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

Abstract B92: Molecular characterization of colorectal cancer in Ghana

Abstract Colorectal cancer is the fourth most common cancer in men and the third most common cancer in women worldwide with significant variation between different parts of the globe. Although colorectal cancer incidence is relatively low in West Africa, the most recent publications from Nigeria and Ghana note significant increase of colorectal cancer incidence in these countries since 1970. These studies also show that colorectal cancer in West Africa has distinctive pattern with young age of onset and predominantly left-sided tumors, yet the spectrum of molecular changes in colorectal tumors has not been characterized in West African populations. The goal of this study was to investigate molecular characteristics of colorectal cancer in Ghana. We retrieved 90 formalin-fixed paraffin embedded (FFPE) colorectal cancer blocks from the University of Ghana Medical School (Accra) diagnosed between 1997 and 2007. Ten 5 μm recuts and H&amp;E slide were prepared for each block and reviewed by the pathologist to determine areas of at least 70% tumor cellularity and areas of adjacent normal tissue. DNA was extracted from the microdissected tumor and normal tissue. Only 71 samples had both tumor and normal tissue within the available specimen. Ten microsatellite marker loci (D10S197, BAT26, beta-catenin, D18S58, BAT40, D2S123, D17S250, BAT25, TGF-b-RIIF, and D5S346F) were used for microsatellite instability (MSI) testing using fluorescently labeled primers and fragment analysis. Tumors with at least one mononucleotide marker and a minimum of three available markers were considered for analysis. The tumors with instability in at least 30% of markers were called MSI-High, less than 30% classified as MSI-Low, and tumors with all stable markers were called microsatellite stable (MSS). Sequencing BRAF and KRAS was repeated twice from both directions and analyzed by two independent readers using Sequencher from GeneCodes (Ann Arbor, MI) and Mutation Surveyor from SoftGenetics (State College, PA) to avoid misinterpretation. Out of 71 colorectal cancer pairs of normal and tumor tissue, MSI testing was informative for 70 pairs. An exceptionally large proportion of cancers were MSI-High (29/70, 41.4%), with 14/70 (20%) MSI-Low tumors, and 27/70 (38.6%) MSS tumors. Sequencing of exons 1 and 2 of KRAS in 75 tumors detected 24 (32%) activating mutations (G12D, G12V, G12C, G12S, G13D, Q61R, and Q61K). Surprisingly, the sequencing of exon 15 of BRAF, the location of frequent activating mutation (V600E), did not show any mutations at codons 599 and 600 in 88 tumor samples. Our study showed a very high frequency of MSI-high colorectal tumors (41.4%), consistent with the higher rates of MSI-High cancers observed in some studies of colorectal cancer in African American patients. The frequency of KRAS mutations is comparable to one found in African Americans, but absence of BRAF mutations is intriguing and requires further analysis of the epidemiology and biology of colorectal cancer in West Africa. Citation Format: Leon Raskin, Jonathan C.B. Dakubo, Nicole Palaski, Joel Greenson, Stephen Gruber. Molecular characterization of colorectal cancer in Ghana. [abstract]. In: Proceedings of the Eleventh Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2012 Oct 16-19; Anaheim, CA. Philadelphia (PA): AACR; Cancer Prev Res 2012;5(11 Suppl):Abstract nr B92.</jats:p

Morbidity and oncological outcomes after intersphincteric resection of the rectum for low-lying rectal cancer: experience of a single center in a lower-middle-income country

Abstract Background Intersphincteric resection (ISR) of the rectum for low-lying rectal cancer with colo-anal anastomosis was introduced years ago, allowing for bowel continuity, and avoiding permanent stomas. The colorectal unit of Korle Bu Teaching Hospital adopted this procedure in 2014 when indicated, for the management of rectal cancers, where hitherto, abdominoperineal resection of the rectum with a permanent stoma was indicated. This study aimed to assess morbidity, mortality, and oncological outcomes associated with ISR of the rectum and determine the factors contributing to these. Methods This was an observational study from prospectively stored data. All patients who underwent intersphincteric resection of the rectum due to low-lying rectal cancer from July 2014 to June 2021 were included in the study, and their records were assessed for intra-operative and 30-day postoperative complications, as well as mortality and their related risk factors and their oncological outcomes in terms of local recurrence at one year. Results 102 patients were included in this analysis. Six percent (6/102) of patients had intra-operative complications, including bleeding, and 41% (42/102) had 30-day postoperative complications, which were associated with pelvic side wall attachment of tumor and intra-op complications. Mortality risk was 12.7% (13/102) in the early postoperative period, and nine patients had a local recurrence within the first year of surgery. Conclusion There is a high risk of early postoperative morbidity and mortality after intersphincteric resection of the rectum in our setting. The oncological outcomes are favorable in a population that abhors a permanent colostomy. </jats:sec

Mucinous adenocarcinoma of a tailgut cyst

A tailgut cyst is a rare congenital lesion that develops from a residual posterior remnant of the intestine and presents as a mass in the presacral space. They are generally asymptomatic or have atypical symptoms, are usually benign but may rarely become malignant. We report a case of a 37-year-old female who initially presented to the Surgical De-partment of Korle Bu Teaching Hospital, Accra, Ghana with a malignant tailgut cyst after having repeated surgical procedures for recurrent perianal infective pathologies but still had persistence of symptoms. The lesion was initially excised and found to be a dermoid cyst histologically. The mass recurred after a year and had a re-excision; the lesion was diagnosed histologically as mucinous adenocarcinoma. This report emphasizes the different forms of presentation of a patient with a tailgut cyst and the possibility of malignant transformation, as well as the presentation of this tailgut cyst which can be diagnosed using radiological investigations and histological findings

Mucinous adenocarcinoma of a tailgut cyst

A tailgut cyst is a rare congenital lesion that develops from a residual posterior remnant of the intestine and presents as a mass in the presacral space. They are generally asymptomatic or have atypical symptoms, are usually benign but may rarely become malignant. We report a case of a 37-year-old female who initially presented to the Surgical De-partment of Korle Bu Teaching Hospital, Accra, Ghana with a malignant tailgut cyst after having repeated surgical procedures for recurrent perianal infective pathologies but still had persistence of symptoms. The lesion was initially excised and found to be a dermoid cyst histologically. The mass recurred after a year and had a re-excision; the lesion was diagnosed histologically as mucinous adenocarcinoma. This report emphasizes the different forms of presentation of a patient with a tailgut cyst and the possibility of malignant transformation, as well as the presentation of this tailgut cyst which can be diagnosed using radiological investigations and histological findings.</jats:p

Evaluation of bacterial infection of split-thickness skin grafts at the Korle Bu Teaching Hospital

Background: Split skin grafts are frequently employed to provide biological cover for extensive wounds. The clinical outcome of skin grafts depends on a variety of factors of which infection is one of the most important. The intent of this study was to define the micro-organisms causing skin graft infections and failures at the National Reconstructive Plastic Surgery and Burns Centre (NRPSBC) at the Korle Bu Teaching Hospital (KBTH). Aim: The study assessed the extent to which bacterial infection of grafted wounds resulted in graft failure and subsequent re- grafting.Materials and Methods: The study was a longitudinal study conducted on the wards of the NRPSBC at the KBTH on patients with wounds who received split skin grafts. Wound swabs of discharging grafted wounds were inoculated into a Stuarts’ transport medium to prevent desiccation and transported immediately to the microbiology laboratory for further processing.Results: Fifteen (20.8%) of the grafts failed to take. The incidence of infected grafted wounds was 79.2% (57). Infected grafted wounds that resulted in graft failure were 14 out of 57 infected wounds (24.6%). Pseudomonas aeruginosa and Other Pseudomonas Species were identified as the bacteria frequently involved in graft failure at the NRPSBC.Conclusion: In this study, we found a graft failure rate of 20.8%. This was influenced by the bacterial load present in the graft bed. </jats:p