Isolated Cecal Rupture after Blunt Abdominal Trauma

Cecal perforation following blunt abdominal trauma is an uncommon and challenging injury. We report a 19-year-old HIV-positive woman who presented with abdominal pain after a high-speed motor vehicle crash. Abdominal exam revealed a seatbelt sign with evidence of peritonitis; Focused Assessment with Sonography for Trauma showed free intraperitoneal fluid. After fluid resuscitation and antibiotics, the patient was taken for urgent laparotomy. Intraoperatively, we discovered hemoperitoneum and an isolated rupture of the cecum. A right hemicolectomy with end-to-end ileo-transverse colon anastomosis was performed. Her only significant postoperative complication was a superficial wound infection. We review the epidemiology of hollow viscus injury in blunt trauma and discuss important considerations in diagnosis and treatment. Keywords: Blunt abdominal trauma, Cecal rupture, HIV positive, Hollow viscu

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Use of Telemedicine for Postdischarge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review With Meta-analysis

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardized assessment tools are needed. // Background: Surgical site infection (SSI) is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. // Methods: The primary outcome of this study was SSI reported up to 30 days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analyzed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30 days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). // Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs 11.1%, P<0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval: 0.63–0.84, P<0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In 9 eligible nonrandomized studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47–0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. // Conclusions: Use of telemedicine to assess the surgical wound postdischarge is feasible, but risks underreporting of SSI. Standardized tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Job Satisfaction and Its Determinants among Nurse Anesthetists in Clinical Practice: The Botswana Experience

Job satisfaction (JS) correlates positively with patients’ satisfaction and outcomes and employees’ well-being. In Botswana, the level of job satisfaction and its determinants among nurse anesthetists were not investigated. A cross-sectional study was conducted from January 2020 to June 2020 encompassing all nurse anesthetists in clinical practice in Botswana. A self-administered questionnaire was used that incorporated demographic data, reasons to stay on or leave their job, and a validated 20-item short form of the Minnesota Satisfaction Questionnaire which was pretested on five of our nurse anesthetists. Percentage is used to describe the data. The independence of categorical variables was examined using chi-square or Fisher’s exact test. p value &lt;0.05 was considered statistically significant. In Botswana, a total of 76 nurse anesthetists were in clinical practice during the study period. Sixty-six (86.9%) responded to the survey. Gender distribution was even, 50.0%. The overall JS was 36.4%. Males had significantly higher JS than females, p = 0.001 . Significantly higher job satisfaction was found in married nurse anesthetists ( p = 0.039 ), expatriate nurse anesthetists ( p = 0.001 ), nurse anesthetists in non-referral hospitals ( p = 0.023 ), and nurse anesthetists with ≥10 years’ experience ( p = 0.019 ). Nurse anesthetists were satisfied with security, social service, authority, ability utilization, and responsibility in ≥60.0% of the cases. They were not satisfied in compensation, working condition, and advancement in a similar percentage. The main reason to stay on their job was to serve the public in 68.2%. In Botswana, employers should make an effort to address the working conditions, compensation, and advancement of nurse anesthetists in clinical practice.</jats:p

Managing adults with previously treated anorectal malformations

Background: Although rare, it is not unheard of to encounter patients whose anorectal malformations have been ignored until adulthood in resource-limited environments. However, it is extremely uncommon to be faced with patients whose early primary management was directed toward a permanent stoma. In cases where the proximal rectum is all but sacrificed, the management for definitive repair and reconstitution of intestinal continuity is a challenge. Little information exists in the literature. Methods: The management of two adult female patients born with rectovestibular fistulas in a resource-limited environment is reviewed. Their management was complicated by inadequate repair, followed by resection of the distal intestine, and creation of a permanent end stoma. Both patients were seeking definitive repair of the inadequately treated anorectal malformation and reconstitution of intestinal integrity. The existing literature is reviewed. Results: Both patients are doing well three years after the final surgical interventions. Neither patient has fecal incontinence. One initially had issues with constipation, but has successfully overcome the problem using dietary measures. Neither has issues with the genitourinary system. Review of the literature revealed numerous articles describing the delayed presentation of patients with anorectal malformations, but none describing this specific group of patients in whom the initial management specifically targeted a permanent stoma. Conclusion: Adults with inadequately repaired rectovestibular fistulas whose initial surgical management specifically targets resection of the proximal rectum and creation of a permanent end colostomy are rare. Their management is a challenge, especially in resource-limited environments. When the anorectal malformation is of a favourable type, appropriate investigation coupled with meticulous surgical planning of the definitive repair may yield excellent outcomes

Isolated Cecal Rupture after Blunt Abdominal Trauma

Cecal perforation following blunt abdominal trauma is an uncommon and challenging injury. We report a 19-year-old HIV-positive woman who presented with abdominal pain after a high-speed motor vehicle crash. Abdominal exam revealed a seatbelt sign with evidence of peritonitis; Focused Assessment with Sonography for Trauma showed free intraperitoneal fluid. After fluid resuscitation and antibiotics, the patient was taken for urgent laparotomy. Intraoperatively, we discovered hemoperitoneum and an isolated rupture of the cecum. A right hemicolectomy with end-to-end ileo-transverse colon anastomosis was performed. Her only significant postoperative complication was a superficial wound infection. We review the epidemiology of hollow viscus injury in blunt trauma and discuss important considerations in diagnosis and treatment.&#x0D; Keywords: Blunt abdominal trauma, Cecal rupture, HIV positive, Hollow viscus</jats:p