Early endoscopic intervention in acute gastrointestinal bleeding may reduce the need for blood transfusion

BackgroundAcute gastrointestinal bleeding (GIB) is a common gastroenterological emergency worldwide with significant morbidity and mortality of 6 per cent–14 per cent. The main causes of death in patients with GIB include shock, aspiration, and therapeutic procedure carried out for the management of the GIB. Thus, the resuscitation strategy of blood transfusion plays a very important role in these patients before any other specific treatment. Currently, endoscopy is considered the mainstay of diagnosis and treatment for patients with GIB.AimsTo assess the effect of an early endoscopic intervention on the need for blood transfusion in patients presented with GIB.MethodsWe retrospectively analysed the data for patients presented with hematemesis, melena, or hematochezia, from July 2015 to July 2016, in Ballarat Base Hospital (BHS) in Victoria, Australia. Data were extracted from the hospital coding system related to patient’s demographic history, alcohol intake, comorbidity, procedure details including the timing and the type of procedure performed, and the number of units of blood transfused. Additionally, the laboratory blood test results for each patient were examined through the electronic records to assess the haemoglobin level before and after the blood transfusion.Results A total of 92 eligible patients with GIB during the 12 months study period, were included in this observational study. The median age of the study population was 67 years (range 24-96) at the time of admission. A total of 67 patients (73 per cent) underwent inpatient endoscopic procedure with gastroscopy performed in 52 patients, colonoscopy in 5 patients, flexible sigmoidoscopy in 3 patients, and combined gastroscopy and colonoscopy in 7 patients. In the enrolled population (n=92), at time of presentation, 11 patients (12 per cent) had the haemoglobin level below 7grams per decilitre (g/dL), 17 patients (18 per cent) had haemoglobin level between 7 and 8g/dL, and 64 patients (70 per cent) had haemoglobin level greater than 8g/dL. Out of the 67 patients who had inpatient endoscopy, 12 patients underwent endoscopic procedure within 12 hours of admission ( 12 hours group), including 31 patients who received blood transfusion. Among participants who received a blood transfusion in the two groups, 1 out of 5 patients in the 12 hours group had haemoglobin level below 8g/dL at the time of transfusion.ConclusionTrends of greater blood transfusion in patients with delayed (> 12 hours) endoscopic procedure and administering blood transfusion at haemoglobin level >8g/dL in patients with early (< 12 hours) endoscopic procedure were observed without achieving statistical significance. The results obtained from this study indicate that more saving in terms of cost of treatment from blood transfusion can be achieved by adopting an optimized restrictive transfusion strategy

Caesarean scar ectopic pregnancy: Experience from an Australian tertiary centre

Background: Despite the rising incidence of caesarean scar pregnancy (CSP), as yet there are no consensus or evidence-based guidelines for management. Aims: To review diagnosis, treatment and management of all women with CSP over a 5 year period at Mater Mothers’ Hospital, Brisbane, Australia. Materials and methods: Retrospective cohort study of CSP between 2013–2018. Data reviewed included demographics, presenting symptoms, gestational age, ultrasound findings, human chorionic gonadotrophin levels, treatment success, complications, and if available, subsequent pregnancy outcomes. Results: Twenty-eight women were treated for CSP during the study period. Initial diagnosis was delayed in ten (36%). Overall success rates of initial treatment were 22/28 (79%). Of the six cases of failed treatment, five had been treated with systemic methotrexate alone. All women requiring further intervention had fetal pole present, and 50% had fetal cardiac activity. Failure rate of systemic methotrexate alone was 5/11 (45%). Eleven women deemed appropriate for conservative management did not require further treatment or experience complications. Nine women had data available for subsequent pregnancies, of whom two developed placenta accreta. Conclusion: This study provides data that may assist in guideline development and decision-making for management of CSP. Conservative management in care- fully selected women appeared to be safe. Nearly half of women treated with systemic methotrexate alone required another treatment modality, suggesting a role for intralesional treatment, particularly in the presence of fetal pole ± fetal cardiac activity. More than one in five women with documented subsequent pregnancies were diagnosed with placenta accreta

Global variation in anastomosis and end colostomy formation following left‐sided colorectal resection

BackgroundEnd colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection.MethodsThis study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model.ResultsIn total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P &lt; 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P &lt; 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P &lt; 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P &lt; 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P &lt; 0·001).ConclusionGlobal differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.The aim of this study was to inform vaccination prioritization by modelling the impact of vaccination on elective inpatient surgery. The study found that patients aged at least 70 years needing elective surgery should be prioritized alongside other high-risk groups during early vaccination programmes. Once vaccines are rolled out to younger populations, prioritizing surgical patients is advantageous

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially