Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

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

Background End 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. Methods This 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. Results In 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 < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 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 < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 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 < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Photorefractive keratectomy in the management of high myopic defect, tissue-saving vs Planoscan

Scopo: : Valutare l'efficacia, la sicurezza e la prevedibilità della cheratectomia fotorefrattiva (PRK) con il laser Technolas 217 z100 Baush&amp;Lomb (algoritmo Zyoptix Tissue Saving) nel trattamento di difetti di rifrazione miopica elevata in pazienti con cornee sottili. Metodi: : Gli autori riportano i risultati durante un periodo di follow-up di 10 mesi di 16 occhi trattati con l'algoritmo Zyoptix Tissue Saving per difetti di rifrazione miopi elevati con e senza astigmatismo in pazienti con cornee sottili e diametro pupillare scotopico maggiore di 6,5. Per ogni paziente l' acuità visiva non corretta (UCVA) e l'acuità visiva migliore (BCVA) pre e postoperatoria sono state classificate dopo 1, 3, 6 e 10 mesi. Risultati: : L'età media dei pazienti era 35,9 (range 22-54). Gli occhi trattati erano 28. Il risparmio medio di tessuto corneale è stato del 24% con ottimi risultati di rifrazione rispetto al trattamento Planoscan. Questo algoritmo ha ridotto le aberrazioni di ordine superiore per mezzo di un profilo di ablazione laser basato sull'aberrometria Zywave Hartmann-Shack e la formula di Munnerlin consentendo un'ablazione di una zona ottica più ampia con risparmio di tessuto corneale. Il trattamento ha considerato la possibilità di una diversa tipologia di ablazione a seconda delle caratteristiche di ciascun paziente; Planoscan Zyoptix personalizzato Tissue Saving. Il post-operatorio non corretto l'acuità visiva in ogni paziente non è mai stata inferiore ai valori pre-operatori. Nel primo mese dopo il trattamento abbiamo riscontrato uno spostamento ipermetropico variabile da + 0,75 a + 2 diottrie (D) nei pazienti con miopia e astigmatismo miopico. I pazienti erano stati informati di queste ipercorrezioni transitorie e dei possibili rischi e benefici del trattamento. Conclusioni: : Gli autori ritengono che la cheratectomia fotorefrattiva sia un valido approccio alla chirurgia refrattiva in pazienti con elevati errori di rifrazione e cornee sottili. Tuttavia, per confermare questi risultati sono necessari ulteriori studi, con un numero maggiore di pazienti e un follow-up più lungo .Purpose: : To evaluate the efficacy, safety and predictability of photorefractive keratectomy (PRK) with the Technolas laser 217 z100 Baush&amp;Lomb (algorithm Zyoptix Tissue Saving) in the treatment of high myopic refractive defects in patients with thin corneas. Methods: : The authors report the results during a 10 month follow–up period of 16 eyes treated with the Zyoptix Tissue Saving algorithm for high myopic refractive defects with and without astigmatism in patients with thin corneas and a scotopic pupillary diameter greater than 6.5. For each patient the pre– and postoperative Uncorrected Visual Acuity (UCVA) and Best–Corrected Visual Acuity (BCVA) was graded after 1, 3, 6, and 10 months. Results: : The mean age of the patients was 35.9 (range 22–54). The treated eyes were 28. Average saving of corneal tissue was 24% with very good refractive results compared to Planoscan treatment. This algorithm reduced the superior order aberrations by means of a laser ablation profile based on Hartmann–Shack Zywave aberrometry and the Munnerlin formula consenting an ablation of a wider optic zone with saving of corneal tissue. The treatment considered the possibility of a different typology of ablation according to the characteristics of each patient; Planoscan Zyoptix personalized Tissue Saving. The uncorrected post–operative visual acuity in each patient was never less than pre–operative values. In the first month after treatment we found a hypermetropic shift varying from + 0.75 to + 2 diopters (D) in the patients with myopia and myopic astigmatism. The patients had been informed about this transitory hypercorrections and the possible risks and benefits of treatment. Conclusions: : The authors believe that photorefractive keratectomy is a valid approach to refractive surgery in patients with high refractive errors and thin corneas. However, further study, with a greater number of patients and longer follow–up, is necessary to confirm these results