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

Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

Results of percutaneous transhepatic biliary drainage

Romualdas Riauka Master's thesis „Results of percutaneous transhepatic biliary drainage“ / Scientific supervisor prof. G. Barauskas, MD, PhD; Lithuanian University of Health Sciences, Faculty of Medicine, Department of Surgery - Kaunas Percutaneous transhepatic biliary drainage (PTBD) acts as an alternative way to achieve biliary decompression in patients with obstructive jaundice, when endoscopic drainage is unavailabe. This procedure can reduce high serum bilirubin levels, this way achieving better liver function, reducing side effects of jaundice and hiperbilirubinaemia and allowing patients to receive further treatment. Aim of this master's thesis was to evaluate the drainage results of patients, who received PTBD in the Department of Surgery of Hospital of Lithuanian University of Health Sciences between year 2014 and 2015. Objectives were: to analyze main indications to perform PTBD, to evaluate procedure's technical success rate and laboratory outcomes, to asses main additional interval procedures and drainage related complications and to analyze main in-hospital mortality causes. Retrospective review of patients with successful or unsuccessful PTBD attempts between year 2014 and 2015 was performed. Patients were reviewed for biliary obstruction causes, laboratory tests prior the procedure, complications related to percutaneous drainage, outcomes (laboratory tests at the time of discharge and additional interval procedures), causes and rate of mortality. Malignant diseases were present in 91,5 % of the patients. Periampullary tumors (33,3%) and liver metastases (32,6%) were main cause of biliary obstruction. PTBD procedure was successful in 123 out of 129 patients (technical success rate - 95,3%). Values of total serum bilirubin, gamma-glutamyltransferase, alkaline phosphatase, aspartate transaminase and alanine transaminase were statistically significantly lower after PTBD, compared to values prior PTBD. There were 71 transhepatic biliary stenting procedures (81,6%) out of 87 additional interval procedures. Drainage catheter discolation occured 34 times out of 49 (69,4%). Out of 38 deceased patients, 20 patients (52,6%) died because of cholangitis and sepsis. Main indication to perform PTBD was obstructive jaundice caused by periampullary tumors and liver metastases. Procedures technical succes rate was 95,3%. PTBD statistically significantly reduced values of total serum bilirubin, gamma-glutamyltransferase, alkaline phosphatase, aspartate transaminase and alanine transaminase, compared to values prior PTBD. Most common additional interval procedure after PTBD was percutaneous transhepatic biliary stenting. Main occuring complication was dislocation of drainage catheter. Most common cause of death was cholangitis and sepsis

Does endoscopic retrograde cholangiopancreatography influence the effectiveness of percutaneous transhepatic biliary drainage?

Background Endoscopic retrograde cholangiopancreatography (ERCP) is a first-choice diagnostic and treatment procedure for patients with malignant obstructive jaundice. If ERCP is impossible to perform percutaneous transhepatic biliary drainage (PTBD) acts as an alternative method. The aim was to evaluate the effectiveness and the influence of ERCP prior PTBD in the treatment of patients with malignant obstructive jaundice. Methods Retrospective review of patients undergoing PTBD from 2014 to 2015 at the Department of Surgery, Hospital of the Lithuanian University of Health Sciences was performed. Group I - ERCP prior PTBD, Group II – no ERCP prior PTBD. Length of hospital stay, total serum bilirubin values, additional interval procedures, complication and mortality rates were compared. Results Group I consisted of 66 patients and Group II of 48 patients. PTBD significantly reduced total serum bilirubin values in both groups: from 287,87±118,99µmol to 178,35±102,61µmol in Group I (p<0,001) and from 306,83±142,83 µmol to 215,97±127,19 µmol in Group II (p<0,001). However there was no statistically significant difference between total serum bilirubin values, drainage related complication and mortality rates, additional interval procedures. Conclusion ERCP attempt prior PTBD was not associated with serum bilirubin reduction, higher drainage related complication or mortality rates. On the other hand, patients after ERCP, tend to stay longer in hospital, what is associated with higher treatment cost

Preoperative Platelet to Lymphocyte Ratio as a Prognostic Factor for Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis

&lt;b&gt;&lt;i&gt;Introduction:&lt;/i&gt;&lt;/b&gt; Various inflammatory markers have been investigated for a prognostic role in patients with resectable pancreatic cancer. However, the value of preoperative platelet to lymphocyte ratio (PLR) remains controversial. We performed a systematic review and meta-analysis of PLR as a preoperative prognostic factor for resectable pancreatic cancer. &lt;b&gt;&lt;i&gt;Material and Methods:&lt;/i&gt;&lt;/b&gt; Systematic literature search was conducted for studies assessing PLR influence as a preoperative prognostic factor in resectable pancreatic cancer patients. Random-effects model was applied for pooling hazard ratios and 95% confidence intervals related to overall survival (OS) and disease-free survival (DFS). &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; Fourteen articles with 2,743 patients were included in the study. According to the analysis, high PLR had no correlation with decreased OS. Due to high heterogeneity among studies, subgroup analysis was performed. Better OS was associated with low PLR in Asian patients, patients with mixed type of operation performed, and patients with preoperative PLR ≤150. Low PLR was associated with significantly better DFS. &lt;b&gt;&lt;i&gt;Conclusions:&lt;/i&gt;&lt;/b&gt; PLR is a predictive factor of better DFS in patients with resectable pancreatic cancer. However, available evidence does not support PLR as a reliable prognostic factor for OS. </jats:p

DNA Methylation of HOXA11 Gene as Prognostic Molecular Marker in Human Gastric Adenocarcinoma

Hypermethylation of tumor suppressor genes and hypomethylation of oncogenes might be identified as possible biomarkers in gastric cancer (GC). We aimed to assess the DNA methylation status of selected genes in GC tissue samples and evaluate these genes’ prognostic importance on patient survival. Patients (99) diagnosed with GC and who underwent gastrectomy were included. We selected a group of genes (RAD51B, GFRA3, AKR7A3, HOXA11, TUSC3, FLI1, SEZ6L, GLDC, NDRG) which may be considered as potential tumor suppressor genes and oncogenes. Methylation of the HOXA11 gene promoter was significantly more frequent in GC tumor tissue (p = 0.006) than in healthy gastric mucosa. The probability of surviving longer (71.2 months (95% CI 57–85.3) vs. 44.3 months (95% CI 34.8–53.9)) was observed with unmethylated HOXA11 promoter in cancer tissues. Survival in patients with a methylation of HOXA11 promoter either in healthy gastric mucosa or gastric cancer tissue was twice as high as in patients with a methylation of HOXA11 promoter in both healthy gastric mucosa and cancer tissue (61.2 months (95% CI 50.9–71.4) vs. 28.5 months (95% CI 20.8–36.2)). Multivariate Cox analysis revealed the HOXA11 methylation as significantly associated with patients’ survival (HR = 2.4, 95% CI 1.19–4.86). Our results suggest that the HOXA11 gene might be a potential prognostic molecular marker in patients with gastric adenocarcinoma.</jats:p

DNA Methylation of HOXA11 Gene as Prognostic Molecular Marker in Human Gastric Adenocarcinoma

Hypermethylation of tumor suppressor genes and hypomethylation of oncogenes might be identified as possible biomarkers in gastric cancer (GC). We aimed to assess the DNA methylation status of selected genes in GC tissue samples and evaluate these genes&rsquo; prognostic importance on patient survival. Patients (99) diagnosed with GC and who underwent gastrectomy were included. We selected a group of genes (RAD51B, GFRA3, AKR7A3, HOXA11, TUSC3, FLI1, SEZ6L, GLDC, NDRG) which may be considered as potential tumor suppressor genes and oncogenes. Methylation of the HOXA11 gene promoter was significantly more frequent in GC tumor tissue (p = 0.006) than in healthy gastric mucosa. The probability of surviving longer (71.2 months (95% CI 57&ndash;85.3) vs. 44.3 months (95% CI 34.8&ndash;53.9)) was observed with unmethylated HOXA11 promoter in cancer tissues. Survival in patients with a methylation of HOXA11 promoter either in healthy gastric mucosa or gastric cancer tissue was twice as high as in patients with a methylation of HOXA11 promoter in both healthy gastric mucosa and cancer tissue (61.2 months (95% CI 50.9&ndash;71.4) vs. 28.5 months (95% CI 20.8&ndash;36.2)). Multivariate Cox analysis revealed the HOXA11 methylation as significantly associated with patients&rsquo; survival (HR = 2.4, 95% CI 1.19&ndash;4.86). Our results suggest that the HOXA11 gene might be a potential prognostic molecular marker in patients with gastric adenocarcinoma

DNA Methylation of HOXA11 Gene as Prognostic Molecular Marker in Human Gastric Adenocarcinoma

Hypermethylation of tumor suppressor genes and hypomethylation of oncogenes might be identified as possible biomarkers in gastric cancer (GC). We aimed to assess the DNA methylation status of selected genes in GC tissue samples and evaluate these genes’ prognostic importance on patient survival. Patients (99) diagnosed with GC and who underwent gastrectomy were included. We selected a group of genes (RAD51B, GFRA3, AKR7A3, HOXA11, TUSC3, FLI1, SEZ6L, GLDC, NDRG) which may be considered as potential tumor suppressor genes and oncogenes. Methylation of the HOXA11 gene promoter was significantly more frequent in GC tumor tissue (p = 0.006) than in healthy gastric mucosa. The probability of surviving longer (71.2 months (95% CI 57–85.3) vs. 44.3 months (95% CI 34.8–53.9)) was observed with unmethylated HOXA11 promoter in cancer tissues. Survival in patients with a methylation of HOXA11 promoter either in healthy gastric mucosa or gastric cancer tissue was twice as high as in patients with a methylation of HOXA11 promoter in both healthy gastric mucosa and cancer tissue (61.2 months (95% CI 50.9–71.4) vs. 28.5 months (95% CI 20.8–36.2)). Multivariate Cox analysis revealed the HOXA11 methylation as significantly associated with patients’ survival (HR = 2.4, 95% CI 1.19–4.86). Our results suggest that the HOXA11 gene might be a potential prognostic molecular marker in patients with gastric adenocarcinoma