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

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

Managing panniculitis in alpha-1 antitrypsin deficiency: Systematic review of evidence behind treatment

AIM To systematically review literature for management of alpha-1 antitrypsin deficiency (AATD) panniculitis. METHODS Multiple databases were searched using combinations of pertinent terms. Articles were selected describing panniculitis treatment in patients with AAT &lt; 11 μmol and/or PiZZ genotype, with no language limitation. All relevant articles were accessed in full text. Independent review of abstracts and full manuscripts was conducted by 2 reviewers, and quality assessment by one reviewer (checked by a second). Data extraction was conducted by one reviewer (checked by a second). Narrative synthesis only was conducted, as data were unsuitable for meta-analysis. RESULTS Thirty-two case reports and 4 case series were found. Augmentation therapy (infusions of plasma-derived AAT) was the most successful, with complete resolution of symptoms in all patients. Dapsone is a less expensive option, and it achieved clinical resolution in 62% of patients, but it is very poorly tolerated. Among other single-agent antibiotics, doxycycline was the most successful with complete clinical resolution seen in 33% of patients. Immunosuppressants were largely unsuccessful; 80% of patients exhibited no response. Liver transplantation and therapeutic plasma exchange displayed complete resolution in 66% of patients. Other strategies, such as non-steroidal anti-inflammatory drugs or antibiotics other than dapsone did not show sufficient response rates to recommend their use. Authors note the risk of bias imposed by the type of evidence (case reports, case series) available in this field. CONCLUSION Dapsone is the recommended first line therapy for AATD panniculitis, followed by augmentation therapy. Plasma exchange may be an alternative in the setting of rapidly progressive disease

Cervical Subcutaneous Emphysema following Total Laryngectomy: An Unusual Complication of Nasogastric Intubation

The nasogastric tube remains an important route of enteral feeding in the early postoperative period following total laryngectomy. Its insertion, however, is not without any risks of complications. In this article, we report an unusual case of inadvertent nasopharyngeal perforation secondary to intraoperative nasogastric tube insertion presenting as unilateral cervical subcutaneous emphysema in a patient who underwent total laryngectomy

Cervical Subcutaneous Emphysema following Total Laryngectomy: An Unusual Complication of Nasogastric Intubation

The nasogastric tube remains an important route of enteral feeding in the early postoperative period following total laryngectomy. Its insertion, however, is not without any risks of complications. In this article, we report an unusual case of inadvertent nasopharyngeal perforation secondary to intraoperative nasogastric tube insertion presenting as unilateral cervical subcutaneous emphysema in a patient who underwent total laryngectomy.</jats:p

Superior Survival with Allogeneic Compared to Autologous Stem Cell Transplantation in Patients with Aggressive T Cell Lymphoma

Abstract Introduction: Aggressive T-cell lymphomas often carry poor prognosis. With the exception of ALK+ anaplastic large cell lymphoma (ALCL), median survival for most entities is &lt; 3 years from diagnosis. Whilst stem cell transplant (SCT) consolidation is sometimes used in an attempt to improve survival, its role remains controversial. Encouraging results have been reported with both autologous (ASCT) and allogeneic stem cell transplant (allo-SCT) but it is unclear if one is better than the other. To inform this debate, we set out to examine outcomes of patients receiving SCT consolidation for aggressive T-cell lymphomas at our institute over a 10-year period (between 2005 Ð 2015), comparing results of ASCT versus allo-SCT. Methods: Review of our transplant database identified 59 patients receiving SCT for T-cell lymphomas between the years 2005 - 2015. We excluded 4 patients with low grade T cell lymphomas (mycosisfungoides/sezarysyndrome) from analysis. A further 4 patients were excluded as they had 2 SCT procedures (ASCT followed by an allo-SCT). Thus, 51 patients were eligible for analysis; all having received a single SCT procedure (either ASCT or allo-SCT) for treatment of aggressive T-cell lymphoma. Results: Median age of the entire cohort at the time of transplant was 54 years (range 18-72 years) with 39 male and 12 female patients. The most frequent histologies were: ALCL (n=13), angioimmunoblastic T cell lymphoma (n=10) and high grade T-NHL/ peripheral T-cell lymphoma (PTCL) not further classified (n=16).Thirty sevenof 51 patients had advanced (stage 3 or 4) disease. Median overall survival (OS) and progression free survival (PFS) for the entire cohort were 67 and 23 months respectively. All 30 patients receiving ASCT were conditioned with the BEAM regimen. Of the 21 patients receiving an allo-SCT, sixteen patients had reduced intensity conditioning and 5 myeloablative conditioning with cyclophosphamide and total body radiotherapy. Stem cell source was sibling donor in 11 and unrelated donor in 10patients.Nineteenpatients received a T-cell depleted graft (17 within vivo campath and 2 with ATG). The ASCT and allo-SCT groups were comparable for several baseline variables including tumour stage, LDH, performance status and presence of B symptoms. The allo-SCT cohort was younger with only 24% being over the age of 60 compared to nearly 47% in the ASCT group (median age 45 vs 56.5 years). The allo-SCT cohort had a higher risk disease with only 14 of the 21 patients (68%) being in 1st / 2nd remission at the time of transplant compared with 27 of 30 (90%) in the ASCT group. Furthermore, 16/21 (76%) patients in the allo-SCT cohort received &gt;2 lines of treatment prior to transplant compared to only 2 (7%) in the ASCT cohort. Three patients in the allo-SCT (14%) and 2 in the ASCT (7%) groups were not in remission at the time of SCT. The 5-year OS for the allo-SCT cohort (68%) was significantly superior to the ASCT cohort (36%) (p=0.01). Median OS was significantly superior for the allo-SCT compared to the ASCT cohort (NR vs 21 months, respectively; p=0.03). The 5-year PFS for the allo-SCT cohort (62%) was significantly superior to that of the ASCT (34%) cohort (p= 0.03). The median PFS for the allo-SCT cohort was superior compared to the ASCT cohort (79 vs 17 months, p=0.083). On Cox regression multivariate analysis, disease status at the time of transplant (1st remission vs 2nd remission vs beyond 2nd remission vs not in remission) was significant for predicting both OS and PFS. Prognosis was dismal for those not in remission at the time of transplant with survival of &lt;12 months. Transplant type (Allo vs auto) was significant for OS (HR 0.087, p=0.001) but not for PFS. Conclusion: Our data suggests allo-SCT may confer a survival benefit compared with ASCT for patients with aggressive T-cell lymphomas. This novel observation has not been reported previously and if validated in a larger cohort will be practice changing. Figure 1 Cumulative overall survival for the autologous (ASCT) and allogeneic stem cell transplant (allo-SCT) cohorts. Figure 1. Cumulative overall survival for the autologous (ASCT) and allogeneic stem cell transplant (allo-SCT) cohorts. Figure 2 Progression free survival for the autologous (ASCT) and allogeneic stem cell transplant (allo-SCT) cohorts. Figure 2. Progression free survival for the autologous (ASCT) and allogeneic stem cell transplant (allo-SCT) cohorts. Disclosures No relevant conflicts of interest to declare. </jats:sec

Absence of Association between Preoperative Estimated Glomerular Filtration Rates and Postoperative Outcomes following Elective Gastrointestinal Surgeries: A Prospective Cohort Study

Background. Preoperative risk stratification and optimising care of patients undergoing elective surgery are important to reduce the risk of postoperative outcomes. Renal dysfunction is becoming increasingly prevalent, but its impact on patients undergoing elective gastrointestinal surgery is unknown although much evidence is available for cardiac surgery. This study aimed to investigate the impact of preoperative estimated glomerular filtration rate (eGFR) and postoperative outcomes in patients undergoing elective gastrointestinal surgeries. Methods. This prospective study included consecutive adult patients undergoing elective gastrointestinal surgeries attending preassessment screening (PAS) clinics at the Queen Elizabeth Hospital Birmingham (QEHB) between July and August 2016. Primary outcome measure was 30-day overall complication rates and secondary outcomes were grade of complications, 30-day readmission rates, and postoperative care setting. Results. This study included 370 patients, of which 11% (41/370) had eGFR of 2 comorbidities (p<0.001). Overall complication rates were 15% (54/370), with no significant difference in overall (p=0.644) and major complication rates (p=0.831) between both groups. In adjusted models, only surgery grade was predictive of overall complications. Preoperative eGFR did not impact on overall complications (HR: 0.89, 95% CI: 0.45–1.54; p=0.2). Conclusions. Preoperative eGFR does not appear to impact on postoperative complications in patients undergoing elective gastrointestinal surgeries, even when stratified by surgery grade. These findings will help preassessment clinics in risk stratification and optimisation of perioperative care of patients