Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Regarding: "Patching versus primary closure for carotid endarterectomy"

We read the article by Rockman et al with great interest, but do not support the conclusions that primary closure during carotid endarterectomy should be abandoned in favor of either eversion endarterectomy or endarterectomy with patch angioplasty. The primary closure group comprised only 11.8% of the study group. This suggests that this particular technique may have been practiced by surgeons performing fewer carotid endarterectomies than their peers. There is some evidence to support a volume-outcome relationship for carotid endarterectomy. It would be interesting to know if those surgeons performing primary closure had a smaller workload than those using patch closure and eversion endarterectomy. No mention is given regarding the use of quality control to determine the technical success of carotid endarterectomy. The use of completion imaging has coincided with an improvement in outcome in many centers, although cause-and-effect is very difficult to prove. During the last 14 years, we have performed 675 consecutive carotid endarterectomies. The primary patch rate was 9.4% based upon small diameter vessels and technical problems with the distal endarterectomy site. A further 3.7% of patients had secondary patching based upon the findings of completion duplex scanning performed after primary closure of the artery but before closure of the wound. The stroke and death rate for the primary closure group was 13 (2.2%) of 586, and that of the patched group was 2 (2.2%) of 89. This stroke and death rate is exactly the same as the best results reported by Rockman et al using eversion endarterectomy and patch closure. The Cochrane review strongly supports the use of patching; however, there are some drawbacks to obligatory use of patch angioplasty. Patch closure does not necessarily abolish technical error. Carotid patching is also not without risks. Not only is it associated with a longer cross-clamp time than primary closure, but vein patch may be susceptible to central rupture or the development of false aneurysms, and prosthetic patches carries a risk of graft sepsis. There is a danger in publishing papers such as Rockman’s that they will be used as evidence in a court of law against a poor outcome using primary closure. Our data indicate that primary closure with selective patching is a safe technique when used in conjunction with quality control in the form of duplex completion imaging. We would strongly recommend completion imaging rather than a particular technique when performing carotid endarterectomy.link_to_subscribed_fulltex

Transcranial Doppler screening for stroke risk in children with sickle cell disease: a systematic review.

Background: Sickle Cell Disease (SCD) is one of the most common causes of stroke in children worldwide. Based on the results of the Stroke Prevention Trial in Sickle Cell Anaemia (STOP), annual Transcranial Doppler Ultrasound (TCD) screening for affected children is standard practice. However, the need for TCD surveillance programmes could override the accuracy of the screening, affecting the correct stratification of stroke risk and subsequent clinical management of the target population. Aims: To shed light on this issue, a systematic review of the literature on TCD screening for children and adolescents with SCD was carried out (CRD42016050549), according to a list of clinically relevant questions, with a particular focus on screening practices in European countries. Quality of the evidence was rated using GRADE. Summary of review: Thirty-three studies published in English or French were included (5 randomised controlled trials, 8 experimental non-randomised and 20 observational studies). The quality of the retrieved evidence ranged between low and high, but was rated as moderate or high most of the times. TCD is effective as a screening tool for primary prevention of stroke in SCD children. There is no high quality evidence on the effectiveness of alternative screening methods, such as imaging-TCD (TCDi) with or without angle correction or magnetic resonance angiography (MRA). No evidence was found on effectiveness of the screening on children on hydroxyurea and with genotypes other than HbSS and HbS/β0. No European data were found on screening rates or adherence of screening practices to the STOP protocol. Conclusions: High quality studies on alternative screening methods that are currently used in real-world practice, and on screening applicability to specific subgroups of patients are urgently needed. Considering the low awareness of the disease in European countries and the lack of data on screening practices and adherence, clinicians need up-to-date guidelines for more uniform and evidence-based surveillance of children with SCD