Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Injury characteristics and their association with clinical complications among emergency care patients in Tanzania

Background

Over 5 million people annually die from injuries and millions more sustain non-fatal injuries requiring medical care. Ninety percent of injury deaths occur in low- and middle-income countries (LMICs). This study describes the characteristics, predictors and outcomes of adult acute injury patients presenting to a tertiary referral hospital in a low-income country in sub-Saharan Africa.

Methods

This secondary analysis uses an adult acute injury registry from Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. We describe this patient sample in terms of socio-demographics, clinical indicators, injury patterns, treatments, and outcomes at hospital discharge. Outcomes include mortality, length of hospital stay, and functional independence. Associations between patient characteristics and patient outcomes are quantified using Cox proportional hazards models, negative binomial regression, and multivariable logistic regression.

Results

Of all injury patients (n=1365), 39.0% were aged 30 to 49 years and 81.5% were men. Most patients had at least a primary school education (89.6%) and were employed (89.3%). A majority of injuries were road traffic (63.2%), fall (16.8%), or assault (14.0%) related. Self-reported comorbidities included hypertension (5.8%), HIV (3.1%), and diabetes (2.3%). Performed surgeries were classified as orthopedic (32.3%), general (4.1%), neurological (3.7%), or other (59.8%). Most patients reached the hospital at least four hours after injury occurred (53.9%). Mortality was 5.3%, median length of hospital stay was 6.1 days (IQR: 3.1, 15.0), self-care dependence was 54.2%, and locomotion dependence was 41.5%.

Conclusions

Our study sample included primarily young men suffering road traffic crashes with delayed hospital presentations and prolonged hospital stays. Being older, male, and requiring non-orthopedic surgeries or having HIV portends a worse prognosis. Prevention and treatment focused interventions to reduce the burden of injury mortality and morbidity at KCMC are needed to lower injury rates and improve injury outcomes.

Factors that enhance compliance with the Surgical Safety Checklist

BACKGROUND

The World Health Organization (WHO) has reported that its Surgical Safety Checklist (SSC) has resulted in significant reductions in morbidity and mortality. Despite its proven success, meaningful compliance with the Surgical Safety Checklist initiative has been low.

AIMS

The authors sought to identify and explore published research on factors that enhance compliance with the SSC within surgical team members.

METHODS

A review of the literature published between January 2017 and January 2021 was undertaken. Six databases were searched, and 1340 studies were screened for eligibility. The 17 studies included were critically appraised using the Crowe Critical Appraisal Tool.

FINDINGS

Three main themes were identified: training and innovations; process adaptations and team leadership.

CONCLUSION

This review of the literature draws attention to the complexities of checklist compliance and identifies the need for training, leadership and adaptation to new safety processes.

Improving quality of surgical and anaesthesia care in sub-Saharan Africa: a systematic review of hospital-based quality improvement interventions

OBJECTIVES

To systematically review existing literature on hospital-based quality improvement studies in sub-Saharan Africa that aim to improve surgical and anaesthesia care, capturing clinical, process and implementation outcomes in order to evaluate the impact of the intervention and implementation learning.

DESIGN

We conducted a systematic literature review and narrative synthesis.

SETTING

Literature on hospital-based quality improvement studies in sub-Saharan Africa reviewed until 31 December 2021.

PARTICIPANTS

MEDLINE, EMBASE, Global Health, CINAHL, Web of Science databases and grey literature were searched.

INTERVENTION

We extracted data on intervention characteristics and how the intervention was delivered and evaluated.

PRIMARY AND SECONDARY OUTCOME MEASURES

Importantly, we assessed whether clinical, process and implementation outcomes were collected and separately categorised the outcomes under the Institute of Medicine quality domains. Risk of bias was not assessed.

RESULTS

Of 1573 articles identified, 49 were included from 17/48 sub-Saharan African countries, 16 of which were low-income or lower middle-income countries. Almost two-thirds of the studies took place in East Africa (31/49, 63.2%). The most common intervention focus was reduction of surgical site infection (12/49, 24.5%) and use of a surgical safety checklist (14/49, 28.6%). Use of implementation and quality improvement science methods were rare. Over half the studies measured clinical outcomes (29/49, 59.2%), with the most commonly reported ones being perioperative mortality (13/29, 44.8%) and surgical site infection rate (14/29, 48.3%). Process and implementation outcomes were reported in over two thirds of the studies (34/49, 69.4% and 35, 71.4%, respectively). The most studied quality domain was safety (44/49, 89.8%), with efficiency (4/49, 8.2%) and equitability (2/49, 4.1%) the least studied domains.

CONCLUSIONS

There are few hospital-based studies that focus on improving the quality of surgical and anaesthesia care in sub-Saharan Africa. Use of implementation and quality improvement methodologies remain low, and some quality domains are neglected.

PROSPERO REGISTRATION NUMBER

CRD42019125570.

Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness

BACKGROUND

Globally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high-income countries, implementing them in low/middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking. We aimed to identify all perioperative safety and QI interventions applied at scale in LMICs and evaluate their implementation mechanisms using implementation theory.

METHODS

Systematic scoping review of perioperative QI interventions in LMICs from 1960 to 2020. Studies were identified through Medline, EMBASE and Google Scholar. Data were extracted in two phases: (1) abstract review to identify the range of QI interventions; (2) studies describing scale-up (three or more sites), had full texts retrieved and analysed for; implementation strategies and scale-up frameworks used; and implementation outcomes reported.

RESULTS

We screened 45 128 articles, identifying 137 studies describing perioperative QI interventions across 47 countries. Only 31 of 137 (23%) articles reported scale-up with the most common intervention being the WHO Surgical Safety Checklist. The most common implementation strategies were training and educating stakeholders, developing stakeholder relationships, and using evaluative and iterative strategies. Reporting of implementation mechanisms was generally poor; and although the components of scale-up frameworks were reported, relevant frameworks were rarely referenced.

CONCLUSION

Many studies report implementation of QI interventions, but few report successful scale-up from single to multiple-site implementation. Greater use of implementation science methodology may help determine what works, where and why, thereby aiding more widespread scale-up and dissemination of perioperative QI interventions.

Surgery as a Global Health Need

Surgical care is now recognized as a fundamental component of universal health coverage. Unfortunately, most of the world is still without access to safe and timely surgical care, including 9 out of 10 people living in low- and middle-income countries (LMICs). Additionally, even in LMICs with sustainable surgical programs, surgical outcomes continue to lag behind those in high-income countries. In this article, we will provide a brief history and introduction to global surgery, an overview of the existing literature on global surgical outcomes, and a discussion surrounding the challenges to building surgical capacity and improving surgical outcomes in LMICs. In addition, we will discuss the existing frameworks for building surgical care into national universal healthcare plans and initiatives striving improve surgical outcomes in LMICs.

Predicting the Severity of Acute Appendicitis in Children Using Neutrophil-to-Lymphocyte Ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR)

Introduction

The ability to predict risk of perforation in acute appendicitis (AA) could direct timely management and reduce morbidity. Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are surrogate severity markers in infections. This study investigates the use of PLR and NLR as a marker for distinguishing uncomplicated (UA) and complicated appendicitis (CA) in children.

Materials and methods

This retrospective single-center study collected data between January 1, 2014, and December 31, 2020. Children between five and 17 years of age with histologically confirmed appendicitis were included. Cut-off values for NLR and PLR were determined by employing the receiver operating characteristic (ROC) curve with sensitivity and specificity in addition to regression analysis.

Results

A total of 701 patients were included with a median age of 13 years. Out of which 52% of the cohort was female. The difference between the NLR and PLR ratios between UA and CA was significant (p=0.05, Kruskal-Wallis). For UA, the area under the ROC curve (AUC) and cut-off for NLR and PLR were 0.741, 3.80 with 95% CI of 0.701-0.781 and 0.660, 149.25 with 95% CI of 0.618-0.703, respectively. In CA, using NLR and PLR, AUC and cut-off were 0.776, 8.86 with 95%CI of 0.730-0.822 and 0.694, 193.67 with 95%CI of 0.634-0.755, respectively. All were significant with p<0.001.

Conclusions

NLR and PLR are reliable, synergistic markers predicting complicated appendicitis which can guide non-operative management in children.

The impact of preoperative oral nutrition supplementation on outcomes in patients undergoing gastrointestinal surgery for cancer in low- and middle-income countries: a systematic review and meta-analysis

Malnutrition is an independent predictor for postoperative complications in low- and middle-income countries (LMICs). We systematically reviewed evidence on the impact of preoperative oral nutrition supplementation (ONS) on patients undergoing gastrointestinal cancer surgery in LMICs. We searched EMBASE, Cochrane Library, Web of Science, Scopus, WHO Global Index Medicus, SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) databases from inception to March 21, 2022 for randomised controlled trials evaluating preoperative ONS in gastrointestinal cancer within LMICs. We evaluated the impact of ONS on all postoperative outcomes using random-effects meta-analysis. Seven studies reported on 891 patients (446 ONS group, 445 control group) undergoing surgery for gastrointestinal cancer. Preoperative ONS reduced all cause postoperative surgical complications (risk ratio (RR) 0.53, 95% CI 0.46-0.60, P < 0.001, I2 = 0%, n = 891), infection (0.52, 0.40-0.67, P = 0.008, I2 = 0%, n = 570) and all-cause mortality (0.35, 0.26-0.47, P = 0.014, I2 = 0%, n = 588). Despite heterogeneous populations and baseline rates, absolute risk ratio (ARR) was reduced for all cause (pooled effect -0.14, -0.22 to -0.06, P = 0.006; number needed to treat (NNT) 7) and infectious complications (-0.13, -0.22 to -0.06, P < 0.001; NNT 8). Preoperative nutrition in patients undergoing gastrointestinal cancer surgery in LMICs demonstrated consistently strong and robust treatment effects across measured outcomes. However additional higher quality research, with particular focus within African populations, are urgently required.

Establishing a baseline for surgical care in Mongolia: a situational analysis using the six indicators from the Lancet Commission on Global Surgery

OBJECTIVES

To inform national planning, six indicators posed by the Lancet Commission on Global Surgery were collected for the Mongolian surgical system. This situational analysis shows one lower middle-income country's ability to collect the indicators aided by a well-developed health information system.

DESIGN

An 11-year retrospective analysis of the Mongolian surgical system using data from the Health Development Center, National Statistics Office and Household Socio-Economic Survey. Access estimates were based on travel time to capable hospitals. Provider density, surgical volume and postoperative mortality were calculated at national and regional levels. Protection against impoverishing and catastrophic expenditures was assessed against standard out-of-pocket expenditure at government hospitals for individual operations.

SETTING

Mongolia's 81 public hospitals with surgical capability, including tertiary, secondary and primary/secondary facilities.

PARTICIPANTS

All operative patients in Mongolia's public hospitals, 2006-2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were national-level results of the indicators. Secondary outcomes include regional access; surgeons, anaesthesiologists and obstetricians (SAO) density; surgical volume; and perioperative mortality.

RESULTS

In 2016, 80.1% of the population had 2-hour access to essential surgery, including 60% of those outside the capital. SAO density was 47.4/100 000 population. A coding change increased surgical volume to 5784/100 000 population, and in-hospital mortality decreased from 0.27% to 0.14%. All households were financially protected from caesarean section. Appendectomy carried 99.4% and 98.4% protection, external femur fixation carried 75.4% and 50.7% protection from impoverishing and catastrophic expenditures, respectively. Laparoscopic cholecystectomy carried 42.9% protection from both.

CONCLUSIONS

Mongolia meets national benchmarks for access, provider density, surgical volume and postoperative mortality with notable limitations. Significant disparities exist between regions. Unequal access may be efficiently addressed by strengthening or building key district hospitals in population-dense areas. Increased financial protections are needed for operations involving hardware or technology. Ongoing monitoring and evaluation will support the development of context-specific interventions to improve surgical care in Mongolia.

Underrepresentation and undertreatment of women in hematology: An unsolved issue

Gender disparity is pervasive and persisting in research. Despite gender being recognized as one of the primary determinants of health, inadequate representation of women in clinical trials has resulted in a deficit pertaining to equity in health care. This gross underrepresentation has exposed women to unforeseen health-related outcomes, and as evident through historic records, unequal distribution of opportunities has further widened this gender gap in health care.

Mortality and pulmonary complications in emergency general surgery patients with COVID-19: A large international multicenter study

OBJECTIVES

The outcomes of emergency general surgery (EGS) patients with concomitant COVID-19 infection remain unknown. With a multicenter study in 361 hospitals from 52 countries, we sought to study the mortality and pulmonary complications of COVID-19 patients undergoing EGS.

METHODS

All patients 17 years or older and diagnosed preoperatively with COVID-19 between February and July 2020 were included. Emergency general surgery was defined as the urgent/emergent performance of appendectomy, cholecystectomy, or laparotomy. The main outcomes were 30-day mortality and 30-day pulmonary complications (a composite of acute respiratory distress syndrome, unexpected mechanical ventilation, or pneumonia). Planned subgroup analyses were performed based on presence of preoperative COVID-related respiratory findings (e.g., cough, dyspnea, need for oxygen therapy, chest radiology abnormality).

RESULTS

A total of 1,045 patients were included, of which 40.1% were female and 50.0% were older than 50 years; 461 (44.1%), 145 (13.9%), and 439 (42.0%) underwent appendectomy, cholecystectomy, and laparotomy, respectively. The overall mortality rate was 15.1% (158 of 1,045 patients), and the overall pulmonary complication rate was 32.9% (344 of 1,045 patients); in the subgroup of laparotomy patients, the rates were 30.6% (134 of 438 patients) and 59.2% (260 of 439 patients), respectively. Subgroup analyses found mortality and pulmonary complication risk to be especially increased in patients with preoperative respiratory findings.

CONCLUSION

COVID-19 patients undergoing EGS have significantly high rates of mortality and pulmonary complications, but the risk is most pronounced in those with preoperative respiratory findings.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

Perioperative Care Pathways in Low- and Lower-Middle-Income Countries: Systematic Review and Narrative Synthesis

BACKGROUND

Safe and effective care for surgical patients requires high-quality perioperative care. In high-income countries (HICs), care pathways have been shown to be effective in standardizing clinical practice to optimize patient outcomes. Little is known about their use in low- and middle-income countries (LMICs) where perioperative mortality is substantially higher.

METHODS

Systematic review and narrative synthesis to identify and describe studies in peer-reviewed journals on the implementation or evaluation of perioperative care pathways in LMICs. Searches were conducted in MEDLINE, EMBASE, CINAHL Plus, WHO Global Index, Web of Science, Scopus, Global Health and SciELO alongside citation searching. Descriptive statistics, taxonomy classifications and framework analyses were used to summarize the setting, outcome measures, implementation strategies, and facilitators and barriers to implementation.

RESULTS

Twenty-seven studies were included. The majority of pathways were set in tertiary hospitals in lower-middle-income countries and were focused on elective surgery. Only six studies were assessed as high quality. Most pathways were adapted from international guidance and had been implemented in a single hospital. The most commonly reported barriers to implementation were cost of interventions and lack of available resources.

CONCLUSIONS

Studies from a geographically diverse set of low and lower-middle-income countries demonstrate increasing use of perioperative pathways adapted to resource-poor settings, though there is sparsity of literature from low-income countries, first-level hospitals and emergency surgery. As in HICs, addressing patient and clinician beliefs is a major challenge in improving care. Context-relevant and patient-centered research, including qualitative and implementation studies, would make a valuable contribution to existing knowledge.

Knowledge, practice, and associated factors towards postoperative wound care among nurses working in public hospitals in Ethiopia: A multicenter cross-sectional study in low resource setting area

Background and Aim

Postoperative wound care is irrigating the surgical wound with normal saline solution and applying sterile gauze or bandage. Even though challenges related to postoperative wound care and its complications are high, information related to the knowledge and practice of nurses on postoperative wound care are minimal. Therefore, this study aimed to find levels of knowledge and practices of nurses on postoperative wound care management and contributing factors among nurses working at public hospitals of West Showa, Oromia region, Ethiopia, 2020.

Method

A facility‐based cross‐sectional study was conducted among 465 Nurses working in public hospitals in West Showa Zone, Oromia, Ethiopia, from June 15 to July 10, 2020. Data were collected using a self‐administered structured questionnaire that was adapted from previous studies. Descriptive statistics were performed and results were presented using tables and graphs. Bivariate and multivariable logistic regression analysis was undertaken, and variables with p < 0.05 at a 95% confidence interval (CI) were considered statistically significant.

Result

Only 44.3% (95% CI = 39.5%, 48.9%) and 48.0% (95% CI = 43.4%, 52.4%) of nurses have good knowledge and practice in postoperative wound care, respectively. Male nurses (adjusted odds ratio [AOR] = 1.90 (1.25–2.89), working in gynecology ward (AOR = 0.42 [0.18–0.95]), experience of ≥2 years in surgical units (AOR = 2.97 [1.10–8.02]), working in secondary hospital (AOR = 1.94 [1.16–3.26]), and working in tertiary hospital (AOR = 3.31 [1.81–6.08]) were significantly associated with the knowledge of nurses. An adequate supply of personal protective equipment (AOR = 3.38 [1.29–8.84]), using infection prevention guidelines (AOR = 5.03 [2.16–11.7]) and the presence of an adequate wound care materials (AOR = 3.67 [1.71–7.88]) were significantly associated with the practice of nurses.

Conclusion

Less than half of nurses had good knowledge and practice in postoperative wound care and several factors contribute to its improvement. Upgrading the nurse's knowledge and practice towards postoperative wound care is essential in preventing postoperative wound infection.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

The Postoperative Short Course Content Study group. Priorities for content for a short-course on postoperative care relevant for low- and middle-income countries: an e-Delphi process with training facilitators

Most surgical and anaesthetic mortality and morbidity occurs postoperatively, disproportionately affecting low- and middle-income countries. Various short courses have been developed to improve patient outcomes in low- and middle-income countries, but none specifically to address postoperative care and complications. We aimed to identify key features of a proposed short-course addressing this topic using a Delphi process with low- and middle-income country anaesthesia providers trained as short-course facilitators. An initial questionnaire was co-developed from literature review and exploratory workshops to include 108 potential course features. Features included content; teaching method; appropriate participants; and appropriate faculty. Over three Delphi rounds (panellists numbered 86, 64 and 35 in successive cycles), panellists indicated which features they considered most important. Responses were analysed by geographical regions: Africa, the Americas, south-east Asia and Western Pacific. Ultimately, panellists identified 60, 40 and 54 core features for the proposed course in each region, respectively. There were high levels of consensus within regions on what constituted core course content, but not between regions. All panellists preferred the small group workshop teaching method irrespective of region. All regions considered anaesthetists to be key facilitators, while all agreed that both anaesthetists and operating theatre nurses were key participants. The African and Americas regional panels recommended more multidisciplinary healthcare professionals for participant roles. Faculty from high-income countries were not considered high priority. Our study highlights variability between geographical regions as to which course features were perceived as most locally relevant, supporting regional adaptation of short-course design rather than a one-size-fits-all model.

Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study

Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.

Outcomes and Their State-level Variation in Patients Undergoing Surgery With Perioperative SARS-CoV-2 Infection in the USA: A Prospective Multicenter Study

OBJECTIVE

To report the 30-day outcomes of patients with perioperative SARS-CoV-2 infection undergoing surgery in the USA.

BACKGROUND

Uncertainty regarding the postoperative risks of patients with SARS-CoV-2 exists.

METHODS

As part of the COVIDSurg multicenter study, all patients aged ≥17 years undergoing surgery between January 1 and June 30, 2020 with perioperative SARS-CoV-2 infection in 70 hospitals across 27 states were included. The primary outcomes were 30-day mortality and pulmonary complications. Multivariable analyses (adjusting for demographics, comorbidities, and procedure characteristics) were performed to identify predictors of mortality.

RESULTS

A total of 1581 patients were included; more than half of them were males (n = 822, 52.0%) and older than 50 years (n = 835, 52.8%). Most procedures (n = 1261, 79.8%) were emergent, and laparotomies (n = 538, 34.1%). The mortality and pulmonary complication rates were 11.0 and 39.5%, respectively. Independent predictors of mortality included age ≥70 years (odds ratio 2.46, 95% confidence interval [1.65-3.69]), male sex (2.26 [1.53-3.35]), ASA grades 3-5 (3.08 [1.60-5.95]), emergent surgery (2.44 [1.31-4.54]), malignancy (2.97 [1.58-5.57]), respiratory comorbidities (2.08 [1.30-3.32]), and higher Revised Cardiac Risk Index (1.20 [1.02-1.41]). While statewide elective cancelation orders were not associated with a lower mortality, a sub-analysis showed it to be associated with lower mortality in those who underwent elective surgery (0.14 [0.03-0.61]).

CONCLUSIONS

Patients with perioperative SARS-CoV-2 infection have a significantly high risk for postoperative complications, especially elderly males. Postponing elective surgery and adopting non-operative management, when reasonable, should be considered in the USA during the pandemic peaks.

OUP accepted manuscript

Background

Existing emergency general surgery (EGS) guidelines rarely include evidence from low- and middle-income countries (LMICs) and may lack relevance to low-resource settings. The aim of this study was to develop global guidelines for EGS that are applicable across all hospitals and health systems.

Methods

A systematic review and thematic analysis were performed to identify recommendations relating to undifferentiated EGS. Those deemed relevant across all resource settings by an international guideline development panel were included in a four-round Delphi prioritization process and are reported according to International Standards for Clinical Practice Guidelines. The final recommendations were included as essential (baseline measures that should be implemented as a priority) or desirable (some hospitals may lack relevant resources at present but should plan for future implementation).

Results

After thematic analysis of 38 guidelines with 1396 unique recommendations, 68 recommendations were included in round 1 voting (410 respondents (219 from LMICs)). The final guidelines included eight essential, one desirable, and three critically unwell patient-specific recommendations. Preoperative recommendations included guidance on timely transfers, CT scan pathways, handovers, and discussion with senior surgeons. Perioperative recommendations included surgical safety checklists and recovery room monitoring. Postoperative recommendations included early-warning scores, discharge plans, and morbidity meetings. Recommendations for critically unwell patients included prioritization for theatre, senior team supervision, and high-level postoperative care.

Conclusion

This pragmatic and representative process created evidence-based global guidelines for EGS that are suitable for resource limited environments around the world.

Validation of a patient safety checklist for radiological procedures in hemodynamics

ABSTRACT Objectives: to carry out cultural adaptation and validation of WHO Surgical Safety Checklist: for Radiological Interventions ONLY to Brazilian Portuguese. Methods: a methodological research with the following stages of the cultural adaptation process: translation of the instrument, achievement of a consensus in Portuguese, evaluation by a committee of judges, back-translation, achievement of a consensus in English, comparison with the original version, and a pre-test. The psychometric properties of the adapted version were evaluated through interobserver reliability. Results: the values of the kappa coefficient ranged from moderate to almost perfect in most instrument items, demonstrating that the instrument items were understandable and reliable when applied to the observed context. Conclusions: the cultural adaptation and validation of face and content of the instrument met the criteria of equivalence between the original and the translated instrument. The tool proved to be understandable and feasible and can be applied in invasive radiological procedures in Brazil.

An Evaluation of Serum IgE and Th2-Associated Interleukins in Children With Uncomplicated and Complicated Appendicitis

BACKGROUND

The pathogenesis of appendicitis is not understood completely and establishing a correct diagnosis can be clinically challenging. Previous investigations have shown an association between a T helper cell (Th)2-mediated inflammatory response, for example immunoglobulin E (IgE)-mediated allergy, and a decreased risk of complicated appendicitis. The present study aimed to evaluate differences in serum concentrations of IgE and Th2-associated interleukins (IL) in children with uncomplicated and complicated appendicitis.

METHOD

A prospective study including children <15 years with appendicitis. Blood samples were collected preoperatively at the time of clinical assessment at the Pediatric Emergency Department and analyzed for concentrations of serum total IgE and IL-4, IL-9, and IL-13. Associations with complicated appendicitis were evaluated through logistic regression adjusting for age, appendicolith, and symptom duration.

RESULTS

138 children with confirmed appendicitis were included. The median age was 10 (IQR 8-12) years, 87 (63%) were boys and 58 (42%) had complicated appendicitis. Children with complicated appendicitis had significantly higher concentrations of IL-9 and IL-13 compared to children with uncomplicated appendicitis. In the univariate logistic regression, high concentrations of IL-13 were associated with an increased risk of complicated appendicitis [OR 1.02 (95% CI 1.01-1.04) p = 0.005], which remained in the multivariate analysis [aOR 1.02 (95% CI 1.01-1.04), p = 0.01]. Serum concentrations of IgE, IL-4, and IL-9 did not significantly affect the risk of complicated appendicitis.

CONCLUSION

High levels of IL-13 seem to be associated with an increased risk of complicated appendicitis. This is incongruent with the hypothesis of an Th1/Th17-driven inflammation in this type of appendicitis.

Surgical Trainee Supervision During Non-Trauma Emergency Laparotomy in Rwanda and South Africa

OBJECTIVE

The primary objective was to describe the level of surgical trainee autonomy during non-trauma emergency laparotomy (NTEL) operations in Rwanda and South Africa. The secondary objective was to identify potential associations between trainee autonomy, and patient mortality and reoperation.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective, observational study of NTEL operations at 3 teaching hospitals in South Africa and Rwanda over a 1-year period from September 1, 2017 to August 31, 2018. The study included 543 NTEL operations performed by the acute care and general surgery services on adults over the age of 18 years.

RESULTS

Surgical trainees led 3-quarters of NTEL operations and, of these, 72% were performed autonomously in Rwanda and South Africa. Notably, trainee autonomy was not significantly associated with reoperation or mortality.

CONCLUSIONS

Trainees were able to gain autonomous surgical experience without impacting mortality or reoperation outcomes, while still providing surgical support in a high-demand setting.

COVIDSurg Collaborative, GlobalSurg Collaborative. Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05-1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4-7 days or ≥ 8 days of 1.25 (1.04-1.48), p = 0.015 and 1.31 (1.11-1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care.

Comparison of Outcomes of Emergency Laparotomies Performed During Daytime Versus Nights and Weekends in Rwandan University Teaching Hospitals

BACKGROUND

Emergency laparotomy is a common procedure with high morbidity and mortality. The aim of this study was to assess if the time of surgery (day versus night and weekend) affects the morbidity and mortality in a low-resource setting.

METHODS

A retrospective study was conducted in 2 university teaching hospitals in Rwanda. Patient characteristics, time of laparotomy, operative details and postoperative outcomes were recorded. Chi-square and Wilcoxon rank sum tests were used to determine factors and outcomes associated with time of surgery. Logistic regression was used to determine factors associated with mortality.

RESULTS

In 309 patients, who underwent emergency laparotomy, 147 (48%) patients were operated during the daytime, 123 (40%) patients were operated during the night shift and 39 (12%) patients were operated on the weekend. Common diagnoses were intestinal obstruction (n = 141, 46%), peritonitis (n = 101, 33%) and abdominal trauma (n = 40, 13%). The overall mortality rate was 16% with 14% in patients operated during day and 17% in patients operated during night and weekends (p = 0.564). Overall, the morbidity rate was 30% with 27% in patients operated during the day compared with 32% in patients operated during night/weekends (p = 0.348). After controlling for confounding factors, there was no association between time of operation and mortality or morbidity.

CONCLUSION

Morbidity and mortality associated with emergency laparotomy are high but the time of day for emergency laparotomy did not affect outcome in Rwandan referral hospitals.

The impact of COVID-19 and social avoidance in urgent and emergency surgeries - will a delay in diagnosis result in perioperative complications?

OBJECTIVE

The sudden COVID-19 outbreak has changed our health system. Physicians had to face the challenge of treating a large number of critically ill patients with a new disease and also maintain the essential healthcare services functioning properly. To prevent disease dissemination, authorities instructed people to stay at home and seek medical care only if they experienced respiratory distress. However, there are concerns those patients did not seek necessary health care because of these orientations. This study aims to see how the pandemic has influenced the severity of the disease, complication, and mortality of patients undergoing emergency cholecystectomy and appendectomy.

METHODS

Retrospective review of medical records of patients admitted to the emergency department and undergoing to cholecystectomy and appendicectomy in the periods from March to May 2019 and 2020.

RESULTS

We observed that COVID-19 did not change the severity of presentation or the outcome of patients with gallbladder disease, but caused a 24.2% increase in the prevalence of complicated appendicitis (p<0.05). However, disagreeing with what was expected, we did not identify a greater number of perioperative complications in patients undergoing an appendectomy.

CONCLUSION

Therefore, it seems that in a university tertiary referral center COVID-19 did not influence the management and outcome of inflammatory diseases treated in the surgical emergency department.

Enhanced postoperative surveillance versus standard of care to reduce mortality among adult surgical patients in Africa (ASOS-2): a cluster-randomised controlled trial

Background

Risk of mortality following surgery in patients across Africa is twice as high as the global average. Most of these deaths occur on hospital wards after the surgery itself. We aimed to assess whether enhanced postoperative surveillance of adult surgical patients at high risk of postoperative morbidity or mortality in Africa could reduce 30-day in-hospital mortality.

Methods

We did a two-arm, open-label, cluster-randomised trial of hospitals (clusters) across Africa. Hospitals were eligible if they provided surgery with an overnight postoperative admission. Hospitals were randomly assigned through minimisation in recruitment blocks (1:1) to provide patients with either a package of enhanced postoperative surveillance interventions (admitting the patient to higher care ward, increasing the frequency of postoperative nursing observations, assigning the patient to a bed in view of the nursing station, allowing family members to stay in the ward, and placing a postoperative surveillance guide at the bedside) for those at high risk (ie, with African Surgical Outcomes Study Surgical Risk Calculator scores ≥10) and usual care for those at low risk (intervention group), or for all patients to receive usual postoperative care (control group). Health-care providers and participants were not masked, but data assessors were. The primary outcome was 30-day in-hospital mortality of patients at low and high risk, measured at the participant level. All analyses were done as allocated (by cluster) in all patients with available data. This trial is registered with ClinicalTrials.gov, NCT03853824.

Findings

Between May 3, 2019, and July 27, 2020, 594 eligible hospitals indicated a desire to participate across 33 African countries; 332 (56%) were able to recruit participants and were included in analyses. We allocated 160 hospitals (13 275 patients) to provide enhanced postoperative surveillance and 172 hospitals (15 617 patients) to provide standard care. The mean age of participants was 37·1 years (SD 15·5) and 20 039 (69·4%) of 28 892 patients were women. 30-day in-hospital mortality occurred in 169 (1·3%) of 12 970 patients with mortality data in the intervention group and in 193 (1·3%) of 15 242 patients with mortality data in the control group (relative risk 0·96, 95% CI 0·69–1·33; p=0·79). 45 (0·2%) of 22 031 patients at low risk and 309 (5·6%) of 5500 patients at high risk died. No harms associated with either intervention were reported.

Interpretation

This intervention package did not decrease 30-day in-hospital mortality among surgical patients in Africa at high risk of postoperative morbidity or mortality. Further research is needed to develop interventions that prevent death from surgical complications in resource-limited hospitals across Africa.

Funding

Bill & Melinda Gates Foundation and the World Federation of Societies of Anaesthesiologists.

Translations

For the Arabic, French and Portuguese translations of the abstract see Supplementary Materials section.

Implementation Strategies and the Uptake of the World Health Organization Surgical Safety Checklist in Low and Middle Income Countries: A Systematic Review and Meta-analysis

OBJECTIVES

To identify the implementation strategies used in World Health Organization Surgical Safety Checklist (SSC) uptake in low- and middle-income countries (LMICs); examine any association of implementation strategies with implementation effectiveness; and to assess the clinical impact.

BACKGROUND

The SSC is associated with improved surgical outcomes but effective implementation strategies are poorly understood.

METHODS

We searched the Cochrane library, MEDLINE, EMBASE and PsycINFO from June 2008 to February 2019 and included primary studies on SSC use in LMICs. Coprimary objectives were identification of implementation strategies used and evaluation of associations between strategies and implementation effectiveness. To assess the clinical impact of the SSC, we estimated overall pooled relative risks for mortality and morbidity. The study was registered on PROSPERO (CRD42018100034).

RESULTS

We screened 1562 citations and included 47 papers. Median number of discrete implementation strategies used per study was 4 (IQR: 1-14, range 0-28). No strategies were identified in 12 studies. SSC implementation occurred with high penetration (81%, SD 20%) and fidelity (85%, SD 13%), but we did not detect an association between implementation strategies and implementation outcomes. SSC use was associated with a reduction in mortality (RR 0.77; 95% CI 0.67-0.89), all complications (RR 0.56; 95% CI 0.45-0.71) and infectious complications (RR 0.44; 95% CI 0.37-0.52).

CONCLUSIONS

The SSC is used with high fidelity and penetration is associated with improved clinical outcomes in LMICs. Implementation appears well supported by a small number of tailored strategies. Further application of implementation science methodology is required among the global surgical community.

Preliminary model assessing the cost-effectiveness of preoperative chlorhexidine mouthwash at reducing postoperative pneumonia among abdominal surgery patients in South Africa

Background

Pneumonia is a common and severe complication of abdominal surgery, it is associated with increased length of hospital stay, healthcare costs, and mortality. Further, pulmonary complication rates have risen during the SARS-CoV-2 pandemic. This study explored the potential cost-effectiveness of administering preoperative chlorhexidine mouthwash versus no-mouthwash at reducing postoperative pneumonia among abdominal surgery patients.

Methods

A decision analytic model taking the South African healthcare provider perspective was constructed to compare costs and benefits of mouthwash versus no-mouthwash-surgery at 30 days after abdominal surgery. We assumed two scenarios: (i) the absence of COVID-19; (ii) the presence of COVID-19. Input parameters were collected from published literature including prospective cohort studies and expert opinion. Effectiveness was measured as proportion of pneumonia patients. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainties. The results of the probabilistic sensitivity analysis were presented using cost-effectiveness planes and cost-effectiveness acceptability curves.

Results

In the absence of COVID-19, mouthwash had lower average costs compared to no-mouthwash-surgery, $3,675 (R 63,770) versus $3,958 (R 68,683), and lower proportion of pneumonia patients, 0.029 versus 0.042 (dominance of mouthwash intervention). In the presence of COVID-19, the increase in pneumonia rate due to COVID-19, made mouthwash more dominant as it was more beneficial to reduce pneumonia patients through administering mouthwash. The cost-effectiveness acceptability curves shown that mouthwash surgery is likely to be cost-effective between $0 (R0) and $15,000 (R 260,220) willingness to pay thresholds.

Conclusions

Both the absence and presence of SARS-CoV-2, mouthwash is likely to be cost saving intervention for reducing pneumonia after abdominal surgery. However, the available evidence for the effectiveness of mouthwash was extrapolated from cardiac surgery; there is now an urgent need for a robust clinical trial on the intervention on non-cardiac surgery.

We Asked the Experts: The Role of Rural Hospitals in Achieving Equitable Surgical Access in Low-Resourced Settings

Strengthening and defining the role of rural hospitals within a surgical ecosystem is essential to improving quality and timely surgical access for rural people in low and middle-income countries (LMICs). Regional hospitals are the cornerstone of LMIC rural surgical care but have insufficient human resources and infrastructure that limit the surgical care they can provide. District hospitals are most accessible for many rural patients but also have limited surgical capacity. In order to surgical access for rural people, both regional and district hospital surgical services must be strengthened. A strong relationship between regional and district hospitals through a hub and spoke model is needed. Regional hospital surgeons can support training and supervision for and referrals from district hospitals. Telemedicine can play a key role to leapfrog physical barriers and surgical specialist shortages. The changing demographics of surgical disease will continue to worsen the strain on tertiary hospitals where most subspecialists in LMICs work. The fewer rural patients who need to travel to urban referral and tertiary facilities for problems that can be managed at lower-level facilities, the better access to timely surgical care for all.

Derivation and validation of a national multicenter mortality risk stratification model - the ExCare model: a study protocol

Introduction

Surgical care is essential for proper management of various diseases. However, it can result in unfavorable outcomes. In order to identify patients at higher risk of complications, several risk stratification models have been developed. Ideally, these tools should be simple, reproducible, accurate, and externally validated. Unfortunately, none of the best-known risk stratification instruments have been validated in Brazil. In this sense, the Ex-Care model was developed by retrospective data analysis of surgical patients in a major Brazilian university hospital. It consists of four independent predictors easily collected in the preoperative evaluation, showing high accuracy in predicting death within 30 days after surgery.

Objectives

To update and validate a Brazilian national-based model of postoperative death probability within 30 days based on the Ex-Care model. Also, to develop an application for smartphones that allows preoperative risk stratification by Ex-Care model.

Methods

Ten participating centers will collect retrospective data from digital databases. Variables age, American Society of Anesthesiologists (ASA) physical status, surgical severity (major or non-major) and nature (elective or urgent) will be evaluated as predictors for in-hospital mortality within 30 postoperative days, considered the primary outcome.

Expected results

We believe that the Ex-Care model will present discriminative capacity similar to other classically used scores validated for surgical mortality prediction. Furthermore, the mobile application to be developed will provide a practical and easy-to-use tool to the professionals enrolled in perioperative care.

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

BACKGROUND

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

METHODS

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

FINDINGS

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality.

INTERPRETATION

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

FUNDING

Wellcome Trust.

Feasibility and diagnostic accuracy of Telephone Administration of an adapted wound heaLing QuestiONnaire for assessment for surgical site infection following abdominal surgery in low and middle-income countries (TALON): protocol for a study within a trial (SWAT)

Background

Surgical site infection is the most common complication of abdominal surgery, with a global impact on patients and health systems. There are no tools to identify wound infection that are validated for use in the global setting. The overall aim of the study described in this protocol is to evaluate the feasibility and validity of a remote, digital pathway for wound assessment after hospital discharge for patients in low- and middle-income countries (LMICs).

Methods

A multi-centre, international, mixed-methods study within a trial, conducted in two stages (TALON-1 and TALON-2). TALON-1 will adapt and translate a universal reporter outcome measurement tool (Bluebelle Wound Healing Questionnaire, WHQ) for use in global surgical research (SWAT store registration: 126) that can be delivered over the telephone. TALON-2 will evaluate a remote wound assessment pathway (including trial retention) and validate the diagnostic accuracy of this adapted WHQ through a prospective cohort study embedded within two global surgery trials. Embedded community engagement and involvement activities will be used to optimise delivery and ensure culturally attuned conduct. TALON-1 and TALON-2 are designed and will be reported in accordance with best practice guidelines for adaptation and validation of outcome measures, and diagnostic test accuracy studies.

Discussion

Methods to identify surgical site infection after surgery for patients after hospital discharge have the potential to improve patient safety, trial retention, and research efficiency. TALON represents a large, pragmatic, international study co-designed and delivered with LMIC researchers and patients to address an important research gap in global surgery trial methodology.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05398-z.

Advancing trauma care through social media

Social media has become an integral part of everyday life. Because of this, medical representation has become increasingly popular across social media. Medical professionals have begun to recognize the value of social media in areas such as research promotion, mentorship program expansion and collaboration with peers. To date, these online medical communities are being underused in the field of trauma. Trauma centers may benefit by creating a more prominent online presence to allow for the dissemination of critical research, expansion of injury prevention programs and participation in national annual meetings. When used properly, social media can serve as a platform for the advancement of trauma care in a cost-effective manner.

The Impact of Quality Improvement Interventions in Improving Surgical Infections and Mortality in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis

BACKGROUND

Morbidity and mortality in surgical systems in low- and middle-income countries (LMICs) remain high compared to high-income countries. Quality improvement processes, interventions, and structure are essential in the effort to improve peri-operative outcomes.

METHODS

A systematic review and meta-analysis of interventional studies assessing quality improvement processes, interventions, and structure in developing country surgical systems was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were conducted in an LMIC, occurred in a surgical setting, and measured the effect of an implementation and its impact. The primary outcome was mortality, and secondary outcomes were rates of rates of hospital-acquired infection (HAI) and surgical site infections (SSI). Prospero Registration: CRD42020171542.

RESULT

Of 38,273 search results, 31 studies were included in a qualitative synthesis, and 28 articles were included in a meta-analysis. Implementation of multimodal bundled interventions reduced the incidence of HAI by a relative risk (RR) of 0.39 (95%CI 0.26 to 0.59), the effect of hand hygiene interventions on HAIs showed a non-significant effect of RR of 0.69 (0.46-1.05). The WHO Safe Surgery Checklist reduced mortality by RR 0.68 (0.49 to 0.95) and SSI by RR 0.50 (0.33 to 0.63) and antimicrobial stewardship interventions reduced SSI by RR 0.67 (0.48-0.93).

CONCLUSION

There is evidence that a number of quality improvement processes, interventions and structural changes can improve mortality, HAI and SSI outcomes in the peri-operative setting in LMICs.

Racial and Ethnic Inequities in Mortality During Hospitalization for Traumatic Brain Injury: A Call to Action

The health disparities which drive inequities in health outcomes have long plagued our already worn healthcare system and are often dismissed as being a result of social determinants of health. Herein, we explore the nature of these inequities by comparing outcomes for racial and ethnic minorities patients suffering from traumatic brain injury (TBI). We retrospectively reviewed all patients enrolled in the Trauma One Database at the Oregon Health & Science University Hospital from 2006 to October 2017 with an abbreviated injury scale (AIS) for the head or neck >2. Racial and ethnic minority patients were defined as non-White or Hispanic. A total of 6,352 patients were included in our analysis with 1,504 in the racial and ethnic minority cohort vs. 4,848 in the non-minority cohort. A propensity score (PS) model was generated to account for differences in baseline characteristics between these cohorts to generate 1,500 matched pairs. The adjusted hazard ratio for in-hospital mortality for minority patients was 2.21 [95% Confidence Interval (CI) 1.43-3.41, p < 0.001] using injury type, probability of survival, and operative status as covariates. Overall, this study is the first to specifically look at racial and ethnic disparities in the field of neurosurgical trauma. This research has demonstrated significant inequities in the mortality of TBI patients based on race and ethnicity and indicates a substantive need to reshape the current healthcare system and advocate for safer and more supportive pre-hospital social systems to prevent these life-threatening sequelae.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Clinical Prediction Scores for Pediatric Appendicitis

INTRODUCTION

 The rate of misdiagnosis of appendicitis in children is a challenge and clinical prediction scores could be part of the solution. However, the pediatric appendicitis score (PAS) and the Alvarado score have shown disappointing diagnostic accuracy in pediatric validation studies, while the appendicitis inflammatory response (AIR) score and the novel pediatric appendicitis risk calculator (pARC) have not yet been validated thoroughly. Therefore, the aim of the present study was to evaluate these four prediction scores prospectively in children with suspected appendicitis.

MATERIALS AND METHODS

 A prospective study was conducted over a 2-year period. All patients <15 years with suspected appendicitis were eligible for inclusion. The four prediction scores were compared regarding predictive values, receiver operating characteristics (ROC) curves, decision curve analysis, and clinical outcome.

RESULTS

 Of the 318 patients included, 151 (47 %) patients had appendicitis. The AIR score and the pARC had substantially higher specificity and positive predictive value, and lower rate of false positives (7% and 2%), than the PAS and Alvarado score (36 and 28%, p < 0.001). Across the different gender and age groups, the AIR score and the pARC generally had fewer false positives than the PAS and Alvarado score. There were no significant differences in sensitivity, negative predictive values, rates of missed appendicitis, or ROC curve analysis. In decision curve analysis, the AIR score and the pARC outperformed the PAS and Alvarado score at most threshold probabilities.

CONCLUSION

 The AIR score and the pARC are superior to the PAS and Alvarado score in diagnosing children with suspected appendicitis.

Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review

OBJECTIVE

The objective of this review was to determine the effect of nurse staffing on patient and nurse workforce outcomes in acute care settings within low- and middle-income countries.

INTRODUCTION

Health care systems in low- and middle-income countries experience a high proportion of the global burden of disease, which is aggravated by several health care constraints. The high rates of both communicable and non-communicable diseases, low numbers in the workforce, poor distribution of qualified professionals, and constraints in medical supplies and resources make the provision of quality health care challenging in low- and middle-income countries. Health care systems in low- and middle-income countries, however, are still expected to address universal health care access and provide high-quality health care. Systematic reviews examining nurse staffing and its effect on patient and nurse workforce outcomes are largely from the perspective of high-income countries. There is a need to understand the evidence on nurse staffing and its impact in the context of low- and middle-income countries.

INCLUSION CRITERIA

Empirical studies that addressed acute care nurse staffing levels, such as nurse-to-patient ratio or nurses' qualifications, experience, and skill mix, and their influence on patient and nurse workforce outcomes were included in the review. Studies conducted in a low- or middle-income country were included. Outcomes must have been measured objectively using validated tools.

METHODS

Studies published until July 2019 were identified from CINAHL, PubMed, Scopus, Embase, PsycINFO, Cochrane Library, Web of Science, and ProQuest Dissertations and Theses. The JBI approach to critical appraisal, study selection, data extraction, and data synthesis was used for this review. Narrative synthesis was conducted due to high heterogeneity of included studies. The level of evidence was determined using GRADEpro.

RESULTS

Twenty-seven studies were included in this review and the level of evidence was low, mainly due to the design of included studies. Low nurse-to-patient ratio or high nurse workload was associated with higher rates of in-hospital mortality, hospital-acquired infection, medication errors, falls, and abandonment of treatment. Findings on the effect of nurse staffing on length of hospital stay and incidence of pressure ulcers were inconsistent. Extended work hours, less experience, and working night or weekend shifts all significantly increased medication errors. Higher nurse workload was linked to higher levels of nurses' burnout, needlestick and sharps injuries, intent to leave, and absenteeism.

CONCLUSIONS

Lower nurse-to-patient ratios and higher nurse workload are linked to in-hospital mortality, hospital-acquired infections, and medication errors among patients, and high levels of burnout, needlestick and sharps injuries, absenteeism, and intention to leave their job among nurses in low- and middle-income countries. The results of this review show similarities with the evidence from high-income countries regarding poor outcomes for patients and nurses. These findings should be considered in light of the lower nurse-to-patient ratios in most low- and middle-income countries.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018119428.

Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

BACKGROUND

The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.

METHODS

We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.

RESULTS

Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.

CONCLUSIONS

Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

A Case of Self-Induced Hydrostatic Colonic Perforation

Introduction: Constipation is a common complaint. The elderly are five times more prone to constipation than young people because of the effects of medication, immobility, and a blunted urge to defecate. Many of these patients are demented, have cognitive deficits, or suffer from a psychiatric disorder.

Colonic perforation caused by hydrostatic pressure is rare, and this typically occurs during fluoroscopic studies resulting when there is excessive intraluminal colonic pressure. Self-induced colonic perforation is even rarer.

Case report: We report the case of a 95-year-old man who presented to the emergency department with an acute surgical abdomen and symptoms of sepsis. He had a history of longstanding constipation. He gave a history of frequent insertion of a rubber hose into his anal canal to relieve his constipation while rinsing his anus after defecation. After resuscitation, an emergency operation was performed, and sigmoid colon perforation was found in addition to pre-existing diverticular disease. Hartmann’s procedure was performed after abdominal washout. Unfortunately, the patient died of multi-organ failure two days after surgery.

Conclusion: Self-induced hydrostatic colonic perforation is rare. The consequence is fatal, especially in the elderly or in cases of delayed presentation.

The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study

BACKGROUND

Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK).

METHODS

Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up.

RESULTS

The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive.

CONCLUSION

COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.

Global Access to Technology-Enhanced Medical Education During the COVID-19 Pandemic: The Role of Students in Narrowing the Gap

Althoughsome medical education institutions in high-income countries have the capacity to shift education to eLearning during the COVID-19 pandemic, educational institutions in low- and middle-income countries might struggle to fully implement it. We argue for medical students to advocate for national and international collaboration in adopting technology-enhanced learning globally.

Appendicitis Mortality in a Resource-Limited Setting: Issues of Access and Failure to Rescue

BACKGROUND

Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi.

METHODS

We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality.

RESULTS

We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation.

CONCLUSIONS

Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease.

Outcomes after emergency abdominal surgery in COVID-19 patients at a referral center in Brazil

Purpose

COVID-19 is associated with high morbidity and mortality in patients undergoing surgery. Contrary to elective procedures, emergency operations should not be postponed. We aim to evaluate the profile and outcomes of COVID-19 patients who underwent emergency abdominal surgery.

Methods

We performed a retrospective analysis of perioperative data of COVID-19 patients undergoing emergency surgery from April 2020 to August 2020.

Results

Eighty-two patients were evaluated due to abdominal complaints, yielding 22 emergency surgeries. The mean APACHE II and SAPS were 18.7 and 68, respectively. Six patients had a PaO₂/FiO₂ lower than 200 and more than 50% of parenchymal compromise on chest tomography.

The most common indications for emergency surgery were hernias (6; 27.2%). The median length of stay was 30 days, and only two patients required reoperation. Postoperatively, 10 (43.3%) patients needed mechanical ventilation for a mean of 6 days. The overall mortality rate was 31.8%.

Conclusion

Both postoperative morbidity and mortality are high in COVID-19 patients with respiratory compromise and abdominal emergencies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13304-021-01007-5.

Moving from an era of open Appendectomy to an era of Laparoscopic Appendectomy: A Nationwide Cohort Study of Adult Patients Undergoing Surgery for Appendicitis

BACKGROUND AND AIMS

During the last decades, laparoscopic surgery has been introduced as an alternative to open surgery. We aimed to examine to what extent laparoscopic surgery has replaced open surgery for appendicitis in an entire nation during the last two decades. Second, we examined the effects of shifting to laparoscopic surgery for appendicitis on different quality indicators such as length of postoperative stay and mortality. We also examined age as a predictor of 30-day mortality.

MATERIALS AND METHODS

During the period 2000 to 2015, all adult patients with appendicitis and surgical removal of the appendix were identified in the Danish National Patient Register. Demographics, type of surgery, time of surgery, and duration of postoperative stay were retrieved form Danish National Patient Register. Vital status was retrieved from the Danish Civil Registration System.

RESULTS

A total of 58,093 patients underwent surgery for appendicitis. In 2000, a total of 274 out of 3717 (7.4%) had a laparoscopic appendectomy, and the postoperative stay was 55 (iqr: 35-88) h and 30-day mortality was 0.91%. In 2015, a total of 3995 out of 4296 (93.0%) had a laparoscopic appendectomy, and the postoperative stay was 16 (iqr: 9-56) h and 30-day mortality was 0.40%. Age as a predictor of 30-day postoperative mortality had an area under the curve of 0.93 (95% confidence interval: 0.92; 0.94).

CONCLUSION

In Denmark, the standard surgical procedure for appendicitis has changed from open surgery to laparoscopic surgery during the period 2000-2015. At the same time, duration of postoperative stay and 30-day mortality has decreased.

The Effect of Conflict on Obstetric and Non-Obstetric Surgical Needs and Operative Mortality in Fragile States

BACKGROUND

Médecins Sans Frontières (MSF) provides surgical care in fragile states, which are more vulnerable to conflict. The primary objective of this study was to compare the indications for operative intervention in surgical projects in fragile states during periods of active conflict (CON) and non-conflict (NON-CON). In addition, risk factors for non-obstetric and obstetric operative mortality were identified.

METHODS

This was a retrospective analysis of MSF surgical projects in fragile states January 1, 2008-December 31, 2017. Variables considered in the analysis include age, gender, American Society of Anesthesiology physical status, emergency status, re-intervention status, indication for surgical intervention, and conflict/non-conflict time period.

RESULTS

There were 30 surgical projects in 13 fragile states with 87,968 surgical interventions in 68,667 patients. Obstetric needs were the most common indication for surgical intervention (n = 28,060, 31.9%) but were more common during NON-CON (n = 23,142, 35.7%) compared to CON periods (n = 4,918, 21.2%, p < 0.001). Trauma was more common during CON (42.0%) compared to NON-CON (23.0%) periods (p < 0.001). Non-obstetric operative mortality was similar during CON (0.2%) compared to NON-CON (0.2%, p = 0.920), but obstetric operative mortality was higher (0.5%) during CON compared to NON-CON (0.2%, p < 0.001) periods. Risk factors for obstetric and non-obstetric mortality included age ≥ 30 years, ASA greater than 1, and emergency intervention.

CONCLUSION

Humanitarian surgeons working in fragile states should be prepared to treat a range of surgical needs including trauma and obstetrics during conflict and non-conflict periods. The mortality in obstetric patients was higher during conflict periods, and further research to understand ways to protect this vulnerable group is needed.

Nutritional status and outcome of surgery: A prospective observational cohort study of children at a tertiary surgical hospital in Harare, Zimbabwe

BACKGROUND

Undernutrition contributes to nearly 50% of all child deaths in the world, yet there is conflicting evidence regarding the association between nutritional status and postoperative complications. The aim was to describe the preoperative nutritional status among pediatric surgery patients in Zimbabwe, and to assess if nutritional status was a risk factor for adverse postoperative outcome of mortality, surgical site infection, reoperation, readmission, and longer length of stay.

METHODS

This prospective observational cohort study included 136 children undergoing surgery at a tertiary pediatric hospital in Zimbabwe. Nutritional status was standardized using Z-scores for BMI, length, weight, and middle upper arm circumference. Primary outcomes after 30 days included mortality, surgical site infection, reoperation, and readmission. Secondary outcome was length of stay. Univariate and multivariable analyses with logistic regression were performed.

RESULTS

Of the 136 patients, 31% were undernourished. Postoperative adverse outcome occurred in 20%; the mortality rate was 6%, the surgical site infection rate was 17%, the reoperation rate was 3.5%, and readmission rate was 2.5%. Nutritional status, higher ASA classification, major surgical procedures, and lower preoperative hemoglobin levels were associated with adverse outcome. Univariate logistic regression identified a seven-fold increased risk of postoperative complications among undernourished children (OR 7.3 [2.3-22.8], p = 0.001), and there was a four- to six-fold increased adjusted risk after adjustment for ASA, major surgery, and preoperative hemoglobin.

CONCLUSION

A third of all pediatric surgery patients were undernourished, and undernourished children had a considerably higher risk of adverse outcome. With a positive correlation identified between undernourishment and increased postoperative complications, future aims would include assessing if preoperative nutritional treatment could be especially beneficial for undernourished children.

LEVELS OF EVIDENCE

Level II treatment study.

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.