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

The effect of type of femoral component fixation on mortality and morbidity after hip hemiarthroplasty:A systematic review and meta-analysis

Background: Hip hemiarthroplasty is a well-established treatment of displaced femoral neck fracture, although debate exists over whether cemented or uncemented fixation is superior. Uncemented prostheses have typically been used in younger, healthier patients and cemented prostheses in older patients with less-stable bone. Also, earlier research has suggested that bone cement has cytotoxic effects and may trigger cardiovascular and respiratory adverse events. Questions/Purposes: The aim of this systematic review and meta-analysis was to compare morbidity and mortality rates after cemented and uncemented hemiarthroplasty for the treatment of displaced femoral neck fractures in elderly patients. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched seven medical databases for randomized clinical trials and observational studies. We compared cemented and uncemented hemiarthroplasty using the Harris Hip Score (HHS), as well as measures of postoperative pain, mortality, and complications. Data were extracted and pooled as risk ratios or standardized mean difference with their corresponding 95% confidence intervals in a meta-analysis model. Results: The meta-analysis included 34 studies (12 randomized trials and 22 observational studies), with a total of 42,411 patients. In the pooled estimate, cemented hemiarthroplasty was associated with less risk of postoperative pain than uncemented hemiarthroplasty. There were no significant differences between groups regarding HHS or rates of postoperative mortality, pulmonary embolism, cardiac arrest, myocardial infarction, acute cardiac arrhythmia, or deep venous thrombosis. Conclusions: While we found that cemented hemiarthroplasty results in less postoperative pain than uncemented hemiarthroplasty in older patients with femoral neck fracture, the lack of significant differences in functional hip scores, mortality, and complications was surprising. Further high-level research is needed

Use of Telemedicine for Postdischarge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review With Meta-analysis

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardized assessment tools are needed. // Background: Surgical site infection (SSI) is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. // Methods: The primary outcome of this study was SSI reported up to 30 days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analyzed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30 days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). // Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs 11.1%, P<0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval: 0.63–0.84, P<0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In 9 eligible nonrandomized studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47–0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. // Conclusions: Use of telemedicine to assess the surgical wound postdischarge is feasible, but risks underreporting of SSI. Standardized tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Rare manifestation of endometriosis causing complete recto-sigmoid obstruction: A case report

AbstractIntoductionEndometriosis is a disease in which endometrial epithelium implanted outside the uterus. Although the endometrial tissue can implant anywhere, the most common places are the ovary and pelvic peritoneum. We present a rare case of recto-sigmoid endometriosis that causes a complete large bowel obstruction in a non-reproductive age woman who came with no specific symptoms of endometriosis and the diagnosis was made after surgical resection.Case presentationA 50 years old female who never been married and admitted to have no sexual experience in her life, presented with symptoms of acute bowel obstruction. She underwent sigmoid colectomy as the primary diagnosis was colonic tumor, but the histopathological reports showed the diagnosis with recto-sigmoidal Endometriosis. At the second laparotomy for closure of colostomy, the uterus was abnormal and she had a hysterectomy with salpingio-oopherectomy to prevent recurrence. The histopathological report revealed cervical, ovarian, and fallopian tube endometriosis.DiscussionUnlike our patient, most patients complain of the common symptoms of endometriosis such as dysmenorrhea, dyspareunia, and dyschezia and many of them came with infertility as a main complaint which make them undergo further investigations like laparoscopy, and lead to pre-surgical diagnosis of endometriosis. But in case of complete bowel obstruction, urgent laparotomy is the treatment of choice.ConclusionAlthough Intestinal endometriosis is rare to cause bowel obstruction physicians and surgeons should always consider it as a differential diagnosis of bowel obstruction even without specific symptoms, to prevent surgery in incomplete obstruction

Dosage of epidural morphine analgesia after lower abdominal cancer surgery: a randomized clinical trial among the older adults

Abstract Background Epidural morphine is considered one of the most potent drugs used for postoperative analgesia; however, its side effects are dose-related and exaggerated in elderly people. In this study, we aimed to determine which of three doses within that range (1.5 mg, 3 mg, or 4.5 mg) can provide adequate pain relief. Methods A total of 102 patients were assessed for allocation into one of four groups to receive either placebo (group Morphine 0, N = 22), 1.5 mg of epidural morphine (Morphine 1.5, N = 22), 3 mg of epidural morphine (Morphine 3, N = 22), or 4.5 mg of epidural morphine (Morphine 4.5, N = 22) before skin incision, 24 h after surgery and 48 h after surgery. Cumulative intravenous IV-PCA morphine consumption, VAS pain scores, modified Ramsay Sedation Scores, nausea, vomiting, and pruritus were evaluated. Results The VAS pain scores at activity of patients who received epidural morphine at doses of 3 mg and 4.5 mg were significantly lower than the placebo and 1.5 mg groups, VAS Score at 72 h was (2 ± 0.8) and (1.7 ± 1) vs (4.3 ± 1.1) and (4 ± 1) respectively, p value = 0.000. The mean total IV-PCA morphine consumption (mg) was significantly higher in patients who received received epidural 0.9% sodium chloride alone compared to 1.5 mg, 3 mg and 4.5 mg epidural morphine groups (38.1 ± 4.8 mg vs 27.2 ± 5.6 mg, 9.2 ± 3.5 mg, and 6.3 ± 3.3 mg respectively), p value = 0.000). However, the difference between the 3 mg and the 4.5 mg groups was not statistically significant in both of VAS scores and IV-PCA morphine consumption (P value > 0.05 for 3 mg vs. 4.5 mg). Patients who received 4.5 mg of epidural morphine experienced a significant increase in the level of sedation, measured by the Ramsay sedation scale, in comparison with 1.5 mg, 3 mg and placebo epidural morphine groups in the first 24 h, the Scale for this group was (2.5 ± 0.5) vs (2.1 ± 0.2, 2.1 ± 0.2, and 2.2 ± 0.5 respectively); p value = 0.000. No relationship between postoperative nausea and the dosage of epidural morphine was found. Conclusion Epidural morphine 3 mg as a bolus every 24 h with add on IV patient control analgesia (PCA) morphine, set to deliver 1.5 mg boluses on demand without background infusion with a lockout period of 45 min, could achieve effective and adequate analgesia lasting up to 72 h postoperatively without increasing in the level of sedation or other side effects in older adults after a lower abdominal cancer surgery