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

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

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)

Another Look at the “Abdominal Cocoon”

Abdominal cocoon is a rare cause of bowel obstruction. The condition was first described three decades ago and about 106 cases have so far been reported in the English literature. It is found mainly among adolescent females in tropical and sub-tropical countries. It is characterized by a thick fibrous membrane encapsulating the small intestines partially or completely. It should be differentiated from Encapsulating Peritoneal Sclerosis (EPS) and Peritoneal Encapsulation (PE) which are sometimes referred to as abdominal cocoon but are of different aetio-pathology. Patients present with features of intestinal obstruction and the diagnosis is usually made intraoperatively. Surgical excision of the membrane with adhesiolysis in an emergency exploratory laparotomy results in complete recovery. Appropriate management of this condition requires adequate knowledge about the disease. We present a review of this rare entity. Key words: abdominal cocoon, intestinal obstructio

Surgical and Gynaecological Abdominal Emergencies in Adults: The Experience of Lagos State University Teaching Hospital, Ikeja, Lagos State, Nigeria.

The objective of this study is to highlight the clinical spectrum of surgical and gynaecological abdominal emergencies in an urban teaching hospital in Nigeria. All emergency abdominal operations carried out in LASUTH between July, 2004 and December, 2006 were retrospectively studied. Data extracted from case files of patients, theatre operation registers and ward registers were analyzed. A total of 803 patients were reviewed. There were 254(31.6%) males and 549(68.4%) females. Ectopic pregnancy accounted for 44% of the emergencies. Acute appendicitis and intestinal obstruction were the reasons for surgery in 22% and 17% of the patients respectively. Less common indications were trauma(5.4%), septic abortion(3.6%), typhoid ileal perforation(3%) and gastroduodenal perforation(2.6%). Obstructed external hernia was the leading cause of intestinal obstruction while complicated appendicitis was the major cause of generalized peritonitis. Mortality rate was 4.5%. Ectopic gestation is the commonest indication for emergency exploratory laparotomy in our centre and should be considered in the diagnosis of acute abdomen in females. Early elective surgery for external hernia and prompt surgical treatment of acute appendicitis may decrease the burden of intestinal obstruction and generalized peritonitis in our practice.Key words: abdominal emergencies, gynaecological emergencies, acute abdomen, surgical abdomen

Ultrasound guided Percutaneous Catheter drainage of Biloma Complicating Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy is the 'gold-standard' of care in the management of gallbladder stones. It has combined advantages of cosmetic surgery, shorter hospital stay, and over-all favourable cost analysis. Complications though infrequent have been recorded. Managing complications following Laparoscopic procedures could pose a challenge in new centres commencing this approach to surgery. This is a report of a 40year old woman with 2 years history of periodic right upper abdominal pain who had laparoscopic cholecystectomy at the Lagos State University Teaching Hospital, Ikeja, Lagos in July 2015 and was discharged home after a brief episode of post-op fever. She was readmitted 3 weeks later with worsening complaints of abdominal distension, fever and Jaundice. At this stage Ultrasound and CT scan confirmed a large, encapsulated cystic mass emanating from the region of the right lobe of the Liver. A diagnosis of Post Cholecystectomy Biloma was made and she underwent Ultrasound guided per cutaneous drainage which yielded 9 litres of bilious fluid over 3 days. Following this intervention she had prompt recovery and was discharged to outpatient clinic. This report underscores the importance of adequate preparations including use of interventionary methods to solve problems complicating laparoscopic surgery.Key Words: Biloma, Ultrasound, Percutaneous, Laparoscopic Cholecystectom

Spontaneous Rupture of the Liver in Hypertensive Disease of Pregnancy

This is a case of spontaneous rupture of the liver in a 34-year old G5P4+0 (3 alive) with hypertensive disease of pregnancy at gestational age of 34weeks. This case is reported because the condition is a recognized but rare complication of hypertensive disease of pregnancy. The typical features of this condition as described in the literature and as seen in this patient are emphasized as increased awareness can lead to early diagnosis and better prognosis. Key Words: Hypertensive disease of pregnancy, Abruptio placenta, Hemorrhagic shock, Hemoperitoneum, Spontaneous rupture of the liver in pregnancy