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 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] 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 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) 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 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

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.

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).

T, Nigo Samuel L, Otuneme C, Prosper N, Umenze F, Boutros M, Caminsky N, Dumitra S, Garfinkle R, Morency D, Salama E, Banks A, Ferri L, He H, Katz A, Liberman AS, Meterissian S, Pang A, Parvez E, Agarwal A, Dare A, Hameed U, Osman F, Sequeira S, Coburn N, Dare A, Jaffer A, Karanicolas P, Mosseler M, Musselman R, Liu X, Yip CW, Garces-Otero JS, Guzman C, Sierra S, Uribe Valencia A, Cabrera Rivera PA, Camelo S, Gonzalez A, González-Orozco A, Mosquera Paz MS, Perez Rivera CJ, Gonzalez F, Isaza-Restrepo A, Nino- Torres L, Arias Madrid N, Mendoza Arango MC, Sierra S, Bake J, Tsandiraki J, Jemendžic D, Kocman B, Šuman O, Canic R, Jurišic D, Karakas I, Krizanovic Rupcic A, Pitlovic V, Samardžic J, Kopljar M, Bacic I, Domini E, Karlo R, Mihanovic J, Miljanic D, Simic A, Ahmed M, Al Nassrallah M, Altaf R, Amjad T, Eltoum R, Haidar H, Hassan A, Khalil O, Qasem M, Ramesh R, Sajith G, Wisal M, Žatecký J, Bujda M, Jirankova K, Paclik A, Abdallah A, Abdulgawad Almogy M, Ayman El-sawy E, ElFayoumy AM, Elghareeb N, Esmat NA, Fadel A, Habater A, Hamdy H, Hefni A, Kamal M, Mohamed Abobakr N, Sayed A, Shaker N, Taha E, Tharwat H, Zakaria O, Abdelmotaleb I, Al-Dhufri A, Al-Himyari HS, El sheikh E, Eldmaty A, Elkhalawy A, M.Elkhashen A, Magdy K, Mostafa S, Sadia HD, Saleh MM, Samir D, Yahia Mohamed Ali M, A. Nassar M, Abdelhady S, Abdelrazek A, Abdelsalam I, El-Sawy A, Essam E, Gadelkarim M, Ghaly K, Hassabalnaby M, Masarani R, Mohamed Shaaban N, Sabry A, Salem M, Soliman NA, Zahran D, Abou El.soud MR, Badr ET, Borham H, Elmeslemany N, Elsayed M, Elsherif F, Eslam S, Gaber G, Ibrahim S, Kamh Y, Mahmoud A, Mohamed SG, Morshedy E, Omar C, Salem Soliman F, Abdelkawy S, Abdelmohsen N, Abdelshakour M, Dahy A, Gamal N, Gamal M, Hasan A, Hetta H, Mousa N, Omar M, Rabie S, Saad M, Saleh B, Sayed Mohamed M, Shawqi M, Abdelhady Mousa H, Alnoury M, Elbealawy M, Elshafey A, Essam Ibrahim El Desouki Muhammad Ahmed M, Ghonaim M, Hgag F, Ibrahim M, Morsy M, Reda Loaloa M, Refaat A, Samir H, Shahien F, Sobhy M, Sroor F, Abdellatif E, Adel M, Afifi AA, Afifi E, Antaky M, Dawoud A, El Zoghby N, El-remaily A, Elzanfaly AA, Gadallah A, Gamal FA, Hashem O, Medhat Youssef S, Muhammad Attyah A, Munir M, Shazly O, Taha E, Wilson K, Adel S, Ali A, Eid E, Elhelow E, Elmahdy M, Elshatby B, Hossam el-din Zakaria A, Hossny A, Ibrahim E, M.Yonis A, Metwalli M, Yousry B, Zid E, A Yacoub M, Abdelhakim A, Abouelsoad N, Alkhatib M, Ashraf A, Ashraf A, Elazab Y, Elfanty M, Elkabir O, Elsayed M, Elshimy A, Elsobky H, Eskander J, Gad A, Hamsho W, Khaled Abdelwahed N, Magdy M, Moharam D, Osama A, Ramadan S, Roum R, Sayed T, Shehada T, Zidan AM, Abbas K, Ali A, Attia M, Balata M, El Nakeeb A, Elewaily MIE, Elfallal A, Elfeki H, Elkhadragy A, Emile S, Ezzat H, Hosni H, Mansour I, Omar W, Othman G, Sadek K, Shalaby M, Shehab-Eldeen N, Anas khalifa R, Badr H, Eldeep M, Eldeep A, Eldoseuky mohammed A, Khallaf S, Magdy Hegazy E, Mahmoud R, Mikhail P, Morsi M, Mowafy S, Raafat D, Safy A, Sera M, Sera AS, AbdAllah MSM, Abdelkader M, Abdou AO, Ahmed A, Gaafar S, Ibrahim negm F, Lapic M, Maher A, Mahmoud H, Mostafa A, Samir M, Samy F, Semeda N, Shalaby HI, El-taweel A, Galal Elnagar A, Hemidan AG, Hussein M, Kandil A, Moawad M, Nasser Hamamah AA, Soliman M, Abdelkhalek M, Abdelmaksoud Tawakel N, Abdelwahed AM, Abdou A, Atallah K, Elsherbeny MY, Emara E, Hamdy M, Hamdy O, Haron A, Ismail S, Metwally IH, Mohamed Hamed Elgaml N, Nassar A, Refky B, Sadek M, Saleh M, Yunes A, Zakaria M, Zuhdy M, Fayed N, Mohammed MMH, Kütner S, Melnik P, Seire I, Teras J, Ümarik T, Ainoa E, Eerola V, Koppatz H, Koskenvuo L, Sallinen V, Takala S, Katunin J, Kechagias A, Turunen A, Christou N, Mathonnet M, Lavoue V, Nyangoh Timoh K, Soulabaille L, Lesourd R, Merdrignac A, Sulpice L, André B, Chantalat E, Vaysse C, Dousset B, Gaujoux S, Martin G, Clonda O, Juodis D, Kienle K, Mravik A, Palmer S, Szabadhegyi G, Agbeko AE, Gyabaah S, Gyamfi FE, Naabo N, Owusu senior A, Yorke J, Owusu F, Abantanga F, Anyomih TTK, Muntaka AJM, Owusu Abem E, Sheriff M, Tabiri S, Wondoh PM, Balalis D, Korkolis D, Gkiokas G, Pantiora E, Theodosopoulos T, Ioannidis A, Konstantinidis K, Konstantinidou S, Machairas N, Paspala A, Prodromidou A, Chouliaras C, Papadopoulos K, Baloyiannis I, Mamaloudis I, Tzovaras G, Akrida I, Argentou MI, Germanos S, Iliopoulos E, Maroulis I, Skroubis G, Theofanis G, Chatzakis C, Ioannidis O, Loutzidou L, Kalles V, Karathanasis P, Michalopoulos N, Theodoropoulos C, Theodorou D, Triantafyllou T, Garoufalia Z, Hasemaki N, Kontos M, Kouraklis G, Kykalos S, Liakakos T, Mpaili E, Papalampros A, Schizas D, Syllaios A, Tampaki EC, Tsimpoukelis A, Antonopoulou MI, Deskou E, Manatakis DK, Papageorgiou D, Zoulamoglou M, Anthoulakis C, Margaritis M, Nikoloudis N, Campo V, Ceballos A, Flores MA, Giron W, Ko D, Martinez G, Recinos G, Rivera Lara V, Rueda N, Sanchez A, Tejeda Garrido JCG, Aguilera-Arevalo ML, Alvarez Rivera AE, Bamaca Ixcajoc EB, Barreda Zelaya LE, Chacòn-Herrera P, Corea Ruiz LM, Echeverria-Davila G, Garcia M, García D, Gutiérrez Mayen EF, José N, Mazariegos N, Méndez D, Paniagua Espinoza M, Baranyai Z, Bardos D, Benke M, Illes K, Kokas BA, Szabó R, Appukuttan A, Asok A, D.k V, Malik K, Ravishankaran P, Tapkire R, Moorthy G, Abraham J, Muthuvel R, Alapatt J, Kattepur A, Pareekutty N, Garod M, Harris C, Wanniang C, Gupta A, Nehra D, Parshad S, Acharya R, Badwe R, Bhandare M, Jain U, Kirti K, Nair N, Shrikhande S, Thakkar P, Anandan P, C S A, Holenarasipur Narasannaiah A, Jagarlamudi T, Kumar Venkatappa S, M R R, Manangi M, Raghavendra A, Rao KS, S V, Sajjan V, Shenoy A, Shivashankar Chikkanayakanahalli S, Tharanath K, V S, Adidharma P, Agarwal R, Amandito R, Anggita Gultom P, Arifin GR, Billy M, Elfizri Z, Fahira A, Felicia D, Gunardi TH, Johanna N, Nugrahadi NR, Panigoro SS, Rahmayanti S, Sihotang RC, Brata SY, Winoto H, Barati N, Karami M, Khorshidi H, Naderifar H, Abdulla MA, Coleman M, Doherty RJ, Hannon R, Murphy B, Stakelum A, Winter D, Aljohmani L, Farnan R, Seldon Y, Tan T, Varghese S, Alherz M, Ather M, Bajilan M, Graziadei V, Pilkington I, Quidwai O, Ridgway P, Shiwani H, Tahir AAR, Blunnie E, Burke D, Kennedy N, Macdonagh K, O'Neill M, Rooney S, Falco G, Ferrari G, Mele S, Nita GE, Ugoletti L, Zizzo M, Confalonieri G, Pesenti G, Tagliabue F, Baronio G, Ongaro D, Pata G, Compagnoni B, Salvadori R, Taglietti L, D'Alessandro N, Di Lascio P, Pascale G, Bortolasi L, Campagnaro T, Carlini M, Lisi G, Lombardi D, Pedrazzani C, Spoletini D, Turri G, Violi P, Altomare DF, Aquilino F, Musa N, Papagni V, Picciariello A, Vincenti L, Andreotti D, Occhionorelli S, Tondo M, Basso SMM, Cirelli R, Maino MEM, Piozzi GN, Picone E, Scaramuzzo R, Sinibaldi G, Amendola A, Anastasio L, Bucci L, Caruso E, Castaldi A, Di Maso S, Dinuzzi VP, Esposito G, Gaudiello M, Giglio MC, Greco PA, Luglio G, Manfreda A, Marra E, Mastella F, Pagano G, Peltrini R, Pepe V, Sacco M, Sollazzo V, Spiezio G, Cianchetti E, Menduni N, Carvello MM, Di Candido F, Spinelli A, Corsi F, Sorrentino L, Marino F, Asti ELG, Bonavina L, Rausa E, Asta M, Belli A, Bianco F, Cervone C, Delrio P, Falato A, Fares Bucci A, Guarino R, Pace U, Rega D, De Luca E, Gallo G, Sammarco G, Sena G, Vescio G, Santandrea L, Ugolini G, Zattoni D, Chetta N, Logrieco G, Vanella S, Garulli G, Zanini N, Bondurri A, Cammarata F, Colombo F, Foschi D, Lamperti GMB, Maffioli A, Sampietro GM, Yakushkina A, Zaffaroni G, Ansaloni L, Cicuttin E, Sibilla MG, Impellizzeri H, Inama M, Moretto G, Mochet S, Ponte E, Usai A, Mancini S, Sagnotta A, Solinas L, Bolzonaro E, Tamini N, Curletti G, Galleano R, Malerba M, Campanella S, Cocorullo G, Colli F, De Marco P, Falco N, Fontana T, Kamdem Mambou LJ, La Brocca A, Licari L, Randisi B, Rizzo G, Rotolo G, Salamone G, Tutino R, Venturelli P, Malabarba S, Sgrò A, Vella I, Cirillo B, Crocetti D, De Toma G, Lapolla P, Mingoli A, Sapienza P, Belvedere A, Bianchini S, Binetti M, Birindelli A, Tonini V, Podda M, Pulighe F, De Rosa M, Bono L, Borghi F, Geretto P, Giuffrida MC, Lauro C, Marano A, Pellegrino L, Salusso P, Sasia D, Campanelli M, Realis Luc A, Trompetto M, Cardia R, Cillara N, Giordano AN, Costanzo A, Giovilli MA, Turati L, Canonico S, Pellino G, Sciaudone G, Selvaggi F, Selvaggi L, Albsoul N, AlBsoul A, Alkhatib AA, Alsallaq O, Amarin JZ, Ayoub R, Bsisu I, El Muhtaseb MS, Jabaiti M, Melhem J, Nour I, Qwaider YZ, Salameh MH, Suleihat A, Suradi HH, Alammarin M, Aljaafreh A, Bani hani M, Bani hani Z, Bani Hani F, Fahmawee T, Hamouri S, Katanani C, Tawalbeh R, Tawalbeh T, Zawahrah H, Abou Chaar MK, Abusalem L, Al-Masri M, Al-Najjar H, Barghuthi L, Ahmed Z, Maulana A, Ngotho O, Kamau C, Stanley Mwenda A, Bosire F, Mwachiro E, Parker R, Simel I, Sylvester K, Althini AAM, Elbarouni S, Elbeshina AE, Gwea A, Malek A, Masoud Farag WA, Abdalei A, Abdel Malik AB, Abo-khammash A, Abuhlaiga M, Adnan N, Albaggar M, Alfitory A, Aljanfi A, Almuzghi F, Altumei Z, Alzabti F, Ashoushan H, Assalhi M, Azzubia J, Bnhameida S, Delhen M, Elshafei H, Elteir H, Esbaga F, Gobbi AA, Hamouda F, Hilan H, Ismail R, Jebran F, Kasbour M, Maderi G, Mohammad S, Mohammed B, Murtadi H, Mustafa H, Rajab M, Trenba S, Wafaa M, Al Sagheir E, Almigheerbi A, Alzahaf A, Bahroun SG, Ben Dallah N, Elshaibani M, Eswaye H, Karar M, Omar S, Younes E, Younes M, Zreeg D, Abujamra S, Ashour F, Elgammudi M, Omar F. Aljadidi W, Saddouh E, Sharif R, Alabuzidi A, Alwerfally A, Aribi S, Bibas F, Elfaituri T, Elhajjaji Y, Khaled A, Khalil W, Layas T, Soula E, Tarek A, Abu hallalah MFK, Abujamra S, Ahmed HA, Alsharef T, Ben Saoud AA, El Gharmoul T, Elhadi A, Elrais S, Shebani A, Zarti H, Zeiton A, Ambrazevicius M, Kaselis N, Stakyte M, Aliosin O, Cizauskaite A, Dailidenas S, Eismontas V, Kybransiene M, Nutautiene V, Samalavicius N, Simcikas D, Slepavicius A, Tamosiunas A, Ubartas N, Zeromskas P, Bradulskis S, Dainius E, Juocas J, Kubiliute E, Kutkevicius J, Opolskis A, Parseliunas A, Subocius A, Venskutonis D, Virbickaite E, Zuikyte D, Bogusevicius A, Buzaite K, Cepuliene D, Cesleviciene I, Cesna V, Gribauskaite J, Ignatavicius P, Jokubauskas M, Liugailaite M, Margelis E, Mazelyte R, Pankratjevaite L, Pažusis M, Rackeviciute A, Saladyte J, Škimelyte M, Šlenfuktas V, Sudeikyte M, Tamelis A, Vanagas T, Žumbakys Ž, Atkociunas A, Dulskas A, Kuliavas J, Birutis J, Paškevicius S, Šatkauskas M, Danys D, Jakubauskas M, Jakubauskiene L, Kryzauskas M, Lipnickas V, Makunaite G, Rasoaherinomenjanahary F, Rasolofonarivo H, Samison LH, Banda B, Malemia P, Msosa V, Ahmad Izzuddin AI, Das A, Gan YY, Shong Sheng T, Siaw JY, Ab Rahim MF, Abang Jamari DZH, Che Husin N, Kamarulzaman MY, Lim YP, Mohamed Kamil NA, Mohd Hassan MR, Mohd Sahid S, Mustafa J, Ng EHB, Wan Khazim WK, Chang Ern N, Lingeshan P, Sulaiman SE, Ang SE, Bin Mohamad Sithik MN, Cheong YJ, Deva Tata M, Jia Xian L, Kadravello A, Koh IE, Ng LY, Ng We Yong YJ, Palayan K, Sam CX, Siow Jin P, Tan Ern Hwei J, Tang Y, Ter AZ, Wong MPK, Zakaria AD, Zakaria Z, Henry F, Kalaiselvan T, Abd Karim MFS, Abdul Aziz MR, Abdul Aziz N, Khong TL, Lau PC, Lim HC, Roslani AC, Seak JCK, Wong SW, Wong LF, Yeen Chin L, Anyanwu MC, Borg E, Busuttil Z, Calleja T, Chircop KL, Cutajar R, Dimech AM, Ellul S, Galea J, Gascon Perai K, Gatt R, Kelman L, Micallef E, Nwolu F, Sammut K, Thompson J, Warwicker S, Zammit M, Cordera F, Cruz González E, Sánchez-García J, Barbosa Camacho FJ, Barrera López FJ, Zuloaga Fernandez del Valle CJ, Acosta E, González Espinoza IR, Moreno P, Cortes-Flores AO, Fuentes Orozco C, Gonzalez Ojeda A, Corro Díaz González S, Martinez L, Ramos-De la Medina A, Mosqueda Amador B, Novoa A, Olazo Espejo DA, Jimenez A, Lopez Rosales F, Vanoye EG, Garcia Gonzalez LA, Miranda-Ackerman RC, Solano-Genesta M, Alvarez-Cano A, Romero-Garza HH, Medina-Franco H, Mejía-Fernández L, Salgado-Nesme N, Vergara-Fernandez O, Gutiérrez-Mota GM, Hernandez Vera FX, Llantada Lopez A, Morgan Villela G, Ramirez Padilla FDJ, Tapia Marin W, Martínez Maldonado M, Sánchez Suárez R, Troche JM, Benyaiche C, Outani O, Amine S, Benkabbou A, Majbar AM, Mohsine R, Rafik A, Oung T, Tin MM, Borowski DW, Plarre P, Borowski DW, Plarre P, Alberga A, Sluiter N, Tuynman J, Blok R, Cömert D, Hompes R, Kalff M, Stellingwerf ME, Tanis P, van Berge Henegouwen M, van Praag EM, Wisselink D, Gerhards M, Lopes Cardozo J, Westerduin E, de Jonge J, van Geloven A, van Schilt K, den Boer F, Stoots S, Vlek S, Adams J, Al-Busaidi IS, Budd G, Choi SI, Chu MJJ, Ganugapati A, McKinstry L, Pascoe R, Richards S, Rosser K, Stevenson A, White R, Farik S, Kwun J, Murad A, Cowan S, Hall T, Hayton M, Malam Sani L, Oumarou Garba S, Adamou H, Amadou Magagi I, Habou O, Aliyu H, Daniyan M, Sholadoye TT, Abdullahi L, Anyanwu LJ, Mohammad Mohammad A, Muhammad AB, Sheshe AA, Suleiman I, Adesina A, Awolowo A, Onuoha C, Salami O, Taiwo O, Taiwo A, Kache S, Makama JG, Sale D, Abiola O, Ajao A, Ajiboye A, Etonyeaku A, Olaogun J, Adebanjo A, Adesanya O, Afolayan MO, Balogun O, Makanjuola A, Nwokocha S, Ojewola RW, Olajide TO, Aderounmu A, Adesunkanmi AR, Adisa A, Agbakwuru A, Akeem Aderogba A, Alatise OI, Arowolo O, Lawal O, Mohammed T, Ndegbu C, Olasehinde O, Wuraola F, Akinkuolie A, Etonyeaku A, Mosanya A, Ayandipo O, Elemile P, Lawal TA, Ali SANI S, Garba S, Hauwa SANI R, Olori S, Onyebuashi H, Umoke I, Adenuga A, Adeyeye A, Habeeb O, Lawal B, Nasir A, Aahlin EK, Kjønås D, Myrseth E, Abbasy J, Alvi A, Saleem O, Afzal A, Nazir A, Farooq M, Liaqat A, Naqi SA, Raza A, Sarfraz M, Sarwar M, Banglani M, Munir A, Sehrish R, Ayub B, Sayyed R, Altaf A, Ayub S, Qureshi AU, Saeed K, Syed B, Akbar SA, Anwer AW, Khan RN, Khan AI, Khattak S, Mohtasham S, Parvaiz MA, Syed AA, Ansari AB, Shahzad N, Khaliq T, Rashid I, Waqar SH, Abu Al-saleem H, Abu Alqumboz A, Alqadi M, Amro A, Assa R, Awesat E, Ayyad R, Hammad M, Haymony A, Hijazi B, Hmeidat B, Lahaseh R, Qawasmi A, Rajabi A, Shehada M, Shkokani S, Yaghi Y, Yaghi N, AlZohour M, Farid M, Habes YM, Juba W, Nubani Y, Rabee A, Sa'deh M, Abed S, Al basos I, Alswerki M, Ashour D, Awad I, Diab S, El Jamassi A, El-Kahlout S, Elhout S, Hajjaj ANK, Hasanain D, Nabil hajjaj B, Obaid M, Saikaly E, Salhi A, Al-Tammam H, Almasri M, Baniowda M, Beshtawi D, Horoub A, Misk R, Mohammad B, Qasrawi R, Sholi T, Abu-Nimeh S, Abu-srour A, Abukhalaf SA, Adawi S, Alsalameh B, Ayesh K, Elqadi M, Hammouri A, Karim Mustafa F, Marzouqa N, Melhem S, Miqdad D, Mohamad B, Rawhi M, Abu Ahammala AB, Abu Ataya A, Abu Jayyab I, Al-Shwaikh S, Alagha O, Alasttal M, Awadallah H, Elblbessy M, Fares J, Jarbou A, Mahfouz I, Albahnasawi MA, Abo mahadi A, Abuelhatal H, Abuelqomboz A, Almoqayyad A, Alwali A, Balaawi R, Hamouda M, Humeid M, Jedyan A, Mahmoud Abu hamam T, Matar G, Salem A, Samra T, Shaheen N, Shihada K, A.Nemer A, Abu Al Amrain M, Abu Alamrain A, Abu Jamie N, Abu-Rous MR, Alfarra N, AlTaweel M, Alwhaidi N, Hamed R, Saqqa B, Shaheen A, Aljaber D, Aljaberi L, Alwaheidi M, Jawaada A, Khaldi H, Qahoush R, Qari J, Saadeh R, Salim A, Yacoub A, Abbas A, Abu shua`ib R, Abu Zainah B, AbuSirrees M, Babaa B, Barhoush O, Belal qadomi A, Daraghmeh L, Haji R, Khatatbeh A, Khatib L, Qarariah S, Quzmar Y, Safadi K, Salameh R, Hassan M, Herzallah S, Massad L, Nazzal A, Nazzal R, Escobar D, Machain V GM, Rodriguez Gonzalez A, Chachaima Mar JE, Chinchihualpa Paredes NO, Cuba V, Lopez W, Niquen Jimenez MM, Sanchez Bartra NA, Sapallanay Ojeda O, Sequeiros D, Toscano Pacheco A, Vergara M, Abarca S, Alcorta R, Borda-Luque G, Eusebio Zegarra IE, Luján López C, Marrufo M, Mogrovejo C, Nomura A, Rodríguez Angeles Y, Vidal Meza MR, Zavala G, Castillo Arrascue JN, Hidrogo Cabrera JC, Larrea vera JJM, Osorio M, Ylatoma Díaz EA, Fontanilla MA, Fuentes JR, Salazar AL, Dominguez G, Lopez MP, Macalindong S, Onglao MA, Ramirez A, Sacdalan MD, Tampo MM, Uy GL, Mangahas J, Yabut K, Cañete JP, Cansana BE, Castro EJ, Lipana MK, Roxas MF, Zara VJ, Chrol M, Franczak P, Orlowski M, Budzynski P, Budzynski A, Bury P, Czerwinska A, Dworak J, Dziedzic J, Kisielewski M, Kulawik J, Lasek A, Major P, Malczak P, Migaczewski M, Pedziwiatr M, Pisarska M, Radkowiak D, Rubinkiewicz M, Rzepa A, Skoczylas T, Stanek M, Truszkiewicz K, Wierdak M, Winiarski M, Zarzycki P, Zub-Pokrowiecka A, Kowalewski P, Roszkowski R, Waledziak M, Tomé M, Patrocinio S, Guerreiro I, Almeida F, de Sousa X, Monteiro N, Costa Santos MT, de Oliveira D, Lopes Serra M, Morgado D, Neves C, Oliveira AC, Pimentel A, Silva S, Carvalho M, Carvalho L, Magalhães J, Matos L, Monteiro T, Ramos C, Santos V, Barbosa J, Costa-Maia J, Devezas V, Fareleira A, Fernandes C, Gonçalves D, Mora H, Morais M, Silva de Sousa F, Catarino Santos S, Logrado A, Tojal A, Amorim E, Cunha MF, Fazenda A, Melo Neves JP, Sampaio da Nóvoa Gomes Miguel II, Veiga D, Azevedo J, Cardoso Louro H, Leite M, Azevedo J, Bairos Menezes M, Gama B, Brito D, Cruz Martins MC, Graça e Magalhães A, Longras AC, Lourenço R, Matos D, Castro L, Policarpo F, Romano J, Leite M, Monteiro C, Pinto D, Duarte M, Fortuna Martins S, Oliveira M, Galvão D, Martins L, Silva A, Taranu V, Vieira B, Neves J, Oliveira S, Ribeiro H, Cinza M, Felix R, Machado A, Oliveira J, Patrício J, Pedroso de Lima R, Pereira M, Rocha Melo M, Velez C, Abreu da Silva A, Claro M, Costa Santos D, Ferreira A, Capote H, Rosado D, Taré F, Nogueira O, Ângelo M, Baiao JM, Guimarães A, Marques J, Nico Albano M, Silva M, Valente da Costa A, Vieira Caroço T, Almeida Braga S, Capunge I, Fragoso M, Guimarães J, Pinto B, Ribeiro J, Angel M, Fialho G, Guerrero M, Campos Costa F, Cardoso D, Cardoso V, Alves M, Estalagem I, Louro T, Marques C, Martelo R, Morgado M, Canotilho R, Correia AM, Martins P, Peyroteo M, Gomes J, Monteiro R, Romano M, Alves DM, Peixoto R, Quintela C, Jervis MJ, Melo D, Pacheco A, Paixão V, Pedro V, Pimenta J, Pimenta de Castro J, Rocha A, Beuran M, Bratu MR, Ciubotaru C, Diaconescu B, Hostiuc S, Negoi I, Stoica B, NA NA, Anokhin E, Kuznetsov G, Oganezov G, Paramzin F, Romanova E, Rutkovskii V, Rutkovskii V, Shushval M, Zabiyaka M, Dzhumabaev K, Ivanov V, Mamedli Z, Achkasov S, Balkarov A, Nabiev E, Nagudov M, Rybakov E, Saifutdinova K, Sushkov O, Vardanyan A, Costas-Chavarri A, Joseph L, Ndayishimiye I, Allen Ingabire JC, Faustin N, Mutabazi AZ, Mvukiyehe JP, Nsengimana VJ, Uwakunda C, Abbas MM, Akeel N, Aljiffry M, Awaji K, Farsi A, Jamjoum G, Khoja A, Maghrabi A, Malibary N, Nassif M, Saleem A, Sultan A, Tashkandi W, Tashkandi H, Trabulsi N, Ba MB, Diallo AC, Ndong A, Cuk V, Jankovic U, Juloski J, Koh SZ, Koh F, Lee KC, Lee KY, Lee S, Leong WQ, Lieske B, Lui SA, Prakash P, Grosek J, Norcic G, Tomazic A, Fitchat N, Jaich R, Wineberg D, Koto MZ, Baiocchi D, Clarke D, Steenkamp CJ, Van Straten S, Bannister S, Boutall A, Chinnery G, Coccia A, Dell A, Karjiker P, Kloppers C, Loxton N, Mabogoane T, Malherbe F, Panieri E, Rayamajhi S, Spence R, van Wyngaard T, Warden C, Madiba TE, Moodley Y, Pillay N, Brooks S, Kruger C, Van Der Merwe LH, Gool F, Kariem M, Bougard H, Chu K, Kariem N, Noor F, Pillay R, Steynfaardt L, González González L, Marín Santos JM, Martín-Borregón P, Martínez Caballero J, Nevado García C, Rodriguez Fraga P, De Castro Parga G, Fernández Veiga MP, Garrido López L, Infante Pino H, Lages Cal I, López Otero M, Nogueira Sixto M, Paniagua García Señorans M, Rodríguez Fernández L, Ruano Poblador A, Rufo Crespo E, Sanchez-Santos R, Vigorita V, Alonso Batanero E, Asnel D, Cifrian Canales I, Contreras Saiz E, De Santiago Alvarez I, Díaz Vico T, Fernandez Arias S, Fernández Martínez D, García Bernardo C, García Flórez LJ, Garcia Gutierrez C, García Munar M, Márquez Zorrilla Molina CA, Merayo M, Michi Campos JL, Moreno Gijon M, Otero-Diez JL, Rodicio Miravalles JL, Solar-Garcia L, Suárez Sánchez A, Truan N, Alejandre Villalobos C, Caballero Díaz Y, Jimenez M, Montesdeoca D, Navarro-Sánchez A, Vega V, Beltrán de Heredia J, Gómez Z, Jezieniecki C, Legido Morán AP, Montes-Manrique M, Rodriguez-Lopez M, Ruiz Soriano M, Trujillo Díaz J, Vazquez Fernandez A, Argudo N, Pera M, Torrent Jansà L, García Domínguez M, Goded I, Roldón Golet M, Talal El-Abur I, Utrilla Fornals A, Zambrana Campos V, Aguilar Martinez MDM, Bosch M, García-Catalá L, Sánchez-Guillén L, Artigau E, Gomez Romeu N, Julià Bergkvist D, Espina Perez B, Morató O, Olona C, Diéguez B, Forero-Torres A, Losada M, Gomez-Abril S, Gonzálvez P, Martinez R, Navarro Martínez S, Payá-Llorente C, Pérez Rubio Á, Santarrufina Martinez S, Sebastián Tomás JC, Trullenque Juan R, Gegúndez Simón A, Maté P, Prieto-Nieto MI, Rubio-Perez I, Urbieta A, Vicario Bravo M, Abelló D, Frasson M, Garcia-Granero A, Abad Gurumeta A, Abad-Motos A, Lucena-de Pablo E, Nozal B, Ripollés-Melchor J, Salvachúa R, Ferrero E, Garcia-Sancho Tellez L, Ortega Vázquez I, Picardo AL, Rojo López JA, Zorrilla Matilla LP, Cagigas Fernandez C, Castanedo Bezanilla S, Estevez Tesouro J, Fernandez-Diaz MJ, García Cardo J, Gomez Ruiz M, Gonzalez-Tolaretxipi E, Jimeno Fraile J, Poch C, Rodriguez-Aguirre M, Troche Pesqueira N, Trugeda-Carrera MS, de la Torre J, Blanco-Colino R, Espin-Basany E, Espinosa-Bravo M, Morales Comas C, Reyes Afonso E, Rivero Déniz J, Siso Raber C, Verdaguer Tremolosa M, Chandrasinghe P, Kumarage S, Wijekoon Arachchilage N, Senanayake KJ, Abdalla Ahmed Elkamel A, A. Adam M, Saleh M, Blomme N, Thorell A, Wogensen F, Älgå A, Ansarei D, Celebioglu F, Heinius G, Nigard L, Pieniowski E, Ahlqvist S, Björklund I, Cengiz Y, Frånberg A, Håkansson M, Adamo K, Franklin O, Sund M, Wiberg R, Andersson Y, Chabok A, Nikberg M, Kugelberg A, Canonica C, Christoforidis D, Fasolini F, Gaffuri P, Giuliani M, Meani F, Popeskou SG, Pozza S, Wandschneider W, Peterer L, Widmer LW, Zimmermann B, Bakoleas P, Chanousi I, Charalampidou L, Grochola LF, Heid F, Ntaoulas S, Outos M, Peros G, Podolska-Skoczek H, Reinisch KB, Zielasek C, Clerc D, Demartines N, Gilgien J, Kefleyesus A, St-Amour P, Toussaint A, Alhimyar M, Alsaid B, Alyafi A, Alkhaledi A, Kouz B, Omarain A, Al-Sabbagh Y, Alkhatib H, Sara S, Alhaj A, Danial A, Kadoura L, Maa Albared S, Monawar Y, Nahas L, Abd B, Saad A, Wakkaf H, Bouaziz H, Bouzaiene H, Ghalleb M, Akaydin E, Akbaba AC, Atakul O, Baltaci E, Besli S, Burgu G, Cenal U, de Muijnck C, Demirkaya HC, Dogruoz A, Gezer ZI, Gündogdu Y, Kara M, Korkmaz HK, Kurtoglu GK, Ozben V, Ozmen BB, Pektas AM, Sel EK, Yenidünya N, Bengur FB, Oral BM, Yozgatli TK, Abdullayev S, Gunes ME, Sahbaz NA, Banaz T, Kargici K, Kuyumcu OF, Yanikoglu E, Yesilsancak M, Yilmaz D, Aktas MK, Rencuzogullari A, Isik A, Leventoglu S, Yalçinkaya A, Yüksel O, Kalayci MU, Kara Y, Sarici IS, Akin A, Alemdag GN, Arslan E, Baki BE, Bodur MS, Calik A, Candas Altinbas B, Cihanyurdu I, Erkul O, Gül B, Guner A, Köse B, Semiz A, Sevim S, Tayar S, Tomas K, Tüfek OY, Türkyilmaz S, Ulusahin M, Usta A, Yildirim R, Güler SA, Tatar OC, Varol E, Kirimtay B, Uysal M, Yildiz A, Kose E, Ciftci AB, Çolak E, Eraslan H, Kucuk GO, Yemez K, Lule H, Bienfait M, Lule H, Bua E, Doe M, Okalany N, Birindelli A, Basarab M, Bielosludtsev O, Freigofer M, Kolhanova K, Perepelytsia K, Romanukha K, Savenkov D, Siryi S, Tereshchenko M, Viacheslav N, Volovetskyi A, Kebkalo A, Tryliskyy Y, Tyselskiy V, Bruce E, Chow BL, Iddles E, McGuckin S, Newall N, Ramsay G, Sharma P, Stewart C, Wong J, Badran A, Bath M, Belais F, Butt E, Joshi K, Kapur M, Shaw M, Townson A, Williams CYK, Gray T, Greig R, Husain M, Murray E, Mustafa A, Asif A, Gokul A, Shah M, Akitikori MT, Charalabopoulos A, Davidson S, McNally S, Rupani S, Juma F, Mills SC, Muirhead L, Sellars K, Walsh U, Warren O, Chambers A, Hunt R, Teasdale E, Boyce S, Cornwall H, Tol I, Argyriou EO, Eardley N, Povey M, Aithie JMS, Irfan A, McGuigan MC, Starr R, Warren CR, Archibald J, Kirby G, Kisyov I, Khoo CK, Lee R, Photiou D, Davis R, Prasad U, Yang PZ, Bird J, Leung E, Summerour V, Currow C, Kiam J, Tan GJS, Muthusami A, Pegba-Otemolu I, Urbonas T, Nunoo-Mensah J, Smolskas E, Boddy A, Gravante G, Hunter D, Andrew D, Koh A, Thompson A, Adams L, Clements HA, De Silva K, Ekpete O, Haque S, Henderson S, Ibrahim B, Jayasinghe T, Livie J, Mailley K, Nair G, Tan D, Baggaley C, Dawidziuk A, Szyszka B, Barter C, Gandhi N, Hassell K, Hitchin S, Kelsall J, Nagy E, Nessa A, Whisker L, Yanni F, Ali M, Arora D, Hediwattege S, Kumarasinghe N, Rathore M, Tennakoon A, Ali Ahmad SM, Bajomo O, Nadira F, Celentano V, Bhangu A, Glasbey J, Griffiths E, Karri RS, Mak JKC, Nepogodiev D, Pipe M, Bhatti MI, Rabie M, Boyle C, Hamilton D, Mihuna A, Ng JCK, Nicholson G, Oliwa A, Pearson R, Rose A, Yong SQ, Boereboom C, Hanna M, Walter C, Greensmith TS, Mitchell R, Monaghan E, Crawford J, Moug S, Blackwell J, Boyd-Carson H, Herrod P, Al-Allaf O, Beattie M, Bullock C, Burman S, Clark G, Flamey N, Flannery O, Harding A, Kodiatt B, Lawday S, Mahapatra S, Mukundu Nagesh N, Ng M, Rye D, Yoong A, Clark L, Deans C, Edirisooriya M, Fairfield CJ, Harrison EM, Carrington EV, Wong TLE, Yusuf B, Chamberlain C, Duke K, Kmiotek E, Botes A, Condie N, Schrire T, Shah R, Thomas-Jones I, Yates C, Anthony N, Matthews E, Sahnan K, Tankel J, Tucker S, Winter Beatty J, Ziprin P, Duggan W, Kantartzi A, Sridhar S, Khaw RA, Srivastava P, Underwood C, Alves do Canto Brum H, Chopra S, Davis L, Hughes R, Tulley J, Alberts J, Athisayaraj T, Olugbemi M, Ahmad K, Chan C, Chapman G, Fleming H, Fox B, Grewar J, Hulse K, Rutherford D, Sinead M, Smith S, Speake D, Vaughan-Shaw PG, Christodoulides N, Kudhail S, Welch M, Husaini SM, Lambracos S, Anyanwu C, Suresh R, Thomas JS, Gleeson E, Platoff R, Saif A, Enumah Z, Etchill E, Gabre-Kidan A, Bernstein M, Carrano FM, Connors J, Lynn P, Melis M, Newman E, Foster DS, Perrone K, Titan A, Weiser TG, Ahmad S, Bafford ACM, Dal Molin M, Hanna N, Zafar SN, Hemmila M, Napolitano L, Wong JJ, Chandler J, Wood L, Wren S, Ottesen T, You L, Yu K, Arciénega Yañez MDP, Ferreira Fernandes M, González D, Cubas S, González MC, Zubiaurre V, Demolin R, Giroff N, Sciuto P, Campos M, Rodríguez Cantera G, Wagner G, Deepika G, Maimbo M, Simuchimba E, Bulaya A, Chibuye C, Chirengendure B, Kabale MR, Kabongo K, Linyama D, Munthali J, Mweso O, Pikiti F, Otieno J, Chan E, Lai LT, Blackman B, Richards S, Subramaniam S, Karim R, Kok N, Lee YD, Ali S, Sinha A, Corrigan R, Barnes N, Wong F, Dennis G, Jedamzik J, Phillips E, Piette W, Van hentenryck M, Koco H, Lawani S, Kassa MW, Santos Bezerra T, Gribnev P, Dimitrov D, Krastev P, Oum S, Bonghaseh DT, Al Farsi M, Alsharqawi N, Agarwal A, Acevedo V, Castillo Barbosa AC, Giron F, Leon Rodriguez JP, Kucan D, Rosko D, Barsic N, Župan D, Hegazi A, Truncíková V, Fryba V, Mohamed M, Sultan A, Nagi A, Rashad Temerik A, Elshawy ME, Mahmoud MI, Omar S, Anwar M, Rageh T, Elmokadem A, Gaballa K, Teppo S, Turunen A, Pengermä P, Ballouhey Q, Bergeat D, Weyl A, Hain E, Gyedu A, Yenli E, Osei-Poku D, Rompou VA, Zoikas A, Gaitanidis A, Koukis G, Perivoliotis K, Tavlas P, Galanos-Demiris K, Zografos G, Karavokyros I, Xanthopoulou G, Iordanidou E, Ayau F, Garcia A, Damján P, Wason D, B L A, Rangganata E, Kamath P, O'Connor DB, Pinto M, Perrone F, Tropeano FP, Troilo F, Bossi D, Scala D, Pulitanò L, Carella M, Pietrabissa A, Gori A, Giraudo G, De Simone V, Russo AA, Braccio B, Al-Taher R, Athamneh S, Parker A, Sawiee A, Kattia A, Salem M, Tababa O, Shaeeb Z, Syminas V, Jurgaitis J, Damuleviciene G, Svagzdys S, Poskus T, Razafimanjato NNM, Chieng Loo L, Tiong IC, Wan Muhmad WF, Vijeyan H, Li Ying T, Grech G, Arrangoiz R, Jimenez Ley VB, Arizpe D, Jimenez Ley VB, Lagunes Lara E, Castro López EV, Eaazim J, Gordinou de Gouberville M, Bastiaenen V, Rottier S, Nahab F, Ji MY, Seyoji M, Nwachukwu C, Emeghara O, Muhammed SE, Idowu A, Sowemimo O, Ogundoyin O, Akande O, Lott A, Nadeem M, Laghari AA, Loya A, Mushtaq H, Abdullah MT, Abuhilal B, Atawneh M, Hamdan H, Alhabil B, Srour A, Mousa I, Da Silva Medina L, Sacdalan MD, Lapitan MC, Sacdalan MD, Sacdalan MD, Bartosiak K, Ferreira P, Francisco V, Lemos R, Frutuoso L, Fernandes S, Fonseca T, Pereira J, Rachadell J, Torre A, Madeira Martins F, Carvalho AC, Rodrigues Ferreira J, Ribeiro da Silva B, Devesa H, Vieira A, Mónica I, Amaro M, Sousa D, Reia M, Louro J, Martins A, Dominguez J, Santos I, Freitas Oliveira NM, Pereira JC, Silva-Vaz P, Freire L, Escrevente R, Negoita VM, Shakhmatov D, Nezerwa Y, Radulovic R, Moore R, Obery G, Viljoen F, Mendes T, Suarez A, Moncada E, Fernandez-Hevia M, Curtis Martínez C, Gil Garcia JM, González Zunzarren M, Idris T, Eklöv K, Grahn O, Amin L, Blomqvist M, Ajani C, Kraus R, Seeger N, Willemin M, Rayya F, Ayash M, Msouti R, Kannas I, Abazid E, Esper A, Slim S, Kavcar AS, Aytac E, Dural AC, Ilker A, Eray IC, Kurnaz E, Altiner S, Tepe MD, Sahin C, Savli E, Innocent A, Babirye L, Diachenko A, Hordoskiy V, Curry H, Chau CYC, Robertson H, Mahmoud A, Lennon H, Loi L, Kirkham E, McCann C, Watts D, Gurung B, Wilson M, Tribedi T, Garofalo E, Zahra B, MacDonald S, Daniels I, Ng N, Khosla S, Olivier J, Yue SYP, Suresh G, Wellington J, Lorejo E, Mossaad M, Tryliskyy Y, Crutcher M, Alimi M, Baiu I, Abdou H, Conway A, Peck C, Wagner G, Perdomo Perez MA, Trostchansky I, Zulu S, Nakazwe M, Knight SR, Drake TM, Nepogodiev D, Fitzgerald JE, Ademuyiwa A, Alexander P, Ingabire JA, Al-Saqqa SW, Biccard BM, Borda-Luque G, Borowski DW, Burger S, Chu K, Clarke D, Costas-Chavarri A, Davies J, Donaldson R, Ede C, Garden OJ, Ghosh D, Glasbey J, Kingham TP, Salem HK, Anyomih TTK, Koto MZ, Lapitan MC, Lawani I, Lesetedi C, Aguilera-Arevalo ML, Mabedi C, Maimbo M, Magill L, Makinde Alakaloko F, Makupe A, Martin J, Ramos-De la Medina A, Monahan M, Moore R, Msosa V, Mulira S, Mutabazi AZ, Muller E, Musowoyo J, Adisa AO, Olory-Togbe JL, Pius R, Qureshi AU, Rayne S, Roberts T, Sacdalan MD, Shaw CA, Smart N, Smith M, Spence R, Van Straten S, Tabiri S, Tayler V, Weiser TG, Windsor J, Yorke J, Yepez R, Lilford R, Morton D, Bhangu A, Sundar S, Harrison EM, Runigamugabo E, Verjee A, Chen J, Daya L, El Aroussi N, Farina V, Gnintedeme Olivier T, Gonzales Nacarino M, Hammani A, Honjo S, Jacobs R, Kimura H, Litvin A, Nkoronko M, Nour I, Oscullo Yepez JJ, Pagano G, Pata F, Pin Hung W, Raj A, Romani Pozo A, Rommaneh M, Sassamela Fabiano SC, Shiroma Gago CM, Shu Yip S, Srinivas A, Sung CY, Tai A, Valle Aranda YC, Venturini S, Vervoort D, Wilguens Lartigue J. Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

Characteristics of Early-Onset vs Late-Onset Colorectal Cancer: A Review

Importance

The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer.

Observations

Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts.

Conclusions and Relevance

The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.

The relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit

BACKGROUND

Anastomosis technique following right sided colonic resection is widely variable and may affect patient outcomes. This study aimed to assess the association between leak and anastomosis technique (stapled versus handsewn) METHODS: This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a two-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30 days of surgery, using a pre-specified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random effect variable.

RESULTS

This study included 3208 patients, of whom 78.4% (n=2515) underwent surgery for malignancy and 11.7% (n=375) for Crohn's disease. An anastomosis was performed in 94.8% (n=3041) of patients, which was handsewn in 38.9% (n=1183) and stapled in 61.1% (n=1858) cases. Patients undergoing handsewn anastomosis were more likely to be emergency admissions (20.5% handsewn versus 12.9% stapled) and to undergo open surgery (54.7% versus 36.6%). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques (p=0.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted odds ratio 1.43, 95% confidence interval 1.04-1.95, p=0.03).

DISCUSSION

Despite being used in lower risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe. This article is protected by copyright. All rights reserved.

Predictors for Anastomotic Leak, Postoperative Complications, and Mortality After Right Colectomy for Cancer: Results From an International Snapshot Audit

BACKGROUND

A right hemicolectomy is among the most commonly performed operations for colon cancer, but modern high-quality, multination data addressing the morbidity and mortality rates are lacking.

OBJECTIVE

This study reports the morbidity and mortality rates for right-sided colon cancer and identifies predictors for unfavorable short-term outcome after right hemicolectomy.

DESIGN

This was a snapshot observational prospective study.

SETTING

The study was conducted as a multicenter international study.

PATIENTS

The 2015 European Society of Coloproctology snapshot study was a prospective multicenter international series that included all patients undergoing elective or emergency right hemicolectomy or ileocecal resection over a 2-month period in early 2015. This is a subanalysis of the colon cancer cohort of patients.

MAIN OUTCOME MEASURES

Predictors for anastomotic leak and 30-day postoperative morbidity and mortality were assessed using multivariable mixed-effect logistic regression models after variables selection with the Lasso method.

RESULTS

Of the 2515 included patients, an anastomosis was performed in 97.2% (n = 2444), handsewn in 38.5% (n = 940) and stapled in 61.5% (n = 1504) cases. The overall anastomotic leak rate was 7.4% (180/2444), 30-day morbidity was 38.0% (n = 956), and mortality was 2.6% (n = 66). Patients with anastomotic leak had a significantly increased mortality rate (10.6% vs 1.6% no-leak patients; p > 0.001). At multivariable analysis the following variables were associated with anastomotic leak: longer duration of surgery (OR = 1.007 per min; p = 0.0037), open approach (OR = 1.9; p = 0.0037), and stapled anastomosis (OR = 1.5; p = 0.041).

LIMITATIONS

This is an observational study, and therefore selection bias could be present. For this reason, a multivariable logistic regression model was performed, trying to correct possible confounding factors.

CONCLUSIONS

Anastomotic leak after oncologic right hemicolectomy is a frequent complication, and it is associated with increased mortality. The key contributing surgical factors for anastomotic leak were anastomotic technique, surgical approach, and duration of surgery. See Video Abstract at http://links.lww.com/DCR/B165. PREDICTORES DE FUGA ANASTOMóTICA, COMPLICACIONES POSTOPERATORIAS Y MORTALIDAD DESPUéS DE LA COLECTOMíA DERECHA POR CáNCER: RESULTADOS DE UNA AUDITORíA INTERNACIONAL DE CORTO PLAZO: La hemicolectomía derecha se encuentra entre las operaciones más frecuentemente realizadas para cáncer de colon, pero faltan datos modernos multinacionales de alta calidad, que aborden las tasas de morbilidad y mortalidad.Reportar la tasa de morbilidad y mortalidad para cáncer de colon del lado derecho, e identificar predictores de resultados desfavorables a corto plazo, después de la hemicolectomía derecha.Estudio prospectivo observacional de corto plazo.Estudio multicéntrico internacional.El estudio de corto plazo de la Sociedad Europea de Coloproctología de 2015, fue una serie prospectiva multicéntrica internacional, que incluyó a todos los pacientes sometidos a hemicolectomía derecha electiva, de emergencia o resección ileocecal, por un período de dos meses y a principios de 2015. Este es un subanálisis, cohorte de pacientes con cáncer de colon.Los predictores de fuga anastomótica, morbilidad y mortalidad postoperatorias a los 30 días, se evaluaron usando modelos de regresión logística de efectos multivariables mixtos, después de la selección de variables con el método Lasso.De los 2,515 pacientes incluidos, se realizó una anastomosis en el 97,2% (n = 2,444); sutura manual en 38.5% (n = 940) y por engrapadora en 61.5% (n = 1504) casos. La tasa global de fuga anastomótica fue del 7,4% (180/2,444), morbilidad a los 30 días fue del 38,0% (n = 956) y la mortalidad fue del 2,6% (n = 66). Los pacientes con fuga anastomótica tuvieron una tasa de mortalidad significativamente mayor (10,6% frente al 1,6% de pacientes sin fuga, p> 0,001). En el análisis multivariable, las siguientes variables se asociaron con la fuga anastomótica: mayor duración de la cirugía (OR 1.007 por minuto, p = 0.0037), abordaje abierto (OR 1.9, p = 0.0037) y anastomosis por engrapadora (OR 1.5, p = 0.041).Este es un estudio observacional y por lo tanto podría estar presente el sesgo de selección. Por esta razón, se realizó un modelo de regresión logística multivariable, tratando de corregir posibles factores de confusión.La fuga anastomótica después de la hemicolectomía derecha oncológica, es una complicación frecuente y asociada a mayor mortalidad. Los factores quirúrgicos clave que contribuyeron a la fuga anastomótica, fueron la técnica anastomótica, abordaje quirúrgico y duración de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/B165. (Traducción-Dr. Fidel Ruiz Healy).

An international multicentre prospective audit of elective rectal cancer surgery; operative approach versus outcome, including transanal total mesorectal excision (TaTME)

INTRODUCTION

Transanal total mesorectal excision (TaTME) has rapidly emerged as a novel approach for rectal cancer surgery. Safety profiles are still emerging and more comparative data is urgently needed. This study aimed to compare indications and short-term outcomes of TaTME, open, laparoscopic, and robotic TME internationally.

METHODS

A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients undergoing elective total mesorectal excision (TME) for malignancy between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak.

RESULTS

Of 2579 included patients, 76.2% (1966/2579) underwent TME with restorative anastomosis of which 19.9% (312/1966) had a minimally invasive approach (laparoscopic or robotic) which included a transanal component (TaTME). Overall, 9.0% (175/1951, 15 missing outcome data) of patients suffered an anastomotic leak. On univariate analysis both laparoscopic TaTME (OR 1.61, 1.02-2.48, P = 0.04) and robotic TaTME (OR 3.05, 1.10-7.34, P = 0.02) were associated with a higher risk of anastomotic leak than non-transanal laparoscopic TME. However this association was lost in the mixed-effects model controlling for patient and disease factors (OR 1.23, 0.77-1.97, P = 0.39 and OR 2.11, 0.79-5.62, P = 0.14 respectively), whilst low rectal anastomosis (OR 2.72, 1.55-4.77, P < 0.001) and male gender (OR 2.29, 1.52-3.44, P < 0.001) remained strongly associated. The overall positive circumferential margin resection rate was 4.0%, which varied between operative approaches: laparoscopic 3.2%, transanal 3.8%, open 4.7%, robotic 1%.

CONCLUSION

This contemporaneous international snapshot shows that uptake of the TaTME approach is widespread and is associated with surgically and pathologically acceptable results.

Safety and efficacy of non-steroidal anti-inflammatory drugs to reduce ileus after colorectal surgery

BACKGROUND

Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non-steroidal anti-inflammatory drugs (NSAIDs) for reducing ileus after surgery.

METHODS

A prospective multicentre cohort study was delivered by an international, student- and trainee-led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre-specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury.

RESULTS

A total of 4164 patients were included, with a median age of 68 (i.q.r. 57-75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1-3, of whom 1061 (92·0 per cent) received non-selective cyclo-oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001).

CONCLUSION

NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.

Risk factors for anastomotic leakage and its impact on long-term survival in left-sided colorectal cancer surgery

Background

Anastomotic leakage (AL) significantly impairs short-term outcomes. The impact on the long-term outcomes remains unclear. This study aimed to identify the risk factors for AL and the impact on long-term survival in patients with left-sided colorectal cancer.

Methods

Nine-hundred patients with left-sided colorectal carcinoma who underwent sigmoid or rectal resection were enrolled in the study. Risk factors for AL after sigmoid or rectal resection were identified, and long-term outcomes of patients with and without AL were compared.

Results

AL rates following sigmoid and rectal resection were 5.1% and 10.7%, respectively. Higher ASA score (III–IV; OR = 10.54, p = 0.007) was associated with AL in patients undergoing sigmoid surgery on multivariable analysis. Male sex (OR = 2.40, p = 0.004), CCI score > 5 (OR = 1.72, p = 0.025), and T3/T4 stage tumors (OR = 2.25, p = 0.017) were risk factors for AL after rectal resection on multivariable analysis. AL impaired disease-free and overall survival in patients undergoing sigmoid (p = 0.009 and p = 0.001) and rectal (p = 0.003 and p = 0.014) surgery.

Conclusion

ASA score of III–IV is an independent risk factor for AL after sigmoid surgery, and male sex, higher CCI score, and advanced T stage are risk factors for AL after rectal surgery. AL impairs the long-term survival in patients undergoing left-sided colorectal surgery.

Elective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries

BACKGROUND

The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs.

METHODS

First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score.

FINDINGS

In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1-84·9), which varied between HIC (88·5 [89·0-88·0]), MIC (81·8 [82·5-81·1]), and LIC (66·8 [64·9-68·7]) settings. In the third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0-4·1; p<0·0001) increase in SVR. This was consistent in HIC (4·8% [4·1-5·5]; p<0·0001), MIC (2·8 [2·0-3·7]; p<0·0001), and LIC (3·8 [1·3-6·7%]; p<0·0001) settings.

INTERPRETATION

The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

FUNDING

National Institute for Health Research (NIHR) Global Health Research Unit on Global Surgery, NIHR Academy, Association of Coloproctology of Great Britain and Ireland, Bowel Research UK, British Association of Surgical Oncology, British Gynaecological Cancer Society, and Medtronic.

Risk factors for unfavourable postoperative outcome in patients with Crohn's disease undergoing right hemicolectomy or ileocaecal resection An international audit by ESCP and S-ECCO

BACKGROUND

Patient and disease-related factors, as well as operation technique all have the potential to impact on postoperative outcome in Crohn's disease. The available evidence is based on small series and often displays conflicting results.

AIM

To investigate the effect of pre- and intra-operative risk factors on 30-day postoperative outcome in patients undergoing surgery for Crohn's disease.

METHOD

International prospective snapshot audit including consecutive patients undergoing right hemicolectomy or ileocaecal resection. This study analysed a subset of patients who underwent surgery for Crohn's disease. The primary outcome measure was the overall Clavien-Dindo postoperative complication rate. The key secondary outcomes were anastomotic leak, re-operation, surgical site infection and length of stay at hospital. Multivariable binary logistic regression analyses were used to produce odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Three hundred and seventy five resections in 375 patients were included. The median age was 37 and 57.1% were female. In multivariate analyses, postoperative complications were associated with preoperative parenteral nutrition (OR 2.36 95% CI 1.10-4.97)], urgent/expedited surgical intervention (OR 2.00, 95% CI 1.13-3.55) and unplanned intraoperative adverse events (OR 2.30, 95% CI 1.20-4.45). The postoperative length of stay in hospital was prolonged in patients who received preoperative parenteral nutrition (OR 31, CI [1.08-1.61]) and those who had urgent/expedited operations (OR 1.21, CI [1.07-1.37]).

CONCLUSION

Preoperative parenteral nutritional support, urgent/expedited operation and unplanned intraoperative adverse events were associated with unfavourable postoperative outcome. Enhanced preoperative optimization and improved planning of operation pathways and timings may improve outcomes for patients. This article is protected by copyright. All rights reserved.

Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection: an international, multi-centre, prospective audit

INTRODUCTION

The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP).

METHODS

A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak.

RESULTS

Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case-mix adjustment using a mixed-effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30-0.92, P = 0.02) but MBP was not (OR 0.92, 0.63-1.36, P = 0.69) compared to NBP.

CONCLUSION

This non-randomised study adds 'real-world', contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice.

Ileus Management International (IMAGINE): protocol for a multicentre, observational study of ileus after colorectal surgery

AIM

The management of postoperative ileus following colorectal surgery remains controversial. It is the commonest complication after elective colorectal resection and is associated with an increased incidence of postoperative adverse events. The prevention and management of postoperative ileus remains unstandardized. This study aims to describe an international profile of gastrointestinal recovery after colorectal surgery and will assess the role of non-steroidal anti-inflammatory drugs, when used as postoperative analgesia, in expediting the return of gastrointestinal function.

METHODS

A multicentre, student- and trainee-led, prospective cohort study will be conducted across both Europe and Australasia. Adult patients undergoing elective colorectal resection during 2-week data collection periods between January and April 2018 will be included. A site-specific questionnaire will capture compliance to Enhanced Recovery after Surgery components at participating centres. The primary outcome is time to gastrointestinal recovery, measured using a composite outcome of bowel function and oral tolerance. The impact of non-steroidal anti-inflammatory drugs on gastrointestinal recovery will be evaluated along with safety data with respect to anastomotic leak, acute kidney injury and complications within 30 days of surgery.

DISCUSSION

This protocol describes the methodology of an international, observational assessment of gastrointestinal recovery after colorectal surgery. It discusses key challenges and describes how the results will impact on future investigation. The study will be conducted across a large student- and trainee-led collaborative network, with prospective quality assurance and data validation strategies.

Results of the double-blind randomized controlled trial comparing laser hemorrhoidoplasty with sutured mucopexy and excisional hemorrhoidectomy

PURPOSE

To compare the results of laser hemorrhoidoplasty (LHP), excisional hemorrhoidectomy (EH), and sutured mucopexy (MP).

METHODS

A randomized, parallel-group, double-blinded, single-center prospective study.

PATIENTS

Symptomatic 2nd- or 3rd-degree hemorrhoids patients.

INTERVENTIONS

Computer randomization sequence, patient blinding, operating surgeon blinding, and surgeon-evaluator blinding. LHP was performed using a 1470 nm diode laser. Up to 250 J of energy delivered per 1 hemorrhoid. The procedure was performed circumferentially. MP ligations were placed in the area of visible hemorrhoidal tissue. Standard EH was performed up to the level of the hemorrhoidal pedicle. Follow-up at 1 and 6 weeks and 1 year.

OUTCOME MEASURES

Recurrence of symptoms requiring treatment, intensity, and duration of pain after the operation, patients' quality of life, fecal incontinence, and patients' evaluation of treatment.

RESULTS

A total of 121 patients. Groups were even preoperatively. LHP took 15 min (SD 5.6), MP took 16 min (SD 5.58), and EH took 29 min (SD 10.3). Recurrence requiring treatment rate was 0% after EH, 10% after LHP, and 22% after MP, p = 0.004. LHP and MP were less painful than EH, p < 0.001. Patients after LHP returned to regular activity after 15 days, after MP after 22 days, and after EH after 30 days, p < 0.001. SF-36 scores were better after EH. Symptoms of fecal incontinence improved in all the groups. Patients evaluate LHP better than EH and MP.

LIMITATIONS

Single-center study.

CONCLUSIONS

Laser hemorrhoidoplasty is a safe, minimally invasive option for hemorrhoids, more effective than MP and less effective than EH. Patients evaluate this technique better than the other two.

Incidence, risk, management, and outcomes of iatrogenic full-thickness large bowel injury associated with 56,882 colonoscopies in 14 Lithuanian hospitals

BACKGROUND

The primary goal of this hospital-based retrospective multicenter case series study was to determine the incidence of large bowel full-thickness injury associated with colonoscopy in Lithuania. We assessed characteristics of patients who were treated as a result of this complication; management and outcomes were the secondary goals of this study.

METHODS

The medical records of patients with iatrogenic large bowel perforations resulting from colonoscopy within the period January 1, 2007, to December 31, 2011, were retrospectively reviewed. Representatives of 14 Lithuanian public and private hospitals participated in the survey.

RESULTS

A total of 56,882 colonoscopies were performed. Forty patients (23 female and 17 male patients) were reported to have iatrogenic full-thickness large bowel injury. Diagnostic and therapeutic colonoscopies resulted in perforation for 28 of 49,795 patients and 12 of 7,087 patients, respectively. A mean age of 70 years and a female preponderance for this complication was revealed. Sigmoid colon and rectosigmoid junction was perforated in 28 patients. All patients underwent surgical management, either primary repair (70.0 %) or bowel resection (30.0 %). Postoperative complications were diagnosed in 15 patients. Immediate treatment resulted in fewer intestinal resections and shorter hospital stays (p < 0.05). Smoking [odds ratio (OR) 14.4, 95 % confidence interval (CI) 1.16-179.8] and a large size perforation site (15 ± 10 vs. 8 ± 5 mm; OR 1.19, 95 % CI 1.03-1.38) were risk factors for developing a postoperative complication after curative surgery. Six patients died. All deaths were related to diagnostic colonoscopy.

CONCLUSIONS

Total incidence of large bowel full-thickness injury in Lithuanian hospitals is 0.07 %. Incidence of this complication after diagnostic and therapeutic colonoscopies is 0.056 and 0.169 %, respectively. The most common site of perforation is sigmoid colon and rectosigmoid junction, at 70 %. Risk rises when colonoscopy is performed in low-volume practice centers. Urgent surgical management resulted in overall mortality rate of 15.0 % and morbidity of 37.5 %.

The impact of stapling technique and surgeon specialism on anastomotic failure after right-sided colorectal resection: an international multicentre, prospective audit

AIM

There is little evidence to support choice of technique and configuration for stapled anastomoses after right hemicolectomy and ileocaecal resection. This study aimed to determine the relationship between stapling technique and anastomotic failure.

METHOD

Any unit performing gastrointestinal surgery was invited to contribute data on consecutive adult patients undergoing right hemicolectomy or ileocolic resection to this prospective, observational, international, multicentre study. Patients undergoing stapled, side-to-side ileocolic anastomoses were identified and multilevel, multivariable logistic regression analyses were performed to explore factors associated with anastomotic leak.

RESULTS

One thousand three hundred and forty-seven patients were included from 200 centres in 32 countries. The overall anastomotic leak rate was 8.3%. Upon multivariate analysis there was no difference in leak rate with use of a cutting stapler for apical closure compared with a noncutting stapler (8.4% vs 8.0%, OR 0.91, 95% CI 0.54-1.53, P = 0.72). Oversewing of the apical staple line, whether in the cutting group (7.9% vs 9.7%, OR 0.87, 95% CI 0.52-1.46, P = 0.60) or noncutting group (8.9% vs 5.7%, OR 1.40, 95% CI 0.46-4.23, P = 0.55) also conferred no benefit in terms of reducing leak rates. Surgeons reporting to be general surgeons had a significantly higher leak rate than those reporting to be colorectal surgeons (12.1% vs 7.3%, OR 1.65, 95% CI 1.04-2.64, P = 0.04).

CONCLUSION

This study did not identify any difference in anastomotic leak rates according to the type of stapling device used to close the apical aspect. In addition, oversewing of the anastomotic staple lines appears to confer no benefit in terms of reducing leak rates. Although general surgeons operated on patients with more high-risk characteristics than colorectal surgeons, a higher leak rate for general surgeons which remained after risk adjustment needs further exploration.

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

BACKGROUND

Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice.

METHODS

COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement.

RESULTS

Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001).

CONCLUSION

Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk.

Immunogradient Indicators for Antitumor Response Assessment by Automated Tumor-Stroma Interface Zone Detection

The distribution of tumor-infiltrating lymphocytes (TILs) within the tumor microenvironment provides strong prognostic value, which is increasingly important with the arrival of new immunotherapy modalities. Both visual and image analysis-based assays are developed to assess the immune contexture of the tumors. We propose an automated method based on grid subsampling of microscopy image analysis data to extract the tumor-stroma interface zone (IZ) of controlled width. The IZ is a ranking of tissue areas by their distance to the tumor edge, which is determined by a set of explicit rules. TIL density profiles across the IZ are used to compute a set of novel immunogradient indicators that reflect TIL gradient towards the tumor. We applied this method on CD8 immunohistochemistry images of surgically excised hormone receptor-positive breast and colorectal cancers to predict overall patient survival. In both cohorts, the immunogradient indicators enabled strong and independent prognostic stratification, outperforming clinical and pathologic variables. Patients with breast cancer with low immunogradient levels had a prominent decrease in survival probability 5 years after surgery. Our study provides proof of concept that data-driven, automated, operator-independent IZ sampling enables spatial immune response measurement in the tumor-host interaction frontline for prediction of disease outcomes.

Impact of radiotherapy on surgical repair and outcome in patients with rectourethral fistula

AIM

Most patients presenting with rectourethral fistula acquire it as a complication of radiotherapy for prostate cancer, as a result of injury to the rectum during prostatectomy, through trauma or from Crohn's disease. This study examined whether choice of operation and results of surgery for rectourethral fistula are influenced by prior radiotherapy.

METHOD

Male patients undergoing surgery for rectourethral fistula were identified from a prospectively maintained database. Data regarding aetiology, surgical treatment and outcomes were analysed.

RESULTS

Fifty patients (median age = 65.5 years) were identified. Radiation was received by 29 patients for prostate or rectal cancer, and 21 patients developed a fistula following prostatectomy, Crohn's disease or pelvic fracture (without radiation). Prior to definitive surgery, 30 patients underwent fecal diversion and 37 underwent urinary diversion. In total, 57 repairs were performed (44 patients had one repair, five patients had two and one patient had three). Definitive surgery was approached predominantly abdominally in radiated patients (90.6 vs 9.3%, P < 0.001) and perineally in nonradiated patients (80 vs 20%, P < 0.001). Successful primary fistula repair was more frequent in the nonradiated group compared with the radiated group (80.9 vs 0%, P < 0.001). Permanent colostomy and urinary diversion were more often required in radiated patients than in nonradiated patients (colostomy: 83 vs 0%, P < 0.001; urorostomy: 100 vs 19%, P < 0.001).

CONCLUSION

Few patients with radiation-induced rectourethral fistula avoid permanent colostomy and urostomy. In contrast, most patients with nonradiation-related fistulae undergo successful perineal repair without permanent faecal and urinary diversion.

Safety of hospital discharge before return of bowel function after elective colorectal surgery

BACKGROUND

Ileus is common after colorectal surgery and is associated with an increased risk of postoperative complications. Identifying features of normal bowel recovery and the appropriateness for hospital discharge is challenging. This study explored the safety of hospital discharge before the return of bowel function.

METHODS

A prospective, multicentre cohort study was undertaken across an international collaborative network. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The main outcome of interest was readmission to hospital within 30 days of surgery. The impact of discharge timing according to the return of bowel function was explored using multivariable regression analysis. Other outcomes were postoperative complications within 30 days of surgery, measured using the Clavien-Dindo classification system.

RESULTS

A total of 3288 patients were included in the analysis, of whom 301 (9·2 per cent) were discharged before the return of bowel function. The median duration of hospital stay for patients discharged before and after return of bowel function was 5 (i.q.r. 4-7) and 7 (6-8) days respectively (P < 0·001). There were no significant differences in rates of readmission between these groups (6·6 versus 8·0 per cent; P = 0·499), and this remained the case after multivariable adjustment for baseline differences (odds ratio 0·90, 95 per cent c.i. 0·55 to 1·46; P = 0·659). Rates of postoperative complications were also similar in those discharged before versus after return of bowel function (minor: 34·7 versus 39·5 per cent; major 3·3 versus 3·4 per cent; P = 0·110).

CONCLUSION

Discharge before return of bowel function after elective colorectal surgery appears to be safe in appropriately selected patients.

Prehabilitation in Modern Colorectal Cancer Surgery: A Comprehensive Review

Simple Summary

Surgical resection is the primary curative treatment option for colorectal cancer. However, colorectal resections remain associated with significant postoperative morbidity and mortality. Furthermore, most rectal cancer patients and some patients with locally advanced colon cancer may need preoperative neoadjuvant therapy. It improves long-term outcomes but impairs patients’ physical fitness and thus further increases surgical risk. Prehabilitation is a novel approach, aiming to improve patients’ physical and psychological capacity to reduce postoperative morbidity and improve treatment outcomes. This study aims to comprehensively overview current knowledge on colorectal cancer surgery’s prehabilitation.

Abstract

Colorectal cancer remains the third most prevalent cancer worldwide, exceeding 1.9 million new cases annually. Surgery continues to be the gold standard treatment option. Unfortunately, colorectal cancer surgery carries significant postoperative morbidity and mortality. Moreover, most rectal cancer patients and some patients with locally advanced colon cancer require preoperative neoadjuvant therapy. It improves long-term outcomes but impairs patients’ physical fitness and thus further increases surgical risk. Recently, prehabilitation has gained interest as a novel strategy to reduce treatment-related morbidity for patients undergoing colorectal cancer surgery. However, the concept is still in its infancy, and the role of prehabilitation remains controversial. In this comprehensive review, we sum up present evidence on prehabilitation before colorectal cancer surgery. Available studies are very heterogenous in interventions and investigated outcomes. Nonetheless, all trials show at least some positive effects of prehabilitation on patients’ physical, nutritional, or psychological status or even reduced postoperative morbidity. Unfortunately, the optimal prehabilitation program remains undetermined; therefore, this concept cannot be widely implemented. Future studies investigating optimal prehabilitation regimens for patients undergoing surgery for colorectal cancer are necessary.

Is acute appendicitis still misdiagnosed?

Objective

The optimal diagnostics and treatment of acute appendicitis continues to be a challenge. A false positive diagnosis of appendicitis may lead to an unnecessary operation, which has been appropriately termed negative appendectomy. The aim of our study was to identify the effectiveness of preoperative investigations in preventing negative appendectomy.

Methods

A retrospective study was performed on adult patients who underwent operation for suspected acute appendicitis from 2008 to 2013 at Vilnius University Hospital Santariskiu Klinikos. Patients were divided into two groups: group A underwent an operation, where appendix was found to be normal (non-inflamed); group B underwent an appendectomy for inflamed appendix. Groups were compared for preoperative data, investigations, treatment results and pathology findings.

Results

554 patients were included in the study. Preoperative laboratory tests results of hemoglobin, hematocrit concentrations and white blood cell count were significantly higher in group B (p<0.001). Ultrasonography was performed for 78 % of patients in group A and 74 % in group B and did not provide any statistically significant results. Comparing Alvarado score results, there were more patients with Alvarado score less than 7 in group A than in group B. In our large series we could find only four independent risk factors, and they could only account for 24 % of cases.

Conclusions

In summary, acute appendicitis is still often misdiagnosed and the ratio of negative appendectomies remains rather high. Additional investigations such as observation and computed tomography should be used to prevent this.

Safety of primary anastomosis following emergency left sided colorectal resection: an international, multi-centre prospective audit

INTRODUCTION

Some evidence suggests that primary anastomosis following left sided colorectal resection in the emergency setting may be safe in selected patients, and confer favourable outcomes to permanent enterostomy. The aim of this study was to compare the major postoperative complication rate in patients undergoing end stoma vs primary anastomosis following emergency left sided colorectal resection.

METHODS

A pre-planned analysis of the European Society of Coloproctology 2017 audit. Adult patients (> 16 years) who underwent emergency (unplanned, within 24 h of hospital admission) left sided colonic or rectal resection were included. The primary endpoint was the 30-day major complication rate (Clavien-Dindo grade 3 to 5).

RESULTS

From 591 patients, 455 (77%) received an end stoma, 103 a primary anastomosis (17%) and 33 primary anastomosis with defunctioning stoma (6%). In multivariable models, anastomosis was associated with a similar major complication rate to end stoma (adjusted odds ratio for end stoma 1.52, 95%CI 0.83-2.79, P = 0.173). Although a defunctioning stoma was not associated with reduced anastomotic leak (12% defunctioned [4/33] vs 13% not defunctioned [13/97], adjusted odds ratio 2.19, 95%CI 0.43-11.02, P = 0.343), it was associated with less severe complications (75% [3/4] with defunctioning stoma, 86.7% anastomosis only [13/15]), a lower mortality rate (0% [0/4] vs 20% [3/15]), and fewer reoperations (50% [2/4] vs 73% [11/15]) when a leak did occur.

CONCLUSIONS

Primary anastomosis in selected patients appears safe after left sided emergency colorectal resection. A defunctioning stoma might mitigate against risk of subsequent complications.

The impact of conversion on the risk of major complication following laparoscopic colonic surgery: an international, multicentre prospective audit

BACKGROUND

Laparoscopy has now been implemented as a standard of care for elective colonic resection around the world. During the adoption period, studies showed that conversion may be detrimental to patients, with poorer outcomes than both laparoscopic completed or planned open surgery. The primary aim of this study was to determine whether laparoscopic conversion was associated with a higher major complication rate than planned open surgery in contemporary, international practice.

METHODS

Combined analysis of the European Society of Coloproctology 2017 and 2015 audits. Patients were included if they underwent elective resection of a colonic segment from the caecum to the rectosigmoid junction with primary anastomosis. The primary outcome measure was the 30-day major complication rate, defined as Clavien-Dindo grade III-V.

RESULTS

Of 3980 patients, 64% (2561/3980) underwent laparoscopic surgery and a laparoscopic conversion rate of 14% (359/2561). The major complication rate was highest after open surgery (laparoscopic 7.4%, converted 9.7%, open 11.6%, P < 0.001). After case mix adjustment in a multilevel model, only planned open (and not laparoscopic converted) surgery was associated with increased major complications in comparison to laparoscopic surgery (OR 1.64, 1.27-2.11, P < 0.001).

CONCLUSIONS

Appropriate laparoscopic conversion should not be considered a treatment failure in modern practice. Conversion does not appear to place patients at increased risk of complications vs planned open surgery, supporting broadening of selection criteria for attempted laparoscopy in elective colonic resection.