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

A Preliminary Clinical Experience Using Hypothermic Oxygenated Machine Perfusion for Rapid Recovery of Octogenarian Liver Grafts

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Subcostal Biportal Right Lower Lobectomy Day Surgery

<p>This video describes a video-assisted thoracoscopic surgery (VATS) subcostal biportal right lower lobectomy performed as a day surgery. This abdominal extrathoracic approach is inspired by both Chinese and UK experience in VATS subxiphoid major pulmonary resections. The motivation was to explore an original way for better recovery and minimizing invasiveness, without making any concessions on safety or carcinologic resection. The patient was a 69-year-old man with normal pulmonary function who presented with a 2 cm carcinoid tumor proximally in the posterobasal segment of the right lower lobe.<br></p> <p>The operation began with a 4 cm paramedian subxiphoid incision, opening only the anterior aponeurosis of the rectus abdominis and finding a subcostal way to the pleura with the finger. A wound retractor was pushed into the pleural cavity, giving anterior access via this working port. The second port was created under optic control, located subcostally on the middle axillary line. This port provided access for a 12 mm trocar dedicated to 30° thoracoscopic camera and an articulated 5 mm grasper for lung exposure. There was no intercostal incision. This was a fissureless lobectomy. The principal instruments used were a LigaSure Maryland jaw (37 cm) and a Scanlan curved suction instrument, associated with classical VATS dissectors.</p><p>The first step began with section of the inferior ligament, followed by dissection and stapling of the inferior pulmonary vein. The stapler came tangentially from the working port. The second step followed with the subcarinal lymphadenectomy of stations 8 and 7. Placing the thoracoscope in the second subcostal port is very useful to give a higher and more panoramic view than one would get with a camera located in the anterior subxiphoid port. The next step was the dissection of the 12R node, an important landmark, for exposure of the middle lobe carina. A tunnel fissure technique was then used to open the anterior part of the major fissure, giving access to the pulmonary artery. The lower lobe bronchus was then dissected and stapled. The 12R node was resected, and the lower lobe arteries were exposed. An accurate 3D pulmonary angiogram assessment is mandatory, especially for this fissureless approach to the procedure, in order to have perfect knowledge of potential anatomical variations. In case of such variations, the tunnel fissure technique could have been completed for better exposure of the artery in the fissure.</p><p>Both the A6 and basal arteries were then dissected and stapled. This provided access to the remaining fissure, which was also stapled, completing the lower lobectomy. The lymphadenectomy was continued on stations 2R and 4R for a free Barety space. The patient was integrated in an Enhanced Recovery After Surgery Program, permitting a day surgery lobectomy without any morphine use. The tube was removed at hour four under Medela Thopaz electric aspiration control, and the patient was comfortable and was discharged at hour eight. An atypic carcinoid tumor was diagnosed with a pT1N1 upstaging, and the patient’s follow-up was uneventful.</p><p>Learn more: https://www.ctsnet.org/article/subcostal-biportal-right-lower-lobectomy-day-surgery</p

Transcriptomic evidence for tumor-specific beneficial or adverse effects of TGFβ pathway inhibition on the prognosis of patients with liver cancer

International audienceTherapeutic targeting of the transforming growth factor beta (TGFβ) pathway in cancer represents a clinical challenge since TGFβ exhibits either tumor suppressive or tumor promoting properties, depending on the tumor stage. Thus, treatment with galunisertib, a small molecule inhibitor of TGFβ receptor type 1, demonstrated clinical benefits only in subsets of patients. Due to the functional duality of TGFβ in cancer, one can hypothesize that inhibiting this pathway could result in beneficial or adverse effects depending on tumor subtypes. Here, we report distinct gene expression signatures in response to galunisertib in PLC/PRF/5 and SNU-449, two cell lines that recapitulate human hepatocellular carcinoma (HCC) with good and poor prognosis, respectively. More importantly, integrative transcriptomics using independent cohorts of patients with HCC demonstrates that galunisertib-induced transcriptional reprogramming in SNU-449 is associated with human HCC with a better clinical outcome (i.e., increased overall survival), while galunisertib-induced transcriptional reprogramming in PLC/PRF/5 is associated with human HCC with a worse clinical outcome (i.e., reduced overall survival), demonstrating that galunisertib could indeed be beneficial or detrimental depending on HCC subtypes. Collectively, our study highlights the importance of patient selection to demonstrate a clinical benefit of TGFβ pathway inhibition and identifies Serpin Family F Member 2 (SERPINF2) as a putative companion biomarker for galunisertib in HCC

The Role of Cavoportal and Renoportal Hemitransposition in Liver Transplantation

International audienceBackground: Few series of cavoportal (CPA) or renoportal (RPA) anastomosis have been published and their survival rates have never been compared. The objective of this study was to evaluate perioperative and long-term outcomes of CPA and RPA in a nationwide multicentric series and to compare hemitranspositions (HT) to paired ortho-topic liver transplantations (OLT). Material/Methods: HT performed in France up to April 2019 were analyzed. Endpoints were the incidence of severe (Clavien-Dindo&gt;IIIa) 90-day perioperative complications and long-term patient and graft survival. Results: Sixty-four HT (13 CPA, 51 RPA) were performed in 59 patients. The rates of perioperative CD&gt;IIIa complica-tions were 64% and 49% in patients with CPA and RPA, respectively (P=0.59), and the rates of portal throm-bosis and ascites were 38.5% and 9.8% (p=0.023) and 53.8% and 21.6% (p=0.049) in patients with CPA and RPA, respectively. The patient and graft perioperative survival rates were 54.4% and 83.3% (HR=3.2; CI 95 [1.1-9.9]; p=0.039) and 54.4% and 77.1% (HR=2.2; CI 95 [0.77-6.4]; P=0.14) in the CPA and RPA groups, respec-tively. Five-year patient survival was 36.4% and 61.8% in the CPA and RPA groups, respectively (HR=2.5; CI 95 [1-6.1]; P=0.039). Compared with OLT grafts, long-term HT graft survival rates were not different (HR=1.7; CI 95 [0.96-3.1]; P=0.066), while patient survival rates were lower in the HT group (HR=4.6; CI 95 [2-11]; P&lt;0.001). Conclusions: Compared to OLT, HT significantly reduces patient survival. Given the poor survival results of CPA, the indica-tion deserves to be limited in the context of organ shortage and RPA should be preferred when HT is needed

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

High-risk exposure without personal protective equipment and infection with SARS-CoV-2 in-hospital workers - The CoV-CONTACT cohort.

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High-risk exposure without personal protective equipment and infection with SARS-CoV-2 in-hospital workers - The CoV-CONTACT cohort

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