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

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p &lt; 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

PATIENT SURVIVAL WITH ypT0N+ FOLLOWING NEOADJUVANT THERAPY IN GASTRIC AND RECTAL CANCERS

Background Survival outcomes of gastric and rectal cancer patients who developed ypT0N+ remain poorly characterized. Methods A survival analysis of the NCDB was conducted on patients with gastric or rectal adenocarcinoma who underwent neoadjuvant therapy and surgery. Results Among gastric cancer patients, achieving ypT0N+ was associated with lower 5-year and 3-year overall survival (OS) than ypT0N0 and ypT1-2N0. There were no differences in 1-year OS between ypT0N+ and ypT0N0 or ypT1-2N0. There were also no differences in 5-year, 3-year, or 1-year OS between ypT0N+ and ypT3-4N0 or ypT1-2N+. Developing ypT0N+ was associated with a higher 5-year OS than ypT3-4N+. There were no differences in 3-year or 1-year OS between ypT0N+ and ypT3-4N+. . Among rectal cancer patients who received total neoadjuvant therapy, developing ypT0N+ was associated with a lower 5-year OS than ypT0N0 and ypT1-2N0. However, ypT0N+ disease was associated with a higher 5-year OS than ypT3-4N+. There were no differences in 5-year OS between ypT0N+ and ypT3-4N0 or ypT1-2N+. Similar findings were noticed among rectal cancer patients who received neoadjuvant chemoradiation and adjuvant chemotherapy. Conclusion Developing ypT0N+ was associated with a lower 5-year OS than ypT0N0 and ypT1-2N0 and a higher 5-year OS than ypT3-4N+ in both gastric and rectal cancers

Survival outcomes of pulmonary metastasectomy in advanced melanoma patients: An inverse probability weighted analysis.

e21518 Background: Pulmonary metastasectomy (PM) is a commonly performed procedure for certain patients with lung metastasis. We aimed to estimate the effect of PM on the survival outcomes of advanced melanoma patients with lung metastasis. Methods: We queried the Surveillance, Epidemiology, and End Results (SEER) database for all adult patients with advanced melanoma (AYA site recode) with lung metastasis (Stage M1b according to AJCC 7th edition) who were diagnosed from 2010 to 2015. Patients with known liver, brain, or bone metastasis were excluded. Our primary outcomes were overall survival (OS) and cancer-specific survival (CSS) in months. We used Kaplan-Meier plots to compare survival outcomes between treatment groups. We adjusted for potential confounders including age, sex, marital status, primary tumor surgery, chemotherapy, and radiotherapy in a multivariate analysis. We carried out an inverse probability (IP)-weighted Cox regression in an attempt to eliminate the effect of nonrandomization when estimating the treatment effect of PM on OS and CSS. Results: We included 520 patients; 98 (18.8%) underwent PM and 422 (81.2%) did not. The sample median age was 71 (IQR: 61-80). T0 stage was prevalent in 179 (34.4%) and N0-1 in 302 (58.1%). Primary surgical resection was performed for 217 (41.7%) patients, 136 (26.2%) patients had undergone chemotherapy, and radiotherapy was administered in 64 (12.3%) patients. Patients who underwent PM had a higher median OS than patients who did not (43.0 months, 95% CI: 25.0-not reached vs. 13 months, 95% CI: 11-16). The median CSS in PM group patients was not reached (95% CI: 43.0-not reached), while it was 16 months (95% CI: 13-21) in non-PM patients. After multivariate adjustment, older age, being single, and not undergoing primary surgical resection, were all significant independent prognostic factors for worse OS and CSS. In contrast, sex and receipt of chemotherapy and/or radiotherapy did not affect either OS or CSS. PM group patients had a significant survival advantage than non-PM patients, in terms of OS and CSS (HR = 0.50, 95% CI: 0.37-0.67 and HR = 0.45, 95% CI: 0.32-0.63, respectively). On the IP-weighted Cox analysis, the survival benefits of PM were still significantly favorable for OS (IP-weighted HR = 0.42, 95% CI: 0.30-0.59) and CSS (IP-weighted HR = 0.38, 95% CI: 0.26-0.57). Conclusions: PM in a multimodality treatment setting resulted in a marked survival advantage for patients with advanced melanoma who had lung metastasis only. The management of such patients should be delicately individualized to optimize their survival outcomes. </jats:p

Neoadjuvant chemoradiotherapy versus neoadjuvant chemotherapy for patients with stage III-N2M0 non-small cell lung cancer (NSCLC): A population-based study.

8503 Background: Stage III-N2 non-small cell lung cancer (NSCLC) is a heterogeneous disease with controversial management options. Induction therapy as part of multimodal treatment is the standard of care for Stage III-N2 NSCLC. We aim to investigate the effect of adding radiotherapy to neoadjuvant chemotherapy on survival outcomes. Methods: All adult NSCLC patients diagnosed between 2004 and 2015 were identified in the Surveillance, Epidemiology, and End Results (SEER) database using ICD-O-3 histologic type coding. Inclusion criteria involved stage III NSCLC patients with ipsilateral lymph node involvement (N2), of any T stage, and with no known distant metastasis (M0). Our main sub-cohorts were patients who either underwent chemoradiotherapy (CRT) or chemotherapy (CT) in neoadjuvant settings. Our primary outcomes were overall survival (OS) and cancer-specific survival (CSS) in months. Cox proportional hazards model was used to analyze the effect of each treatment modality on OS and CSS in univariate and multivariate fashions. Multivariate analysis was adjusted for age, sex, marital status, T stage, resected lymph node status, tumor histology, primary site, laterality, and surgical procedure. Inverse probability treatment weighting (IPTW) was applied to create weighted samples based on study covariates. Results: Our analysis included 1175 patients; 799 (68.0%) underwent neoadjuvant CRT and 376 (32.0%) underwent neoadjuvant CT. Sample median age was 63 (IQR:56-69) years. T2 stage was the most prevalent (N =561, 47.7%), followed by T4 (N=243, 20.7%), T1 (N=228, 19.4%), and T3 (N=143, 12.2%). The main tumor histology was non-squamous cell carcinoma in 773 (65.8%) patients. The upper lobe was the most common primary tumor site (N =788, 67.1%). Patients underwent lobectomy (N=917, 78.0%), pneumonectomy (N=184, 15.7%), or sub-lobar resection (N=69, 5.9%). Adding radiotherapy to chemotherapy showed a slightly higher median OS than chemotherapy alone in neoadjuvant settings (51 vs. 47 months, respectively), and a higher median CSS (75 vs. 59 months, respectively). However, these differences were not statistically significant for OS or CSS (HR = 1.08, 95% CI: 0.91-1.28 and HR = 1.04, 95% CI: 0.89-1.21, respectively). After adjustment, age, T3-T4 stage, non-squamous histology, lower lobe primary site, positive resected lymph nodes, and pneumonectomy were all significant independent predictors for worse OS and CSS. IPTW analysis showed no remarkable survival advantage for CRT patients (HR = 1.15, 95% CI: 0.95-1.40 and HR= 1.12, 95% CI: 0.90-1.39) for OS and CSS, respectively. Conclusions: Adding radiotherapy to neoadjuvant CT did not result in significant survival benefits. Multiple prognostic factors should be taken into consideration when identifying the optimal choice and sequence of multimodal treatment for stage III-N2M0 NSCLC patients. </jats:p