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

Autophagy in the control and pathogenesis of parasitic infections

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Effects of concentration of corn distillers dried grains with solubles and enzyme supplementation on cecal microbiota and performance in broiler chickens

With the increasing production of ethanol for biofuels, a by-product of corn-based ethanol fermentation, dried distillers grains with solubles (DDGS) is finding its way into the feed of agricultural animals including cattle, pigs, poultry, sheep, goats, aquaculture species and horses. Corn DDGS contains very high levels of non-starch polysaccharides and could be considered a good source of fibre. Despite knowledge of the role of the fibre in modulating intestinal microbiota and consequently influencing health, there is currently little information on the interactions between DDGS and intestinal microbiota. We assessed the changes in the cecal microbiota of broilers feed rations supplemented with DDGS (five concentrations: 0, 6, 12, 18 and 24% w/w) with and without presence of digestive enzymes. DDGS concentration was strongly positively correlated (P\ua0=\ua03.7e, r\ua0=\ua00.74) with feed conversion efficiency (FCR), diminishing broiler performance with higher concentrations. Additionally, DDGS concentrations positively correlated with Richness index (P\ua0=\ua01.5e, r\ua0=\ua00.5), increasing the number of detectable species in the cecum. Among the most affected genera, Faecalibacterium (P\ua0=\ua00.032, r\ua0=\ua0−0.34) and Streptococcus (P\ua0=\ua07.9e, r\ua0=\ua0−0.39) were negatively correlated with DDGS, while Turicibacter (P\ua0=\ua02.8e, r\ua0=\ua00.52) was positively correlated with the DDGS concentration. Enzymes showed minimal effect on cecal microbiota

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\ub75%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31\ub72%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10\ub72%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12\ub73%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9\ub74%] of 7339 patients), middle (549 [14\ub70%] of 3918 patients), and low (298 [23\ub72%] of 1282) HDI (p&lt;0\ub7001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17\ub78%] of 574 patients in high-HDI countries; 74 [31\ub74%] of 236 patients in middle-HDI countries; 72 [39\ub78%] 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\ub760, 95% credible interval 1\ub705\u20132\ub737; p=0\ub7030). 132 (21\ub76%) 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\ub76%) of 295 patients in high-HDI countries, in 37 (19\ub78%) of 187 patients in middle-HDI countries, and in 46 (35\ub79%) of 128 patients in low-HDI countries (p&lt;0\ub7001). 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. Funding: DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant