained nursing staff. Also, implementation of Enhanced Recovery after Surgery (ERAS) fast-track principles is being addressed now with active multidisciplinary collaborations. At our center, interdisciplinary team discussion for selection of patients and close coordination between surgeons, anaesthesiologists, nursing team, physiotherapists, dieticians, ostomy nurse, and the patient’s guardian, with the patient at the core in the perioperative period, have become the cornerstone of the surgical management. With more accessibility to our center, growing experience of the surgical team, and the increasing number of cases and greater governmental support for covering treatment costs, we are expecting improved perioperative outcomes. Also, the standardization of preoperative evaluation and surgical steps and monthly surgical audits have actively contributed to our pursuit of improving the outcomes [20, 21].

A major strength of this study is that it provides real-world data about short-term surgical outcomes in a Tier-2 city in India and the evolution of the colorectal unit at our center. However, the limitations of the study also need to be addressed, which include its retrospective nature, single-institution data, and missingness of datasets for many past patients. Further, the long-term survival outcomes were not studied in our cohort, as the majority of our patients were operated on in the last 2 years. Hence, clinically meaningful follow-up was not achieved to calculate the survival outcomes. Also, the study includes other pathologies, including melanoma and neuroendocrine tumors, and it is important to note that the focus of this study is evaluating short-term surgical outcomes of curative colorectal resections and is not restricted to colorectal adenocarcinoma alone.

Through the National Cancer Grid of India, it is the right time for member institutions to collaborate and develop India-centric registries, identify challengesand propose India-centric solutions. This can help upcoming centers like ours to compare their outcomes and evolve methods to take corrective measures [22]. In the long run, this can help in re-allocation of resources to centers across India and develop centers of excellence for colorectal cancer treatment and cater to the needs and challenges unique to each region.