Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

Локальная R-наблюдаемость систем дифференциально- алгебраических уравнений

A nonlinear system of first order ordinary differential equations is considered. The system is unresolved with respect to the derivative of the unknown function and it is identically degenerate in the domain. An arbitrarily high unresolvability index is admited. Analysis is carried out under assumptions that ensure the existence of a global structural form that separates "algebraic" and "differential" subsystems. Local R-observability conditions are obtained by linear approximation of the systemРассматривается система нелинейных обыкновенных дифференциальных уравнений, не разрешен- ная относительно производной искомой вектор-функции и тождественно вырожденная в обла- сти определения. Допускается произвольно высокий индекс неразрешимости системы. Анализ проводится в предположениях, обеспечивающих существование структурной формы с разделен- ными "дифференциальной" и "алгебраической" подсистемами, которая эквивалентна исходной системе в смысле решений. Получены условия локальной R-наблюдаемости такой системы по ее первому линейному приближени

Дифференциальная управляемость линейных систем дифференциально-алгебраических уравнений

Linear controllable system of first order ordinary differential equations is considered. The system is unresolved with respect to the derivative of the unknown function and it is identically degenerate in the domain. An arbitrarily high unresolvability index is admitted. Differential controllability of the system is investigated under assumptions that ensure the existence of a global structural form that separates "algebraic" and "differential" subsystemsРассматривается линейная система обыкновенных дифференциальных уравнений с переменными коэффициентами, не разрешенная относительно производной искомой вектор-функции и тожде- ственно вырожденная в области определения. Допускается произвольно высокий индекс неразре- шенности системы. Исследуется дифференциальная управляемость такой системы в предполо- жениях, обеспечивающих существование эквивалентной в смысле решений структурной формы с разделенными "дифференциальной" и "алгебраической" подсистемам

Локальная R-наблюдаемость систем дифференциально- алгебраических уравнений

A nonlinear system of first order ordinary differential equations is considered. The system is unresolved with respect to the derivative of the unknown function and it is identically degenerate in the domain. An arbitrarily high unresolvability index is admited. Analysis is carried out under assumptions that ensure the existence of a global structural form that separates "algebraic" and "differential" subsystems. Local R-observability conditions are obtained by linear approximation of the systemРассматривается система нелинейных обыкновенных дифференциальных уравнений, не разрешен- ная относительно производной искомой вектор-функции и тождественно вырожденная в обла- сти определения. Допускается произвольно высокий индекс неразрешимости системы. Анализ проводится в предположениях, обеспечивающих существование структурной формы с разделен- ными "дифференциальной" и "алгебраической" подсистемами, которая эквивалентна исходной системе в смысле решений. Получены условия локальной R-наблюдаемости такой системы по ее первому линейному приближени

Дифференциальная управляемость линейных систем дифференциально-алгебраических уравнений

Linear controllable system of first order ordinary differential equations is considered. The system is unresolved with respect to the derivative of the unknown function and it is identically degenerate in the domain. An arbitrarily high unresolvability index is admitted. Differential controllability of the system is investigated under assumptions that ensure the existence of a global structural form that separates "algebraic" and "differential" subsystemsРассматривается линейная система обыкновенных дифференциальных уравнений с переменными коэффициентами, не разрешенная относительно производной искомой вектор-функции и тожде- ственно вырожденная в области определения. Допускается произвольно высокий индекс неразре- шенности системы. Исследуется дифференциальная управляемость такой системы в предполо- жениях, обеспечивающих существование эквивалентной в смысле решений структурной формы с разделенными "дифференциальной" и "алгебраической" подсистемам

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

Background: Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.Methods: This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.Results: A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 percent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 percent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 percent; however, it was 41 per cent in low-to-middle-compared with 19 per cent in very high-HDI countries.Conclusion: Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761)

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)